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Diagnosis of Lateralized Lumbosacral Disk Herniation with Magnetic Resonance Imaging

A left-lateralized, lumbosacral intervertebral disk herniation, which was not apparent on epidurography, was diagnosed in a dog with magnetic resonance imaging. Precise, preoperative localization and characterization of the lesion allowed surgical approach and excision with minimum disruption of surrounding tissues.
J Am Anim Hosp Assoc 1997;33:2969.

Jonathan N. Chambers, DVM Barbara A. Selcer, DVM Stacey A. Sullivan, DVM Joan R. Coates, DVM, MS

Introduction
The use of continuously improved spinal imaging techniques has allowed more precision in the preoperative localization and characterization of surgical lesions. The once ritualistic and often excessive exploratory surgery to confirm the presence, nature, and extent of a lesion rarely is necessary, and thus treatment successes have increased and morbidity has decreased as patients have benefited from less normal tissue disruption. 1 Epidurography has proven to be a sensitive test for the typical, ventral midline, lumbosacral degenerative disk herniations seen in large-breed dogs. 2 When combined with a consistent history, physical signs, and electromyogram, the positive epidurogram usually is sufficient to make a decision regarding the indication for surgery. Additional corroborative imaging procedures are indicated only if the diagnosis is equivocal or if further information may alter the treatment plan. 3,4 Magnetic resonance imaging (MRI) and computed tomography (CT) have revolutionized the characterization and management of lumbosacral disease in humans. The appearances of the normal and the degenerated lumbosacral spines of dogs using these techniques have been described recently. 47 Reported here is a case where imaging beyond epidurography was required for presurgical localization and distinction.

Case Report
A six-year-old, female Labrador retriever was admitted to the University of Georgia Veterinary Teaching Hospital with a history of a spontaneously appearing dysfunction of the left pelvic limb that had been progressive over five weeks. The problem first was noted as a reluctance and then a refusal to jump. The dog would use the affected limb with a noticeable limp while walking and running, but would hold the paw slightly off the ground when standing. The owner believed that the limb lacked normal strength and coordination and that the dog occasionally exhibited pain when touched in the pelvic region. Upon physical examination, the off-weight bearing standing posture of the left pelvic limb was as the owner had described. The walking gait was abnormal with deficient hock flexion during the swing phase of the limb. The withdrawal reflex was weak and was predominantly stifle flexion without hock flexion. The cranial tibial reflex was markedly weaker compared to the opposite side, but the quadriceps reflex was normal. There was moderate, generalized atrophy in the limb, including the muscles surrounding the hip. HyperesJOURNAL of the American Animal Hospital Association

From the Departments of Small Animal Medicine (Chambers, Sullivan, Coates) and Anatomy and Radiology (Selcer), College of Veterinary Medicine, The University of Georgia, Athens, Georgia 30602.

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Figure 1D Lateral view of the lumbosacral (L-S) epidurogram made with pelvic extension. No abnormalities are noted. Figure 1A Lateral radiograph of the lumbosacral (L-S) junction demonstrating sclerosis and smooth-to-irregular remodeling of the cranial endplate of the sacrum. Partial bridging spondylosis deformans is seen ventrally.

Figure 1E Dorsoventral view of the lumbosacral (L-S) epidurogram. There is slight narrowing of the epidural space over the L-S junction (arrow).

Figure 1B Lateral view of the lumbosacral (L-S) epidurogram made with the L-S spine in neutral position. No definitive compressive lesion is noted.

Figure 1C Lateral view of the lumbosacral (L-S) epidurogram made with pelvic flexion. No abnormalities are noted.

thesia was noted when pressure was applied over the lumbosacral junction. The remainder of the physical examination was normal. A tentative diagnosis of a predominately left-sided, seventh lumbar (L 7) to first sciatic (S 1) nerve root lesion was made. Routine laboratory tests including a complete blood count (CBC), serum chemistry profile, and urinalysis were normal. The dog was placed under general anesthesia for electrodiagnostics and an epidurogram. Abnormal spontaneous activity was identified with electromyography, predominantly in the muscles innervated by the left sciatic nerve (i.e., interosseous, gastrocnemius, cranial tibial, and biceps femoris muscles) and the muscles of the proximal tail. Other electrodiagnostic tests consisting of tibial nerve conduction velocity and repetitive nerve stimulation were normal. A lateral survey radiograph [Figure 1A] was obtained prior to the epidurography. Epidurographic views included neutral, flexed and extended laterals, and dorsoventral [Figures 1B1E]. The radiographic study was considered inconclusive.

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Figure 2A T1 b -weighted sagittal image of the lumbosacral (L-S) junction. The image plane is through the left intervertebral foramen. A hypointense (i.e., dark) signal mass is present within the foramen, obscuring the normal, uniform, hyperintense (i.e., bright white) signal from the epidural fat.

Figure 2B T1 b -weighted axial image of the lumbosacral (L-S) junction at the level of the exiting nerve roots. The normally present hyperintense (i.e., white) signal from the epidural fat surrounding the nerve roots exiting the left intervertebral foramen is not visualized (L=left; R=right).

Figure 2C T1 b -weighted dorsal plane image of the lumbosacral (L-S) junction. The normally present hyperintense (i.e., white) epidural fat surrounding the exiting nerve roots is not seen on the left side. Instead, a hypointense (i.e., dark) mass effect is present along the cranial margin of the sacrum, possibly protruding into the left intervertebral foramen and vertebral canal (arrow) (R=right; L=left).

The dog was reanesthetized one week later for MRI of the lumbosacral spine using a 0.5 Telsa superconducting scanner. a Slices (3-mm thick) were obtained with the dog in sternal recumbency with the pelvic limbs extended. T1 b -weighted images (repetition time [TR], 550 to 750 msec; echo delay time [TE], 25 msec) were obtained in sagittal [Figure 2A], axial [Figure 2B], and dorsal [Figure 2C] planes. Changes identified on the MRI study included loss of the normal T1 hypointense (i.e., uniform black) signal from the intervertebral disk at L 7 -S 1 and the presence of a left-sided, hypointense signal mass obscuring the normally hyperintense (i.e., bright white) signal from the fat-filled intervertebral foramen at L 7-S 1 [Figure 2A]. The exiting nerve roots on the left side of the intervertebral foramen at L 7-S 1 were visualized poorly [Figure 2B]. Possible new bone formation or mineralized disk material was iden-

tified at the level of the left L 7-S 1 intervertebral canal [Figure 2C]. The lesion was approached surgically from the dorsal aspect, which included excision of the interarcuate ligament, limited midline laminectomy of L 7 and S 1 , and near total left facetectomy. A spherical mass (5 mm in diameter) protruded from the disk space into the left L 7-S 1 intervertebral foramen. The mass consisted of a combination of herniated intervertebral disk material and a large osteophyte from the margin of the L 7 vertebral body. The L 7 nerve root was compressed between the herniated disk and the L 7 pedicle, and it was swollen. The compressive mass was excised with rongeurs, curettes, and a pneumatic burr. The dog recovered uneventfully, showed progressive improvement in limb function, and was without pain for the subsequent six months, at which time she was readmitted for a left hemiparesis that subsequently proved to be caused by an intradural nervesheath tumor located at the first-to-second cervical region. Electromyography at that time revealed persisting, abnormal spontaneous activity in the left

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interosseous and proximal tail muscles, but no abnormal activity in the other previously affected muscles.

MR MAX; General Electric, Milwaukee, WI Transverse plane to longitudinal plane proton relaxation time

Discussion
Magnetic resonance imaging and CT have specific roles of delineating lateralized lesions in dogs with compressive lumbosacral disease. 4,6 An entirely presumptive diagnosis of lateralized disk herniation could have been made in this case based on the history, neurological signs, and electromyography, and the definitive diagnosis could have been made at exploratory surgery; but an epidural versus extraspinal plexus lesion could not be ruled out preoperatively. Similar signs could have been caused by a foreign body reaction, penetrating injury, abscess, or neoplasm. 8 An extraspinal lesion most likely would be poorly detected, characterized, and managed via a dorsal midline surgical approach. The MRI allowed characterization and precise localization of the lesion such that a good prognosis could be offered, and the operation was individualized to address only the specific problem, with resultant reduction in surgical trauma. 1

References
1. Long DM. Laminotomy for lumbar disc disease. In: Watkins RG, Collis JS, eds. Lumbar discectomy and laminectomy. Rockville, MD: Aspen Publishers, 1987:1737. Selcer BA, Chambers JN, Schwensen K, Mahaffey MB. Epidurography as a diagnostic aid in canine lumbosacral compressive disease: 47 cases (19811986). Vet Comp Orthop Trauma 1988;2:97103. Watkins RG. Clinical application of diagnostic evaluation. In: Watkins RG, Collis JS, eds. Lumbar discectomy and laminectomy. Rockville, MD: Aspen Publishers, 1987:13941. Chambers JN, Selcer BA, Butler TW, Oliver JE, Brown J. A comparison of computed tomography to epidurography for the diagnosis of suspected compressive lesions at the lumbosacral junction in dogs. Progress Vet Neuro 1994;5:304. Jones JC, Wright JC, Bartels JE. Computed tomographic morphometry of the lumbosacral spine of dogs. Am J Vet Res 1995;56:112532. Adams WH, Daniel GB, Pardo AD, Selcer R. Magnetic resonance imaging of the caudal lumbar and lumbosacral spine in 13 dogs (1990 1993). Vet Radiol 1995;36:313. Karkkainen M, Punto LU, Tulamo R. Magnetic resonance imaging of canine lumbar spine diseases. Vet Radiol 1993;34:399404. Shires P (commentary). Lateral intervertebral disk extrusion causing lameness in a dog. J Am Vet Med Assoc 1994;205:183.

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