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2 February 1997
Continuing Education Article
FOCAL POINT 5Careful attention to postoperative
management techniques in dogs that have undergone spinal surgery will improve surgical success rates and client satisfaction.
Postoperative Management of the Canine Spinal Surgery Patient—Part I
Texas A&M University
s Untreated pain can lead to unfavorable physiologic and psychologic responses that can delay normal healing. s Failure to maintain adequate voiding of urine can lead to cystitis, bladder atony, and pyelonephritis. s Pharmacologic agents can assist in overall bladder management but do not restore normal bladder function. s Physical therapy should begin as soon after surgery as the patient’s clinical condition allows.
Richard M. Jerram, BVSc, MRCVS Robert C. Hart, DVM Kurt S. Schulz, DVM, MS
he two broad areas of vertebral surgery are (1) spinal cord decompression (or exploratory surgery) for treatment of intervertebral disk disease, neoplasia, and lumbosacral disease and (2) vertebral stabilization for treatment of atlantoaxial subluxation, cervical vertebral instability (wobbler syndrome), lumbosacral disease, and spinal fracture/luxation. 1 Although surgery is only one component in a comprehensive management plan for dogs with spinal neurologic disease, the scientific literature has focused on the surgical procedure—leaving postsurgical management in need of further attention. Postsurgical management is a critical determinant of the success rate of spinal surgery. It is often difficult to accurately predict the outcome of animals after spinal surgery. Some completely recover, whereas others remain permanently paralyzed. Because each animal that will go undergo spinal surgery presents with a different level of neurologic compromise, it is essential to develop a plan that is tailored to meet the specific surgical, therapeutic, and nursing care needs of that animal. Client education must begin immediately after the decision to proceed with surgery because clients need to be aware of the time and effort required in the postsurgical period. This two-part article focuses on helping veterinarians better understand the key issues, required treatments, and some of the potential complications associated with the postoperative management of dogs that have undergone spinal surgery. Six primary areas of concern will be reviewed. Part I discusses pain management, bladder management, and physical therapy. Part II will address gastrointestinal complications, such as fecal incontinence and steroid-induced colitis; wound complications, such as discharge, seroma and infection; and re-
The Compendium February 1997
same stimulus applied to an animal should also be considered painful. Treatment based on this anthropomorphic view of pain should not be considered inappropriate6,7 (Figure 1). The clinical signs and physiologic effects of pain seen in dogs after spinal surgery are given in the box. All of these signs are not present in every patient, but a subjective diagnosis of Figure 1—A dachshund in its cage after spinal surgery. It is pain can be made if several often difficult to determine whether a dog is experiencing of these signs occur concurPAIN MANAGEMENT “Pain is an unpleasant sen- pain after surgery because signs of pain are varied and non- rently.6–12 Because animals may not sory and emotional experi- specific. vocalize until pain is severe, ence associated with actual vocalization is not a sensitive indicator of pain.6–12 Also, or potential tissue damage.”2 Surgical events, such as pain, hemorrhage, tissue damage, hypothermia, and many animals vocalize in the dysphoric phase of norhypoxia, initiate stress responses. These responses can mal anesthetic recovery, thus making vocalization even be metabolic, inflammatory, neural, or endocrine and more difficult to interpret.12 3,4 result in physiologic changes in the body. Pain can Analgesic Agents lead to hypoxia, hypercalcemia, lung atelectasis, and Clinical and Analgesics should be a stanpneumonia. Physiologic Signs dard component (unless conCompensatory responses to the demands of damaged of Paina traindicated because of undertissue include an increase in the release of cortisol, catecholamines, renin, and inflammatory mediators.5 If these unfavorable physiologic changes become extreme, a delay in normal healing may occur. These changes are of particular importance in animals that have undergone neurosurgery. Recovery is often prolonged as a result of neurologic dysfunction, and unnecessary impediments to healing should be avoided.5 In addition, the psychologic impact of pain is to create a cycle of anxiety, fear, and sleep deprivation, all of which further exacerbate the delay in tissue healing.5 The key steps to managing pain successfully are to (1) recognize the presence of pain and identify its source and (2) provide the most appropriate form of analgesia. Good-quality nursing care must also be provided. After surgery, animals should be placed in a quiet environment with warm, dry, and well-padded cages. lying cardiovascular or respiratory disease) of the anesthetic premedications given to dogs undergoing spinal surgery. Opioids, nonsteroidal antiinflammatory drugs (NSAIDs), and local analgesics are the predominant types of drugs used for postoperative pain relief.6,8,10,12,14 Although pain is most commonly reduced by pharmacologic methods, alternative pain relief methods may be explored. Acupuncture has long been recognized as an effective treatment for pain and has been used successfully in the conservative management of intervertebral disk disease in dogs.10,13 Other available methods include transcutaneous electrical stimulation (TENS) and acupressure.10
s s s s s s s s s s s s s s Depression Reluctance to move Timidity Inappetence Restlessness Anxiety Guarding of surgical area Vocalization? Tachypnea Tachycardia Mydriasis Salivation Hyperglycemia Premature atrial or ventricular contractions
cumbency management, with special attention to bedding, bathing, nutrition, and walking aids for patients whose recovery period is prolonged. The postsurgical needs of animals with spinal cord disease can be time-consuming and frustrating. The rewards, however, of improved neurologic function and client satisfaction can be significant.
Recognizing Pain Veterinarians must be able to determine whether an animal is in pain. If behavioral changes or clinical signs that are abnormal for the individual or for the species are observed, pain should be suspected. A stoic animal may need to be assessed subjectively. For instance, if a stimulus applied to a human is considered painful, the
Each animal responds differently to pain. The signs of pain may be difficult to interpret.
PHYSIOLOGIC CHANGES s CLINICAL SIGNS s PHARMACOLOGIC MANAGEMENT
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TABLE I Drugs Used for Postoperative Pain Relief in Canine Spinal Surgery Patients Drug Opioids Morphine Oxymorphone Meperidine Butorphanol Buprenorphine Dosage (mg/kg) 0.25–1.25 IM, SQ 0.05–0.2 IV, IM 2.0–5.0 IM, SQ 0.1–0.8 IV, IM, SQ 0.005–0.01 IV, IM, SQ Duration (hr) 3–5 2–5 1–2 2–4 6–8 Side Effects Emesis; respiratory depression; increased intracranial pressure Respiratory depression; auditory hypersensitivity; altered thermoregulation Mild gastrointestinal effects Some nausea and vomiting Mild respiratory depression; sedation
Nonsteroidal Antiinflammatory Drugs Aspirin 10 PO Phenylbutazone Piroxicam Carprofen Ketoprofen 20 IV, PO 0.2–0.4 PO 4.0 IV, SQ, PO 1.0 IV, IM, PO
12–14 12–24 12–24 12–24 12–24
Gastrointestinal hemorrhage; platelet dysfunction Gastrointestinal hemorrhage; renal toxicity Gastrointestinal hemorrhage; renal toxicity None Gastrointestinal hemorrhage; renal toxicity
IM = intramuscularly, IV = intravenously, PO = orally, SQ = subcutaneously.
Opioids Narcotic agonists have traditionally been the mainstay of postoperative analgesia in dogs (Table I). Opioids act both peripherally, by inhibiting transmission from primary afferent nociceptors to the dorsal root ganglia, and centrally, by inhibiting nociceptive conditions locally in the spinal cord. Morphine has profound analgesic and sedative effects.8,10,14 The onset of action of morphine can be up to 45 minutes, and it has an intermediate duration of action of 3 to 5 hours.15 The side effects of morphine include emesis and defecation, respiratory depression, and increases in intracranial pressure.8,10,14 Meperidine has milder narcotic and gastrointestinal effects than morphine but only provides effective analgesia for 1 to 2 hours.8,10,14,15 Intravenous injection of morphine or meperidine has been associated with histamine release; therefore, these drugs should be administered by intramuscular and subcutaneous routes only.15 Oxymorphone is commonly used and provides good analgesia with mild sedative effects. It has 10 times the potency of morphine, with less respiratory depression
and less gastrointestinal stimulation.8,10,14 Buprenorphine is a partial opioid agonist that is 30 times more potent than morphine. It provides excellent analgesia for 6 to 8 hours and has minimal respiratory and gastrointestinal effects.15,16 Butorphanol is a mixed agonist–antagonist that is five times more potent than morphine. It is an excellent analgesic for moderate levels of pain. The respiratory depression associated with butorphanol is dose related up to a point beyond which higher doses do not further depress respiratory effort.8,10,14,15 Fentanyl, which has a short duration of action when given parenterally, is now available in a transdermal therapeutic system patch.17,18 Effective pain relief has been attained using the transdermal patch in our clinic. Advantages of using the patch are that therapeutic levels of fentanyl are achieved and that injections of other opioids are required less frequently or not at all.17,18
Nonsteroidal Antiinflammatory Drugs Nonsteroidal antiinflammatory drugs exert their analgesic effect by acting peripherally, with the inhibi-
DURATION OF ACTION s RESPIRATORY EFFECTS s GASTROINTESTINAL EFFECTS
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tion of cyclooxygenase, and thereby blocking the production of prostaglandins during the inflammatory process. NSAIDs have less sedative effect and a longer duration of action than opioids. Although not as effective as opioids for the acute phase of postoperative pain, NSAIDs can be administered 72 hours after surgery if pain persists. Because all NSAIDs can produce gastric irritation, caution must be exercised with their use in patients that have undergone spinal surgery and that have previously received corticosteroids.8,10,14 A new NSAID, carprofen, which is a weak inhibitor of cyclooxygenase, has been recently shown to have equal or better analgesic effects than meperidine or papaveretum (a morphine-based opioid).19,20 Whether carprofen is associated with gastrointestinal side effects is unknown. 19,20 Additional studies are necessary to evaluate its efficacy after spinal surgery.
The upper motor neuron bladder results from spinal cord lesions between the pons and the lumbar spinal cord segment 7. Reflex micturition can occur, but voluntary control of urination is lost. Overflow incontinence without any attempt to urinate may be present in the early stages after surgery.22,24 Usually, urethral sphincter tone is exaggerated, and the bladder may be extremely difficult to express.21,24 Several days to weeks may pass before the sacral reflex is restored.22 When the upper motor neuron bladder persists for a prolonged period, the animal urinates without awareness, and a large residual volume of urine is usually retained after voiding.21–24
Adequacy of Analgesia A recent retrospective study showed that dogs and cats may not be receiving adequate analgesia postoperatively; therefore, it is important for veterinarians to anticipate the likelihood of postsurgical pain and to administer appropriate analgesic therapy. 11 Animals should not be expected to tolerate pain any greater than humans would voluntarily tolerate.11 Careful patient monitoring and a sound knowledge of the pharmacology of analgesics are necessary to ensure that pain does not occur during the postoperative period. BLADDER MANAGEMENT Bladder management is the most important and most challenging issue faced after spinal surgery. Failure to maintain adequate voiding of urine can lead to such potentially severe problems as cystitis, bladder atony, pyelonephritis, and iatrogenic bladder rupture. The neurogenic bladder dysfunction that is generally seen in patients with spinal cord disease is described on the basis of location of the lesions (termed lower motor neuron bladder and upper motor neuron bladder). The lower motor neuron bladder occurs with spinal cord lesions at the level of the sacral cord, cauda equina, pelvic nerve, and pudendal nerve. Such lesions abolish both the voluntary and reflex phases of normal micturition. Consequently, contraction of the detrusor muscle is eliminated, and urethral sphincter muscle tone is lost.21–24 The bladder retains urine, and overflow incontinence results. Manual bladder expression is generally straightforward, but voiding occurs only as long as external pressure is applied.23 In rare instances, innervation to the internal sphincter via the hypogastric nerve can remain intact, resulting in a bladder that is difficult to express.22,24
Manual Bladder Expression and Catheterization The primary goal of bladder management immediately after surgery is to maintain normal or reduced bladder volume and to prevent bladder overdistention.24 Because the abdominal muscles are often tense after surgery, the bladder may be difficult to palpate. Ultrasonography can help determine the extent of bladder distention. Alternatively, the patient can be catheterized to measure urine volume. Manual expression and intermittent or indwelling catheterization can be used to help dogs void urine. Our preference is for manual expression, except in dogs with excessive urethral tone or when nursing care is facilitated by catheterization. Most dogs with lower motor neuron bladders and some with upper motor neuron bladders respond to manual expression. In smaller dogs, the caudal abdomen is gently squeezed with the thumb and fingers of one hand while supporting the dog with the other hand.25 In larger dogs, both hands are required to express the bladder. The pressure applied should be firm enough to create a steady stream of urine.21 Initially, this procedure should be repeated every 4 to 6 hours. This interval can be adjusted later, depending on the amount of bladder distention and the volume of urine voided (Figure 2). Catheterization of the bladder may be necessary in dogs with neurogenic bladder dysfunction, particularly those with hypertonic urethral sphincters. Strict attention to aseptic technique (e.g., using sterile catheters and gloves) helps reduce the incidence of nosocomial infections caused by bladder catheterization.26 The vulva or prepuce should be surgically prepared, and a sterile lubricant should be applied to the tip of the catheter. Catheters are made of a variety of materials, including plastic, rubber, metal, glass, and nylon.26 Some dogs may have an inflammatory reaction to a particular type of catheter, but such responses seem to vary among dogs and catheters. 27 A red rubber feeding tube or
CARPROFEN s NEUROGENIC BLADDER DYSFUNCTION s CATHETERIZATION
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polypropylene catheter of pair the mucosal defense the smallest diameter should barrier.26 26–28 A Foley-type Urinary tract infection be used. catheter can be used as an may be a complication after indwelling catheter in fespinal surgery because of an male dogs because the balincrease in the residual volloon can be inflated to aid ume of urine and the need in catheter retention.26,28 for catheterization. UrinalyIntermittent, as opposed sis and urine culture should to indwelling, catheterizabe performed if catheterization may reduce the risk of tion continues for more bladder infection.26,29 Interthan 4 days or if clinical mittent catheterization, signs of cystitis occur. In however, must be repeated dogs with spinal cord injury, regularly (depending on the Figure 2—With a small dog, the bladder can be expressed by the classic signs of dysuria amount of urine retrieved) gently squeezing the bladder with the thumb and fingers of and pollakiuria may not be to ensure that the bladder one hand while supporting the dog with the other hand. present, but hematuria should does not become overdisbe readily identifiable. 25 Common bacteria found on tended. The risk of bladder culture of urinary tract ininfection increases with the fections include Escherichia number of catheterizations.26 Because intermittent cathecoli, Staphylococcus species, Streptococcus species, and terization may be difficult to Proteus mirabilis. Klebsiella perform in female dogs, inpnemoniae and Pseudomonas dwelling catheterization may aeruginosa have also been be preferable. recognized.25,32 When using an inAntibiotic selection should dwelling catheter, a closed be based on the results of urinary collection system is bacterial sensitivity testessential. An empty intraing.25,32 Empirical treatment venous fluid bag attached to with penicillins, cephalothe catheter via a sterile insporins, trimethoprim-sulfatravenous fluid line makes Figure 3—A closed urinary collection system is essential with an excellent closed drainage an indwelling catheter. The collection bag should be posi- diazine, or enrofloxacin should not be discouraged system (Figure 3). The pro- tioned lower than the dog. while awaiting results of the phylactic use of antibiotics sensitivity testing. It is recwith catheterization is conommended that monthly or bimonthly culture and uritraindicated because of the inherent risk of developing nalysis be done in animals with long-term hindlimb resistant bacteria.26–28 and urinary paralysis.25,32 Urinary Tract Infections Various defense mechanisms in the bladder and urePharmacologic Bladder Management Drug therapy is occasionally necessary to improve thra protect the normal canine bladder from infecbladder and urethral function. The pharmacologic tion.30,31 Normal micturition provides complete voiding of an adequate volume of urine. Anatomic structures, management of bladder disorders, however, is not alsuch as urethral length, urethral peristalsis, and urethral ways effective and should be done on a short-term basis high-pressure zones, contribute to resistance from inonly.21 Owners should be made aware that the drugs 30,31 The mucosa of the bladder wall and urethra being prescribed do not restore normal bladder control fection. in addition to the antimicrobial effects of the urine itbut merely assist in overall bladder management. Drug self provide a barrier to infection.30,31 The protective eftherapy aids micturition until normal bladder function fect of many of these factors is greatly reduced, howevis restored (Table II). er, in animals with neurogenic bladder dysfunction. The hypertonicity of the internal urethral sphincter Abnormal urine voiding and altered urethral tone imin animals with upper motor neuron bladders may be
BLADDER INFECTION s URINE CULTURE s ANTIBIOTICS
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TABLE II Drugs Used for Pharmacologic Management of Neurogenic Bladder Dysfunction Drug Phenoxybenzamine Bethanechol Dosage 5–15 mg SID, PO 2.5–25 mg TID, PO Clinical Effects
α-Adrenergic; reduces hypertonicity
Side Effects Hypotension, tachycardia Vomiting, diarrhea, hypersalivation, abdominal cramps Sedation Weakness, hepatotoxicity Hypertension Constipation, decreased salivation, gastric hypermotility
of internal urethral sphincter Cholinergic; enhances detrusor contractility Indirect skeletal muscle relaxant Direct skeletal muscle relaxant
α-Adrenergic agonist; increases
Diazepam Dantrolene Phenylpropanolamine Propantheline
2–10 mg TID, PO 1–5 mg/kg BID, PO 12.5–50 mg TID, PO 7.5–30 mg/kg TID, PO
urethral sphincter tone Anticholinergic; decreases detrusor contraction
BID = twice daily, PO = orally, SID = once daily, TID = three times daily.
reduced by using the α-adrenergic blocking agent phenoxybenzamine. Response to treatment depends on the type of lesion. An assessment of effectiveness may require several days. Treatment should be discontinued after 1 to 2 weeks if no clinical response is seen.22–24,33 Detrusor contractility may be enhanced with the cholinergic drug bethanechol. The extent of detrusor atony determines the clinical response to this drug. If no response is seen after 1 week of treatment, therapy should be considered to be ineffective. In addition, bethanechol has a weak nicotinic effect on the bladder neck, which can increase urethral outflow resistance. For this reason, bethanechol may be used most effectively in combination with phenoxybenzamine. Bethanechol should not be used if urethral obstruction is suspected.22–24,33 The tone of the external urethral sphincter, which consists of skeletal muscle, may be reduced by using diazepam.22–24,33 Less frequently used drugs for bladder management include dantrolene, phenylpropanolamine, and propantheline.22–24,33
muscle atrophy and fibrosis may be prevented.36,37 A well-designed physical therapy program can decrease the duration of hospitalization and help to improve patient attitude and mental status.37 Initiation of physical therapy depends on the location and severity of the lesion; the surgical technique performed; and the animal’s condition, attitude, and demeanor.
PHYSICAL THERAPY After spinal surgery, patients are often recumbent and confined to their cages. Physical therapy plays a key role in hastening successful recovery. Physical therapy can improve muscular strength and speed the healing of inflamed and injured tissues while helping to maintain the normal range of motion in joints.34–36 In addition,
Cold Therapy Cold therapy using the conduction of cold with cold packs, cold water, or ice may be indicated in the first 12 to 48 hours after surgery. Local hypothermia decreases nerve conduction velocity (creating mild analgesia), causes vasoconstriction (reducing edema), and relaxes skeletal muscles.36–39 Cold packs should be placed over a sterile, waterimpermeable dressing and should be kept in place for 5 to 10 minutes, two to four times daily. Treatments should never exceed 30 minutes because extended cold therapy sessions may lead to vasodilatation and subsequent edema formation.36 Commercially produced cold packs that are available for human physical therapy can be adapted for use in dogs. A simple ice pack can be constructed by filling a plastic bag with ice, wrapping the bag in a towel, and placing the bag on the wound.36–39 Heat Therapy Heat therapy is indicated from 48 to 72 hours after
BETHANECHOL s RECOVERY PROCESS s COLD PACKS
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surgery to decrease swelling, kneading, and friction. pain, and muscle spasm at Stroking is a superficial touch the surgical site.36–39 In addithat precedes kneading and tion, heat therapy may enfriction. It is performed by hance subsequent massage using light strokes of uniand exercise therapy and, form pressure—working therefore, should precede from the edge to the center these supplementary theraof the area to be massaged— pies. at a rate of 15 strokes/min. Local hyperthermia inStroking accustoms the anicreases tissue temperature, mal to the therapist’s touch thereby producing analgesia, and produces a mild sedasedation, and an increase in tive effect.34–38,40 Kneading involves picking local metabolism. The results of local hyperthermia Figure 4—Local hyperthermia (as provided here by a hot pack up the skin and muscle, combined with the concur- on the back of this dog) decreases swelling, pain, and muscle which are then rolled and rent vasodilatation aid the spasm at the surgical site. Hot packs should be insulated compressed—always in the direction of the heart. Kneadhealing process by enhanc- from the patient’s skin. ing should be done firmly ing local blood flow and debut gently enough not to creasing edema.36–39 Absorbent paper towels or cause pain34–38,40 (Figure 5). cloths that have been imFriction is useful for loosmersed in water and then ening scar tissue and adheplaced in a sealable plastic sions as well as for aiding the bag can be heated in a miabsorption of local effusion. crowave oven to make an The skin is moved rapidly in excellent, inexpensive, and a circular motion over a reusable hot pack. Commersmall area three to four times cial hot packs are available; before moving to an adjahot towels may also be cent area. Pressure should be used.36–39 moderate and should not Treatments should last because pain.34–38,40 Massage sessions usually tween 10 and 20 minutes and can be repeated two to Figure 5—Massage therapy decreases the incidence of muscle last between 15 and 20 minthree times daily. 36–39 Hot atrophy and fibrosis. Massage sessions should be performed utes and should be repeated packs should be insulated one to two times daily for between 15 and 20 minutes per every 12 to 24 hours. The from the skin with towels or session. sessions should begin and paper tissue to eliminate the end with stroking to mainpossibility of burning. The tain muscle relaxation and skin should be felt every few minutes to ensure that it is the sedative effects.34–38,40 not excessively hot (Figure 4). Passive Exercise Massage Therapy Passive exercise involves no voluntary muscle conThe objective of massage is to increase blood and traction and usually follows heat therapy and massage. lymph flow through the massaged tissues. This action The therapist flexes and extends the limbs through a increases the delivery of nutrients to the area and hasnormal, pain-free range of motion. This is done 5 to 10 tens the removal of waste products and edema flutimes for two to three sessions daily, beginning 3 or 4 id.34,36–38,40 Muscle atrophy, a common postoperative days after surgery.36 Limbs can be handled individually, complication in recumbent animals, is minimized by or both limbs on the ipsilateral side of the animal can using massage in combination with passive and active be treated concurrently.36 Passive exercise maintains the 38 normal range of motion in joints and prevents contracexercise. Massage can also stretch tendons and decrease the likelihood of fibrosis. ture and muscle wasting. It also improves blood flow Three forms of massage used for dogs are stroking, and sensory awareness.35,36
LOCAL HYPERTHERMIA s STROKING s KNEADING s FRICTION
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The physical therapy regActive Exercise imen is enhanced when heat Active exercise involves and water turbulence (which voluntary motor control by provide a form of heat therthe animal. This form of exapy and massage) are added ercise is very beneficial to to the hydrotherapy. 34–38,40 recovering spinal surgery paHeating the water to between tients. Active exercise pro35.5˚ and 40.0˚C (96˚– duces an improvement in 105˚F) produces a superficoordination and cardiovascial hyperthermic effect.34–38,40 cular function.35,38 In addiWhirlpools use a combination, repeated voluntary tion of water currents and contractions of muscles in air bubbles to add a mild affected limbs may decrease massaging action to hysynaptic resistance, thereby improving nerve impulse Figure 6—Active exercise helps to improve muscle strength, drotherapy.34–38,40 Swimming and whirlpool conduction. The result is in- coordination, and cardiovascular function. Active exercise can be assisted with the use of a towel under the dog’s ab- sessions should begin slowly creased muscle strength.38 to accustom the animal to During active exercise, the domen or a commercially available sling. the water and the procepatient should always be endure. Weak patients may recouraged and supported. If the animal’s mental attitude quire constant manual support. Depending on the neuworsens, the therapy may be ineffective and even detrirologic status of the animal, the level of the water can mental, thereby delaying recovery.36 be adjusted to allow some weight bearing. When stabilization procedures are performed, for exHydrotherapy sessions should not begin until apample, in dogs with atlantoaxial instability, cervical verproximately 5 to 7 days after surgery. Sessions should tebral instability, or spinal fracture/luxation, it is imlast between 5 and 30 minutes. The surgical wound portant not to risk implant failure. In these cases, active should be dry and impervious to water. Swimming and exercise and hydrotherapy should be delayed. whirlpool tanks should be regularly disinfected. AntiFor active exercise, the therapist assists the patient by septics (e.g., povidone-iodine) can be added to the wapartially supporting its weight. Tail walking is the simter to prevent urine scald, pyoderma, and decubital ulplest form of assisted active exercise and is best used for cers.34–38,40 paraparetic small dogs. Tail walking consists of holding the tail at its base and allowing the dog to walk with its Client Education pelvic limbs on a nonslip surface. The amount of supAll appropriate physical therapy techniques must be port needed depends on the neurologic status of the demonstrated at the clinic to owners. Owners should animal. then be observed while they perform the physical theraIn larger dogs, a similar technique that involves suppy with their animals to ensure that techniques are beporting the dog’s weight with a towel or commercially ing done correctly. In addition, before an animal is disavailable hindlimb sling around the dog’s caudal abcharged, owners must be made aware of the importance domen is used (Figure 6). Two assistants may be needof encouraging and supporting their pet for physical ed with large-breed dogs.34–38,40 Quadriplegic animals therapy to be successful. can be placed in specially constructed body slings. A physical therapy chart for recording daily sessions These slings enable the dog to bear some weight on all should be given to clients to assist in compliance and four limbs and reduce the incidence of decubital understanding of the required therapy. 37 Regular ulcers.34–38,40 rechecks and/or in-clinic therapy sessions should be scheduled in advance to assess patient progress and Hydrotherapy maintain client contact. Hydrotherapy is an ideal form of active exercise. The animal’s natural buoyancy and the hydrostatic pressure CONCLUSION of water provide support and help improve circulaThe management of dogs that have undergone spinal tion.34–38,40 A paraparetic patient will move its joints volsurgery is a challenging undertaking, but successful reuntarily far more readily in water. Swimming also aids turn to satisfactory neurologic function can be very rein cleansing paraplegic animals of feces and urine on warding to both practitioners and pet owners. Early the skin.34–38,40
TAIL WALKING s SWIMMING s WHIRLPOOLS s PATIENT MONITORING
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and preemptive use of analgesic agents to manage pain results in less patient apprehension and distress when the important phases of bladder management and physical therapy begin. The goal of bladder management is to ensure adequate voiding of urine using physical and/or pharmacologic means and to quickly diagnose and treat urinary tract infections. Physical therapy can maintain strength and integrity of muscles and joints with such modalities as cold therapy, heat therapy, massage, and passive and active exercise. Part II of this article will address the potential complications associated with the surgical wound, the gastrointestinal tract, and the long-term management of recumbency.
12. 13. 14. 15. 16. 17. 18. 19.
About the Authors
Drs. Jerram and Hart are affiliated with the Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, Texas A&M University, College Station, Texas. Dr. Schulz was also at the Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, Texas A&M but is currently at the Department of Surgical and Radiological Sciences, School of Veterinary Medicine, University of California, Davis, California. Dr. Schulz is a Diplomate of the American College of Veterinary Surgeons.
20. 21. 22. 23. 24. 25. 26.
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