LITHUANIAN UNIVERSITY OF HEALTH SCIENCES

VETERINARY ACADEMY

Faculty of Veterinary Medicine

Lisa Maria Ask Johansen

The usefulness of neurolocalisation in the diagnosis and

treatment of canine intervertebral disc herniation

Neurolokalizacijos nustatymo nauda diagnozuojant ir

gydant tarpslankstelinio disko išvaržą šunims

MASTER THESIS
of Integrated Studies of Veterinary Medicine

Supervisor: Assoc. Prof. Dr. Martinas Jankauskas

KAUNAS 2020

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THE WORK WAS DONE IN THE DEPARTMENT OF SMALL ANIMAL CLINIC
CONFIRMATION OF THE INDEPENDENCE OF DONE WORK
I confirm that the presented Master Thesis “The usefulness of neurolocalisation in the diagnosis and
treatment of canine intervertebral disc herniation”.

1. has been done by me;

2. has not been used in any other Lithuanian or foreign university;
3. I have not used any other sources not indicated in the work and I present the complete list of the
used literature.

Lisa Maria Ask Johansen

(date) (author’s name, surname) (signature)

CONFIRMATION ABOUT RESPONSIBILITY FOR CORRECTNESS OF

THE ENGLISH LANGUAGE IN THE DONE WORK

I confirm the correctness of the English language in the done work.

Lisa Maria Ask Johansen
(date) (editor’s name, surname) (signature)

CONCLUSION OF THE SUPERVISOR REGARDING DEFENCE OF

THE MASTER THESIS
Martinas Jankauskas
(date) (supervisor’s name, surname) (signature)

THE MASTER THESIS HAVE BEEN APPROVED IN

THE DEPARTMENT/CLINIC/INSTITUTE

(date of approval) (name, surname of the head of (signature)

department/clinic/institute)

Reviewer of the Master Thesis

(name, surname) (signatures)

Evaluation of defence commission of the Master Thesis:

(date) (name, surname of the secretary of the defence (signature)

commission)

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 TABLE OF CONTENTS

1. SUMMARY………………………………………………………………………………….4
2. SANTRAUKA……………………………………………………………………………….5
3. ABBREVIATIONS………………………………………………………………………….6
4. TERMS…………………………………………………………………………...………….7
5. INTRODUCTION………………………………………………..………………………….8
6. AIMS AND OBJECTIVES………………………………………………………………….9
7. LITERATURE REVIEW………………………………………………………..…....10 – 15
7.1. The canine intervertebral disc……………………………………..…..……….10
7.2. Intervertebral disc herniation…………………………………….….……10 – 11
7.3. The canine spinal cord and its functional divisions………………...….…11 – 12
7.4. Diagnostic imaging – CT and MRI …………………………………....……....12
7.5. Treatment of canine intervertebral disc herniation…………………….…12 – 13
7.5.1. Conservative…………………………………………...……..…12 – 13
7.5.2. Surgical…………………………………………...……..……………13
7.6. Neurolocalisation …………………………………………………………14 – 15
8. RESEARCH METHODOLOGY…………………………………………...……..…..16 – 19
8.1. Neurological theory………………………………………….....……..…..16 – 17
8.2. Collection of material…………………………………………......…..………..18
8.3. Classification of data…………………………………………...……..………..18
8.4. Calculations and data analysis……………………..…………...……..…..18 – 19
9. RESULTS……………………………………………………..……………...……..…20 – 23
9.1. Occurrence of neurolocations and the sensitivity of neurolocalisation.......20 – 21
9.2. Occurrence of non-neurolocalised patients and the specificity of
neurolocalisation……………………………………………………...……..…21 – 22
9.3. The correlation between neurolocalisation, diagnostic method and
treatment………………………………………………………………….........22 – 23
10. DISCUSSION OF RESULTS……………………………………...……..…………...24 – 25
11. CONCLUSIONS……………………………………………………………...…...……..…26
12. ACKNOWLEDGEMENTS…………………………………………....…………...….……27
13. LITERATURE LIST…………………………………………...……..……...….….....28 – 30
14. ANNEXES………………………………………………………………………...…...……31
14.1. Annex 1: Patient list ……………………...…………………………...……....31

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 1. SUMMARY
The usefulness of neurolocalisation in the diagnosis and treatment of canine intervertebral disc
herniation

Lisa Maria Ask Johansen

Master Thesis

This master’s thesis is performed as part of the department of Dr. L. Kriaučeliūno small
animal clinic of Lithuanian University of Health Sciences in Kaunas. It aims to evaluate the usefulness
of neurolocalisation and its effect on diagnostic method and treatment in canine patients with
intervertebral disc herniation.

The data was collected from the patient record of Fredrikstad Dyrehospital veterinary animal
hospital in Norway between January and December 2020. The data was focused on patients with
confirmed disc herniation by CT or MRI. The aim was achieved by evaluating the specificity and
sensitivity of the neurolocalisation process, as well as calculating the dependence between
neurolocalisation and diagnostic method and treatment. The conclusion was made based on all the
factors of the results of the study.

The results indicated a great specificity of neurolocalisation at 98.7%, however a notably low
sensitivity at 40.7%. There was no indication of any significant correlation between the
neurolocalisation and the diagnostic method or treatment (p > 0.05).

The conclusion was that due to a small sample size in this study, further investigations should
be carried out on a larger sample size in order to confirm the results found. However, the results of the
sensitivity of neurolocalisation indicated a great potential for improvement in this method of clinical
diagnosis.

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 2. SANTRAUKA
Neurolokalizacijos nustatymo nauda diagnozuojant ir gydant tarpslankstelinio disko išvaržą
šunims

Lisa Maria Ask Johansen

Magistro baigiamasis darbas

Šis magistro darbas atliktas Lietuvos sveikatos mokslų, Veterinarijos akademijos, Dr. L.
Kriaučeliūno smulkiųjų gyvūnų klinikos katedroje. Jo tikslas įvertinti neurolokalizacijos nustatymo
naudą ir efektyvumą atliekant diagnostiką ir taikant gydymą šunims esant tarpslankstelinio disko
išvaržai.

Duomenys buvo surinkti Fredrikstad Dyrehospital veterinarijos klinikoje Norvegijoje. Tyrimo

laikotarpis nuo 2019 meų sausio mėnesio iki 2020 metų gruodžio mėnesio. Duomenys buvo atrinkti ir
į tyrimą įtraukti, tik patvirtinus diagnozę kompiuterinės tomografijos ar magnetinio rezonanso tyrimo
metodu. Buvo siekta įvertinti neurolokalizacijos tyrimo specifiškumą ir jautrumą taip pat patikrinti
priklausomybę tarp neurolokalizacijos ir diganostikos metodų ir gydymo.

Rezultatai parodė didelį tyrimo specifiškumą - 98,7%, tačiau ypač mažą jautrumą - 40,7%.
Reikšmingos koreliacijos tarp neurolokalizacijos ir diagnostikos bei gydymo nebuvo (p>0.05).

Manoma, kad rezultatams įtakos turėjo maža imtis, todėl būtų tikslinta atlikti didesnės imties
tolimesnius tyrimus, norint gauti patikimesnius rezultatus. Tačiau stebimas didelis neurolokalizacijos
tyrimo jautrumas, kas atskleidžia didelę praktinę naudą, diagnostikoje.

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 3. ABBREVIATIONS

BCS – Body Condition Score

CNS – Central Nervous System
IVD – Intervertebral disc
IVDD – Intervertebral disc disease
IVDH – Intervertebral disc herniation
LMN – Lower Motor Neuron
PNS – Peripheral nervous system
UMN – Upper Motor Neuron

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 4. TERMS
Functional division (of the spinal cord) – A group of caudally and cranially connected spinal segments
which are classified together, which when compromised will produce similar clinical signs
Intervertebral space – The space between two adjacent vertebrae
Neurolocation – A functional division of the spinal cord which has been diagnosed on clinical
examination by neurolocalisation
Neurolocalisation – The process of localising a neurological disorder to a specific area of the nervous
system by clinical diagnosis
Spinal segment – A small neuroanatomical part of the spinal cord (not corresponding to anatomical
divisions of vertebrae)

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 5. INTRODUCTION

Intervertebral disc herniation (IVDH), or slipped disc, is among the most frequently occurring
spinal diseases in dogs. Although commonly associated with intervertebral disc degenerative disease, it
is known as an acute acquired disorder and is usually seen following spinal trauma. Even minor impacts
to the spine, such as jumping, can be a sufficient source of trauma. Intervertebral disc herniation causes
clinical signs varying in degree and can present as severe neurological deficits and pain. It is considered
to be a neurological disease of importance, the clinical effects arising from the mechanical pressure on
the spinal cord.
In accordance with the widely acknowledged guidelines of common clinical neurology practice,
these patients should receive thorough neurological examinations with the goal of an accurate diagnosis.
In order to reach this diagnosis, neurolocalisation has been a part of common veterinary practice for
many years and is often considered a gold standard for the clinical examination of neurological patients.
However, the diagnostic value of this categorization of patients in the relation to IVDH has
been previously undocumented and unevaluated. Moreover, a major aspect of neurolocalisation of
patients with spinal disorders is that not all patients will present with clinical signs sufficient to perform
a proper neurolocalisation at all. These patients will commonly present with severe local pain of the
neck and/or back.
It is the aim of this study to evaluate the sensitivity of neurolocalisation in canine patients with
IVDH. Our goal is to determine its usefulness in the diagnostic process and its significance in relation
to the choice of treatment. We will do so by comparing the prevalence of neurolocalisation to the
diagnostic method and chosen treatment in a group of dogs with diagnosed IVDH. We will also evaluate
the accuracy of the neurolocalisation by comparing the findings on diagnostic imaging to the spinal
segments of the neurolocations, in order to determine the specificity of neurolocalisation in practice. The
clinical significance of these results will be in the concluded value of neurolocalisation and its necessity
or lack thereof in patients with IVDH, and potentially other spinal cord injuries.

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 6. AIMS AND OBJECTIVES
The aim of this study is to investigate the usefulness of neurolocalisation in canine patients with
IVDH. The goal is to determine the value and significance of neurolocalisation in the diagnostic process,
as well as to make an evaluation regarding the significance of neurolocalisation in the choice of
treatment. The objectives are as listed, numbered according to their order of importance:
1. To determine the sensitivity of neurolocalisation in a group of 26 canine patients
diagnosed with IVDH
2. To determine the specificity of neurolocalisation in a group of 26 canine patients
diagnosed with IVDH
3. To study the correlation between neurolocalisation on clinical exam and the
diagnostic method and treatment applied in a group of 26 canine patients diagnosed with IVDH

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 7. LITERATURE REVIEW

7.1. The canine intervertebral disc

The general anatomy of the canine intervertebral disc has long been agreed upon. For the last
60 years approximately, articles and research work discussing the canine vertebrae and intervertebral
discs have showed a general consensus regarding its structure and function. King et al., 1955, Bray et
al., 1998, and later De Decker et al., 2010, Miller et al., 2013 and Dewey, 2016, all agree with Hansen
in his distinguished article from 1952[1–6]. Existing between almost all vertebral bodies, the
intervertebral disc (IVD) is an important part of the canine spinal anatomy. The canine intervertebral
disc is divided into two anatomical structures and consists of a gelatinous core known as the nucleus
pulposus, and the surrounding ring of fibrous tissue known as the anulus fibrosus. Resembling the
structure of a round cushion, the intervertebral disc provides the spinal cord and surrounding vertebrae
with protection against pressure, shock and trauma related with activity and impact. Only the
intervertebral space between C1 and C2, the atlanto-axial joint, lacks the presence of an intervertebral
disc[4]. The discs will vary in shape, size and thickness depending on their locations; the cervical discs
being circular, the thoracic more of an oval shape, and the lumbar discs typically having a bean shape
[1,7]. The cervical intervertebral discs are the thickest, reaching their thickest between the most caudal
cervical vertebrae, and gradually decreasing in thickness and size caudally throughout the spine [4].

7.2. Intervertebral disc herniation

Having been described as common and presumed to be affecting a significant portion of the
world’s canine population[2], intervertebral disc disease (IVDD) is of considerable relevance in the field
of veterinary neurology. The chondrodystrophic breeds have been reported to be particularly
predisposed to these pathologies, and the Dachshund showed a prevalence of 15,7% in a recent study
published in 2016[8].
Intervertebral disc herniation, also known as a disc prolapse or slipped disc, is one of the more
commonly represented causes of canine myelopathy and neurological dysfunction. Two main
pathologies of intervertebral disc herniation were described by Hansen in 1952[6]. These include
protrusion, in which the nucleus pulposus remains inside the anulus fibrosus and they both protrude
outward into the vertebral canal, and extrusion, in which the anulus fibrosus ruptures due to increased
pressure and only the nucleus pulposus extrude through it and into the vertebral canal. These two types
of herniations have been categorized by Hansen in 1952 as Hansen type I, or extrusion, and Hansen type
II, or protrusion[6,9]. A decade later, an addition was made to these classifications by Furnquist, who
described a subcategory of the Hansen type I. Although originally described by Furnquist and not
included in Hansen’s original classifications, it is currently known as the Hansen type III, or high

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velocity – low, volume extrusion[9]. This herniation is however most commonly seen as non-
compressive, which may explain why the Hansen type I and II are the most widely used in veterinary
neurology[5,7,8].
The clinical effects of an intervertebral disc herniation are explained by the mechanical pressure
to the spinal cord, causing neurological deficits of the spinal nerves affected. It is also believed to be
partly due to the inflammatory chemokines present as a result of the local tissue trauma[10]. However,
despite the severe clinical signs that have been related to this disease[11,12], it has also been reported in
clinically normal patients [3]. Intervertebral disc herniation could therefore be considered to be an
asymptomatic, accidental finding, as well as a symptomatic finding with clinical significance. It is
accepted as both in the field of veterinary neurology.

7.3. The canine spinal cord and its functional divisions

Lesion localisation has been a highly recognised tool in veterinary neurology for a long time
and is currently used in the diagnosis of neurological disorders. In order to accurately diagnose
neurological pathologies in dogs, lesion localisation, or neurolocalisation, is a common practice by the
veterinary neurologist. By evaluating mental status, nervous response and muscle condition, we can not
only identify whether a problem is neurological in nature, but also localise what part of the nervous
system is affected. Furthermore, by examining function and dysfunction of the spinal nerves specifically
and evaluating their neurological deficits, the differential diagnosis can be limited to a smaller area of
the spinal cord. These areas, known as spinal segment groups [4,5] or functional divisions [13], have
been defined differently by various authors.
Although there is no disagreement regarding the number of canine vertebrae and their
respective classifications [4,5,11,12], there have been some differences in the definitions of the spinal
segments. The canine spine consists of 30 consistent vertebrae, divided into 7 cervical, 13 thoracic, 7
lumbar and 3 sacral vertebrae. In addition, caudal vertebrae are found caudally to the sacral vertebrae
and will vary in number between 6 and 23 [4]. Notably, the 3 sacral vertebrae are fused.
Regarding the spinal segments, they have been categorised into four or five groups of segments,
with varying definitions depending on the author. Da Costa et al. described five groups of spinal
segments in 2010, defined as C1-C5, C6-T2, T3-L3, L4-S3 and lastly what they referred to as “Vertebrae
L6 Through L7 and Sacrum”, which effectively amounted to the Cd1-Cd5[11]. In 2016, Dewey
described five similar groups of spinal segments, the first three in agreement with the article from 2010.
However, Dewey contradicted the former definitions of the last two groups of spinal segments, defining
them instead as L4-L6 and L7-S3[5]. Later, Wininger described four groups of spinal segments defined
as C1-C5, C6-T2, T3-L3 and L4-S3[14]. This classification is perhaps the most commonly used, and
was also described previously in 2004 by LeCouteur[15]. It should be noted that the spinal segments do

11
not correspond to the anatomical division of vertebrae, and are defined by borders specific for the
segments of the spinal cord[4,5].

7.4. Diagnostic imaging – CT and MRI

Diagnostic imaging is essential in the diagnosis of intervertebral disc herniations. Although
traditional X-ray could be utilized to evaluate the distance between vertebrae and make an assumption
regarding the diagnosis, computed tomography, with or without myelography, and magnetic resonance
imaging are the diagnostic methods of choice in patients with suspected IVD herniation. Despite CT
being both more convenient and therefore more widely used due to the specific requirements of MRI
equipment, research has proven MRI to be more accurate in the diagnostic process.
In a study performed by Cooper et al. in 2013, MRI was reported to be superior to CT not only
in the diagnosis of spinal cord compression associated with IVD herniation, but also to distinguish
between protrusion and extrusion of the intervertebral disc [16]. A 10% difference in sensitivity was
reported between CT and MRI in the diagnosis of intervertebral disc herniations. MRI was also favoured
by Robertson et al. in 2011, in a study comparing CT and myelography to MRI as a diagnostic tool in
patients with suspected IVD herniations.
One of the arguments made to support their claim was that CT myelography was inferior in
patients with parenchymal lesions and circumferential reduction of the subarachnoid space, and that
these lesions would only be apparent on CT if there was either swelling of the spinal cord or introduction
of contrast medium into the spinal cord, both of which are uncommon. Their conclusion was that prior
to MRI, a large number of patients probably received unnecessary decompressive surgery due to the
uncertainty of the CT diagnosis [17]. Notably, a study was performed by Noyes et al. in 2017,
investigating the differences in surgical plans formed with MRI as a diagnostic tool compared to CT.
The results showed that in 57% of the cases, surgeons tended to plan larger laminectomy windows when
using MRI compared to CT in the same patients [18]. Therefore, although MRI is a more accurate
diagnostic tool, it may also motivate unnecessarily invasive procedures, and may even have an effect on
clinical recovery.

7.5. Treatment of canine intervertebral disc herniation

7.5.1. Conservative
There is a consensus in the field regarding conservative treatment of IVD herniation in dogs,
most authors agreeing that it relies heavily on the rest and restricted activity of the patient. The duration
of this restriction will vary depending on clinical signs and severity, but a minimum time limit of 4 to 6
weeks has been suggested [19]. The treatment will also typically include the use of analgesic medication
and anti-inflammatories such as corticosteroids or NSAIDs, along with physiotherapy [19,20].

12
 The goal of the conservative treatment is to indirectly decompress the spinal cord by decreasing
the oedema surrounding the herniated disc created by the inflammatory process following the herniation
[21]. This is usually accomplished directly by anti-inflammatories, and indirectly by decreasing the
activity level and strain on the area, thus reducing further progression of the inflammatory process. In
2018, Nessler et al. performed a study comparing the outcome in patients receiving surgical treatment
to those receiving conservative treatment, and concluded that the surgical intervention made an
insignificant impact on the recovery period. Nessler et al. agreed with Borlace et al. and described their
study from 2017 as the first study which clearly stated that surgical treatment was not superior to
conservative in regards to recovery period [20].
However, in 1983, Davies et al. made a similar conclusion, stating that surgical fenestration
offered no positive effect on the recovery rate of patients treated conservatively. Davies et al. also cited
Funkquist from 1978, suggesting that this theory was already supported by similar research 40 years
prior to the study performed by Nessler et al [22].
In regards to performance animals and canine athletes, an interesting comment was made by
Lotsikas et al. in 2020, suggesting that for these patients, conservative treatment should only be
considered in cases of very mild clinical signs, and surgery should be considered in all cases where the
patient was unable to carry its own weight [19]. Whether this was aimed at paretic patients or completely
non-ambulatory patients only is uncertain, however it does suggest a specific line separating the
conservative from the surgical patients.

7.5.2. Surgical
The surgical treatment applied in cases of IVD herniations offers two different general
techniques, the fenestration and the laminectomy, respectively. Of the two, the laminectomy is the
surgical treatment of choice, although the fenestration is still performed [20,21]. As previously
discussed, the benefits of surgical treatment in patients with less severe clinical signs are minor.
However, in paralytic and non-ambulatory patients, surgical intervention is necessary and should be
considered the only option [19,21].
Early intervention is still essential and it recovery rate has been reportedly improved if the
surgery was performed within 12 hours of losing deep pain perception [21]. Additionally, a study
performed by Jeong et al. in 2019 also reported a correlation between the postoperative
physiotherapeutic rehabilitation and the improvement of neurologic functions following surgical
decompression [23]. Particularly in the patients with a more severe clinical presentation, the
implementation of physiotherapy in the recovery process considerably improved the outcome.

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 7.6. Neurolocalisation
Neurolocalisation is the process of localising a neurological disorder to a specific area of the
nervous or muscular system by clinical diagnosis. In practice, this is done by evaluating the function and
dysfunction of different parts of the neuromuscular system, namely the cranial and spinal reflexes,
mental status and motor and sensory functions [15]. Based on the previously established knowledge of
neuroanatomy, agreed upon by authors such as LeCouteur, 2004, De Risio, 2005, Da Costa et al., 2010
and Dewey, 2016 [5,11,15,24], the results of these clinical tests will give an indication of where in the
neuromuscular system the lesion is located. Another important aspect of neurolocalisation is of course
to determine whether the lesion is located within the neuromuscular system at all [24].
The process of neurolocalisation is generally agreed upon by most recent authors, specifically
considering what clinical tests should be performed and what aspect of the neuromuscular system they
evaluate. However, the value of certain reflexes in clinical examination has been discussed by some
authors such as Levine et al. Their research from 2002 evaluated the influence of age on the patellar
tendon reflex and concluded that older dogs, although neurologically normal, showed a decrease in the
patellar tendon reflex [25]. Similarly, Gutierrez-Quintana et al., 2012, evaluated the accuracy of the
cutaneous trunci reflex. Their findings indicated that the results of clinical evaluation of the cutaneous
trunci reflex can be used to identify a spinal cord lesion with a margin of 4 vertebrae [26]. Although this
is impressively accurate for a clinical examination, the functional divisions of the spine are separated by
adjacent borders of the spinal segments [5]. Therefore, a margin of error of 4 vertebrae can theoretically
be enough to cause a mistake in neurolocalisation. As suggested by these authors, some parts of
neurolocalisation may not be completely reliable.
Within the general neurolocation of the spinal cord, neurolocalisation also distinguish between
the functional divisions mentioned in Chapter 6.3. There is a general consensus among authors regarding
the neurolocalisation within the spinal cord, and most authors will separate them based on Upper Motor
Neuron (UMN) and Lower Motor Neuron (LMN) deficits [5,13–15,24]. In a clinical examination, UMN
deficits will present as paresis or paralysis, with normal or increased muscle tone and reflexes, and only
mild muscle atrophy. Comparably, LMN deficits will also present as paresis or paralysis, but with
reduced or completely absent reflexes, reduced muscle tone and severe muscle atrophy [5]. Applying
this to the neurolocalisation of spinal cord lesions, the general consensus is that lesions within the
functional division C1-C5 will show UMN deficits in both the thoracic and pelvic limbs, while lesions
within C6-T2 will show LMN deficits in the thoracic limbs Table 1: Functional divisions of the
spine and their neurological deficits
and UMN deficits in the pelvic limbs. Lesions located Thoracic limb Pelvic limb
within T3-L3 will show no deficits in the thoracic limbs, C1-C5 UMN UMN
C6-T2 UMN LMN
while presenting as UMN deficits in the pelvic limbs.
T3-L3 Normal UMN
Lastly, lesions located within L4-S3 will present as L4-S3 Normal LMN

14
normal thoracic limbs and LMN deficits in the pelvic limbs [5,13,14,24]. The functional divisions and
their corresponding neuron deficits are presented in Table 1.

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 8. METHODOLOGY

8.1. Neurological theory

The canine neurological system consists of the central nervous system (CNS) and the peripheral
nervous system (PNS). Neurological disorders can be classified into three main groups of spinal
disorders, brain disorders and peripheral nervous system disorders, where the former two are located
within the CNS. The latter can be further divided into nerve root disorders, neuromuscular disorders and
synapse disorders. A basic classification of canine neurological disorders is presented in Figure 1,
collected from Johansen, 2020 [27].

CENTRAL PERIPHERAL
NERVOUS SYSTEM NERVOUS SYSTEM

SPINAL CORD PNS DISORDERS

BRAIN
B DISORDERS DISORDERS

NEUROMUSCULAR SYNAPSE NERVE ROOT

BRAIN STEM FOREBRAIN CEREBELLUM DISORDERS DISORDERS DISORDERS

CRANIAL NERVE SPINAL NERVE

DISORDERS DISORDERS

Fig. 1: A basic classification of canine neurological disorders

[Johansen LMA, Myasthenia Gravis in dogs – clinical signs, diagnosis and treatment of canine neurological
muscle weakness, 2020]

In practice, neurolocalisation is used to as a tool of clinical diagnosis to differentiate between

these parts of the neuromuscular system. The common aspects of neurological examination and their
corresponding evaluated parts of the neuromuscular system is presented in Figure 2. Because the suitable
diagnostic method will change depending on where the lesion is localised, neurolocalisation is also used
as an indication of how to further process the patient. In patients with suspected spinal cord disorders,
both CT and MRI are suitable diagnostic methods, despite research favouring one over another, as
mentioned in Chapter 7.4. A list of the parts of the neuromuscular system and their corresponding
diagnostic methods is presented in Figure 3.

16
 CONSCIOUSNESS BEHAVIOR POSTURE GAIT
•Brain •Brain •Brain •Brain
•Spinal cord •Spinal cord
•Neuromuscular •Neuromuscular
•Synapse
•Nerve root

POSTURAL SENSORY
CRANIAL NERVE EVALUATION
REACTIONS SPINAL REFLEXES REFLEXES
•Brain •Brain
•Spinal cord •Spinal cord •Spinal cord •Spinal cord
•Neuromuscular •Neuromuscular •Neuromuscular •Neuromuscular
•Synapse •Synapse •Synapse •Synapse
•Nerve root •Nerve root •Nerve root •Nerve root

Fig. 2: A basic classification of canine neurological disorders

[Johansen LMA, Myasthenia Gravis in dogs – clinical signs, diagnosis and treatment of canine neurological
muscle weakness, 2020]

Incorporating these theories into practice, neurolocalisation was used in the patients of this
study to indicate the specific functional
division of the spinal cord in which the
BRAIN SPINAL CORD PNS
lesion was located. This was performed by
MRI MRI Blood work
veterinary neurologists at the clinic where
CT CT EMG
the research material was collected.
Neurolocalisation may also EEG X-ray ENG

indicate a treatment plan and expected CSF Myelography MRI

prognosis early in the diagnostic process. CSF CSF

This study will therefore evaluate the Biopsy

usefulness of neurolocalisation in canine
patients with IVDH by comparing
occurrence of and Fig. 3: A basic classification of canine neurological disorders
neurolocalisation
[Johansen LMA, Myasthenia Gravis in dogs – clinical signs,
neurolocations to the diagnostic methods diagnosis and treatment of canine neurological muscle
and choice of treatment in 26 canine weakness, 2020]
patients with diagnosed intervertebral disc
herniation.

17
 8.2. Collection of research material
This is a retrospective study in which the patient histories of 26 canine patients were collected
from the patient records of Fredrikstad Dyrehospital veterinary animal hospital in Norway between
January and December 2020. All patients had been diagnosed with intervertebral disc herniation between
01.01.2019 and 01.01.2020 and had been examined with diagnostic imaging, which was either computed
tomography (CT) or magnetic resonance imaging (MRI). The patients were categorised by age, breed,
gender and Body Condition Score (BCS), presence or absence of neurolocalisation on initial clinical
examination, diagnostic tool (CT/MRI), treatment type (conservative/surgical) and the location of the
diagnosed herniation on diagnostic imaging. The latter was defined based on the anatomical
intervertebral space and not the spinal segment affected.

8.3. Classification of data

The dogs were divided into two groups of Neurolocalised (NL) patients and Non-neurolocalised
patients (NNL) based on the information from the neurological examination collected from the patient
records. The neurolocalised patients were further categorised into four groups based on their
neurolocations. These groups were defined using the functional divisions of the canine spine established
by Richard A. LeCouteur in his lecture Localization of spinal cord lesions from 2004[15]. The
neurolocations were defined as spinal segments C1-C5, C6-T2, T3-L3 and L4-S3, the last group also
including the five cauda equina spinal segments and their corresponding nerve roots. The individual
spinal segments were defined using the spinal segment borders described by Dewey in Practical guide
to Canine and Feline Neurology from 2016[5].
Both groups NL and NNL were also categorised based on the exact location(s) of their
diagnosed herniation(s) on diagnostic imaging. It should be noted that some patients had multiple
diagnosed intervertebral disc herniations. In the NL group, these results were used to further divide the
patients into two groups of Matching (M) and Non-Matching (NM), based on whether the location of
the herniation was within the spinal segment borders of the neurolocation given on neurological
examination. In the NNL group, the results were used to divide them into four groups of functional
divisions corresponding to the neurolocations used in the NL group. These artificial neurolocalisations
of the NNL patients were used to evaluate which functional divisions most frequently presented without
clinical signs sufficient for a neurolocalisation.

8.4. Calculations and data analysis

Further, the correlation between the neurolocalisation on clinical examination, the diagnosed
herniation location on diagnostic imaging and the choice of treatment was evaluated using a p value
calculated by the Chi square formula of independence, defined as

18
 (𝑂 − 𝐸)!
𝑝 = $
𝐸
where
p = Chi square value
O = observed values
E = Expected values
Statistical dependence between two groups was defined as p > 0,05.
The sensitivity of the neurolocalisation process was defined as

𝑇𝑃
𝑆𝑒𝑛𝑠𝑖𝑡𝑖𝑣𝑖𝑡𝑦 = 100
(𝑇𝑃 + 𝐹𝑁)

The specificity of the neurolocalisation process was defined as

𝑇𝑁
𝑆𝑝𝑒𝑐𝑖𝑓𝑖𝑐𝑖𝑡𝑦 = 100
(𝑇𝑁 + 𝐹𝑃)

where
TP = true positives
TN = true negatives
FP = false positives
FN = false negatives
It should be noted that out of all the patients in the studied group, only one patient had
herniations located within two different functional divisions, whereas the rest had herniations located in
only one functional division of the spinal cord.
The margin of error was calculated using the formula
𝑠
𝑀 = 𝑡
√𝑛
where
M = margin of error
t = critical value (in this study, with a confidence interval of 95%, t = 1,96)
s = standard deviation

19
 9. RESULTS

9.1. Occurrence of neurolocations and the sensitivity of neurolocalisation

Out of 26 patients, only 46,2% ± 0.19 (=12 patients) were neurolocalised on clinical
examination. Of these NL patients, 75% (=9 patients) were neurolocalised as a T3-L3 spinal cord deficit.
Only 8,3% (=1 patient) was neurolocalised as a C1-C5 deficit, while the remaining 16,7% (=2 patients)
were neurolocalised as L3-S4 spinal cord deficits. No NL patients were neurolocalised as C6-T2 spinal
cord deficits. The occurrence of neurolocations in the NL group is presented in Figure 4.

C1-C5 T3-L3 L4-S3

10
9
9
8
7
Patients

6
5
4
3
2
2
1
1
0
Neurolocation
Fig. 4: Occurrence of neurolocations in neurolocalised patients
Of the 12 neurolocalised patients, no patients had more than one neurolocation on clinical exam.
Of the 12 neurolocations given on clinical
examination, 11 proved to be correct (M) Not neurolocalised Matched Not matched

and 1 proved to be incorrect (NM) when 3,8%

compared to the exact location of the 1
42,3%
herniation found on diagnostic imaging.
These results are presented in Figure 5.
Artificial neurolocations were
11
14
given to each of the 14 patients with no
neurolocation on clinical examination.
These added up to 15 neurolocations, as one 53,8%

of the patients had herniations within the

spinal segment borders of two functional Fig. 5: The occurrence of correctly and
incorrectly neurolocalised patients
divisions. Adding these neurolocations to
20
those of the 12 neurolocalised patients, a total of 27 potential positive neurolocalisations were possible.
Of these 27, 40,7% (=11 neurolocations) were diagnosed correctly, as presented in Figure 5. The
sensitivity of neurolocalisation in this study, defined as the percentage of true positive occurrences, was
40,7% ± 0.11.

9.2. Occurrence of non-neurolocalised patients and the specificity of neurolocalisation

Out of 26 patients, 53,8% ± 0.19 (=14 patients) were not neurolocalised on clinical examination.
Some of these patients may have presented with neurological deficits, however these were insufficient
for neurolocalisation. Each of the patients in the NNL group were given an artificial neurolocation based
on the exact location(s) of their diagnosed herniation(s) and the spinal segment borders of the functional
divisions of the spine. In one of the NNL patients, this corresponded to two functional divisions. In the
rest, it corresponded to a single functional division. The frequency of each functional division in the
NNL group is presented in Figure 6.

C1-C5 C6-T2 T3-L3 L4-S3

8
7
7

6
5
Patients

3
2
2
1
1

0
Functional division
Fig. 6: Occurrence of functional divisions in non-neurolocalised patients
With 26 patients and four possible neurolocations, 104 possible neurolocations could be
neurolocalised. Only one patient showed herniations in two different functional divisions on diagnostic
imaging. Therefore, out of those 104 neurolocations, 27 neurolocations were potential positives. The
remaining 77 neurolocations were potential negatives. These numbers are presented in Table 2.
Out of those 77 potential negatives, 41 negatives were correctly non-neurolocalised in the NNL
group. One neurolocation was incorrectly non-neurolocalised in the NL group, which was the
neurolocation of the Non-Matched patient. 35 neurolocations were correctly non-neurolocalised in the
NL group. 76 true negatives out of 77 potential negatives were diagnosed using neurolocalisation. The

21
specificity of neurolocalisation, defined as the percentage of true negative occurrences, in this study was
98,7% ± 0.025. The specificity and sensitivity is presented in Figure 7.

Table 2: The occurrence of positive and negative results in the statistical analysis of 26 canine
patients with intervertebral disc herniation
Positive Negative Total
False 16 1 17
True 11 76 87
Total 27 77 104

Specificity Sensitivity
True negative False positive True positive False negative
1,3%

40,7%

59,3%

98,7%

Fig. 7: Sensitivity and specificity of neurolocalisation in 26 canine patients with intervertebral disc
herniation

9.3. The correlation between neurolocalisation, diagnostic method and treatment

In order to properly statistically evaluate the correlation between neurolocalisation and the
choice of diagnostic method and treatment, the Chi square formula of independence was used as
previously mentioned in Chapter 7, page 13. In the case of diagnostic methods, only diagnostic imaging
was evaluated. This was either CT or MRI. In one case, both CT and MRI was used. The calculated
frequencies of CT and MRI in the neurolocalised versus non-neurolocalised patients showed that 100%
of the patients examined with only MRI were neurolocalised patients. The one patient which was
examined with both CT and MRI was a non-neurolocalised patient. Of the 14 non-neurolocalised
patients, CT based diagnosis was performed in 92,8%, while it only accounted for 75% of the 12
neurolocalised patients.

22
 The distribution of CT between the two groups was 40,9% and 59,1% in the NL and NNL
group, respectively. The Chi Square test p value indicated no significant correlation between the
neurolocalisation and the diagnostic method used, with p > 0.05 (p = 0,1).
In regards to treatment, the statistical analysis showed that 100% of the patients which
received conservative treatment, as well as 100% of the euthanized patients, were in the Non-
neurolocalised group. In accordance with this, the analysis showed 100% of the patients in the
Neurolocalised group were treated surgically. Nevertheless, the distribution of surgical treatment
between the two groups was notably balanced, and was calculated at 47.8% and 52.2% in the Non-
neurolocalised and Neurolocalised group, respectively. In the matter of correlation of between
neurolocalisation and choice of treatment, the p value of the Chi Square test again indicated no
significant correlation, with p > 0.05 (p = 0,2).

23
 10. DISCUSSION OF RESULTS

Although the Chi Square test of independence showed no significant correlation between
neurolocalisation and diagnostic method, it should be noted that due to the small sample size, further
investigations should be performed with a larger sample size before a final conclusion is made. Most
notably, the results of this study showed a tendency to rely solely on MRI for the diagnostic imaging in
cases with neurolocalised patients. Taking into consideration the results found in the research performed
by Noyes et al. in 2017 [18], this may indicate that neurolocalised patients typically receive more
extensive surgeries.
In addition, although only one such case was seen in this study, the results suggest that
neurolocalisation will eliminate the need to use both CT and MRI. The authors are however reluctant to
make this conclusion based on this study alone, due to a limiting occurrence in the sample population.
When discussing the results of the correlation between neurolocalisation and treatment, it
should be noted that despite the lack of neurolocalisation, all dogs in this study were examined using
diagnostic imaging and the exact locations of intervertebral disc herniations were found. Therefore,
although the results show a tendency to prefer conservative treatment or euthanasia in Non-
neurolocalised patients only, this should not be due to a lack of diagnostic information. However, other
factors such as owner’s wishes or the severity of clinical signs may be the explanation. These factors
were not considered in this study.
The results showed no indication of a significant correlation between neurolocalisation and
treatment method in this study, however as previously mentioned the authors recommend further
investigations using a larger sample size for a more accurate evaluation. Comparing this to the results of
Borlace et al, 2017 and Nessler et al., 2018 [20,28], the difference in recovery between patients treated
surgically and those treated conservatively is inconsiderable in most patients, regardless of lesion
location. Consequently, lesion location and therefore neurolocalisation may not be significant when
deciding the treatment method in patients with IVDH.
However, Davies et al., 1983, investigated the outcome in patients with thoracolumbar
intervertebral disc disease and found that recovery depended more on the severity of clinical signs than
on the treatment method [22]. Although only thoracolumbar herniations were included in their research,
when comparing their results to the ones found in this study, this may suggest that the severity of clinical
signs has a more significant impact on diagnosis and treatment than the location of the lesion.
Consequently, a grading system of clinical severity, such as the one used by Davies et al. [22], may be
more valuable than neurolocalisation in patients with IVDH.
The sensitivity and specificity of neurolocalisation in dogs with IVD herniations were both
evaluated in this study. The results of the specificity were extremely positive at 98.7%, suggesting a

24
highly reliable positive neurolocalisation result. However, the sensitivity was notably low at 40.7%. In
practice, this would mean that over half of the cases with a spinal cord injury arising from IVD herniation
would not be neurolocalised on a clinical exam. This could potentially be true in cases of other spinal
cord injuries as well, such as vertebral fractures. Consequently, it raises the question of whether the
process of neurolocalisation of individual functional divisions of the spinal cord is useful in a clinical
situation, or if it would be more beneficial to simply categorize these patients as spinal cord disorders.
Notably, other authors have also previously reported a lack of reliability in certain aspects of the
neurological examination, namely the patellar tendon reflex [25], the cutaneous trunci reflex [26] and
the withdrawal reflex [29].
The effect of neurolocalisation on the diagnostic method and treatment of IVD herniations in
this study has proven to be insignificant. Ignoring the potential economic benefit of minimizing the area
of interest on diagnostic imaging, the results of this study suggest a lack of value in categorizing patients
with spinal cord injuries based on the spinal segments affected. More importantly, however, the results
of this study suggest great room for improvement in the neurolocalisation of spinal cord injuries.
Comparing these results to the reports of the other authors mentioned, the indication is that the diagnostic
value of neurolocalisation may be secondary to a grading system of the severity of clinical signs.

25
 11. CONCLUSIONS

This study aimed to investigate the usefulness of neurolocalisation in canine patients with
intervertebral disc disease. The conclusions of this study are as follows, in no particular order of
importance:
1. The sensitivity of the neurolocalisation process in dogs with intervertebral disc
herniations is low. A negative neurolocalisation should therefore not be trusted as a negative
diagnosis of intervertebral disc disease. This could potentially be applicable in cases involving
other spinal cord disorders as well.
2. The specificity of the neurolocalisation process in dogs with intervertebral disc
herniations is notably high and a positive neurolocalisation on clinical examination strongly
suggests a positive diagnosis of intervertebral disc disease. As with the sensitivity, the
conclusions regarding specificity could be applicable in cases involving other spinal cord
disorders as well.
3. There is no evidence suggesting a correlation between a positive neurolocalisation
and the choice of diagnostic method and treatment. This suggests the neurolocalisation process
which is practiced today, although able to correctly diagnose approximately 40% of IVD
herniation locations, does not have any significant impact on the diagnostic process and treatment
scheme.

26
 12. ACKNOWLEDGEMENTS

I would like to express my gratitude to all the people supporting me during this work. I would
like to devote a special thanks to Fredrikstad Dyrehospital veterinary animal hospital and their team
for their contribution to this work.

27
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Anim Vet Assoc World Congr Proc. 2013;VetLearn, New Zealand Veterinary Association, Massey

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University, Palmerston North, New Zealand.
14. Wininger F. Neurolocalization Basics and “The Gait Game”. Presentation lecture presented at;
2017; Fetch DVM360 Conference.
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Association World Congress Proceedings, 2004; 2004.
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computed tomography and magnetic resonance imaging for detection and characterization of
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resonance imaging versus computed tomography to plan hemilaminectomies in chondrodystrophic
dogs with intervertebral disc extrusion. Vet Surg. 2017 Oct;46(7):1025–31.
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conservative treatment of hydrated nucleus pulposus extrusion in dogs. J Vet Intern Med. 2018
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thoracolumbar intervertebral disc disease in the dog. J Small Anim Pract. 1983 Dec;24(12):721–9.
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 14. ANNEXES

Annex 1: List of the 26 canine patients included in the study

Neurolocation Diagnostic Treatment Gender Breed Age Diagnose
code method code
NL01 CT Surgical Male Mixed breed 7 DL02
NL03 CT Surgical Female Mixed breed 10 DL03
NL03 CT Surgical Female Mixed breed 6 DL03
NL03 CT Surgical Female Dachshund 9 DL03
NL03 CT Surgical Male Dachshund 11 DL03
NL03 CT Surgical Male Dachshund 8 DL03
NL03 MRI Surgical Male Dachshund 8 DL03
NL03 MRI Surgical Female Mixed breed 3 DL03
NL03 MRI Surgical Male Dachshund 15 DL03
NL03 CT Surgical Male Dachshund 5 DL03
NL04 CT Surgical Female French Bulldog 5 DL04
NL04 CT Surgical Female Gordon Setter 6 DL04
NEG CT Surgical Female Japanese Spitz 11 DL01
NEG CT Surgical Danish-Swedish farm 5 DL01
dog
NEG CT, MRI Surgical Male Rottweiler 5 DL02
NEG CT Conservative Male Löwchen 8 DL03
NEG CT Surgical Female Coton de Tulear 7 DL03
NEG CT Surgical Female Miniature Dachshund 4 DL03
NEG CT Euthanasia Female Dachshund 4 DL03
NEG CT Surgical Female Miniature Dachshund 8 DL03
NEG CT Surgical Male Dachshund 3 DL03
NEG CT Conservative Female Cocker Spaniel 5 DL03,
DL04
NEG CT Surgical Male Mixed breed 5 DL04
NEG CT Surgical Male Jack Russel Terrier 6 DL04
NEG CT Surgical Male Mixed breed 6 DL04
NEG CT Surgical Female Parson Russel Terrier 8 DL04

Explanations:
Neurolocation code: Diagnose code:
NL01 = C1 – C5 DL01 = C1 – C5
NL02 = C6 – T2 DL02 = C6 – T2
NL03 = T3 – L3 DL03 = T3 – L3
NL04 = L4 – S3 DL04 = L4 – S3
NEG = Not neurolocalised

31