101 | Everything you need to know about caring for spinal patients as a veterinary nurse (ft Zoe Hatfield, VTS-Neurology)
There’s a lot to think about when it comes to caring for spinal patients as a veterinary nurse or technician.
But luckily, we’ve got a guest with us today to guide us through it!
Today I’m delighted to be joined once again by Zoe Hatfield who is bringing us her expertise on nursing neuro patients! Zoe is a neurology RVN and a Veterinary Technician Specialist in neurology, working at Glasgow University’s Small Animal Hospital.
And today she’s shedding light on one of the most common neurological problems we encounter in practice, and arguably one of the diseases we can make the biggest difference in as nurses and technicians, and that’s nursing patients with intervertebral disc disease, or IVDD.
If you want to know how to care for these patients confidently and use more of your skills when doing so, Zoe’s spending this episode giving you all the knowledge, tips and tricks you need.
So Zoe, perhaps you could start us off with what IVDD is, and how it impacts our patients.
Intervertebral disc disease is an umbrella term used to describe several different spinal conditions. Understanding the different classifications of intervertebral disc disease (IVDD) makes it easier to understand why some patients need surgery, while others can be managed conservatively.
Before we look at what IVDD is, we need to take a brief trip back to A&P…
As we briefly mentioned in episode 98, our neuroanatomy episode, there is an intervertebral disc between each vertebral space from C2-C3 caudally to L7-S1. The purpose of the intervertebral discs is to act as shock absorbers which take the force of daily activities off the vertebral column and offer stability to the spine.
The disc is composed of two parts; the gelatinous nucleus pulposus (which has a high-water content of 88% and is the central portion of the disc) and the annulus fibrosis (this contains collagen and is tougher, it is the outer part of the disc).
So what happens when a patient has IVDD?
There are several distinct causes of IVDD, including disc herniation due to degeneration, and different types of disc extrusion.
Intervertebral Degeneration
Intervertebral disc degeneration is the most common reason for herniation. It is effectively an aging process, which is influenced by genetics. Intervertebral disc disease can be exacerbated by biomechanical strain on the spine as well as trauma.
Intervertebral Disc Extrusion - Hansen Type I
Intervertebral disc extrusion (IVDE) is the most common cause of spinal cord injury in dogs; it occurs due to chondroid metaplasia and calcification of the disc material.
There is a high prevalence of this occurring amongst French Bulldogs and Dachshunds, as these patients have an early onset of progressive dehydration and calcification in their discs.
Because of this, IVDD is seen commonly in chondrodystrophic breeds, and in young-to-middle-aged patients.
This condition is often painful, and some patients can even present with pain being their only clinical sign.
Treatment often depends on the severity of clinical signs. Patients with pain (that is responsive to analgesia), ataxia or ambulatory paraparesis may be managed conservatively, and only being operated on if symptoms worsen.
Most non-ambulatory paraparetic/paraplegic patients will likely have surgery; however, the evidence shows unless deep pain perception is negative the outcomes between conservative treatment and surgery are similar. This is important to note especially in times of financial hardship.
Intervertebral Disc Extrusion with Extensive Haemorrhage
Disc extrusion with extensive haemorrhage is another form of disc herniation which occurs due to degenerative changes.
While the calcified nuclear material is extruded into the vertebral canal, in some cases this can cause a laceration to occur in the internal vertebral venous plexus. This in turn causes haemorrhage and the possible haematoma to develop.
These patients appear to progress neurologically rapidly, often quickly becoming paraparetic to plegic, and because of this, patients will usually have surgery as soon as possible to avoid further deterioration.
These patients should be closely monitored for the development of myelomalacia post-operatively.
What is myelomalacia?
Progressive myelomalacia (PMM), also called ascending-descending myelomalacia, is a fatal disease characterized by progressive ascending and descending necrosis of the spinal cord after an acute intervertebral disc extrusion (IVDE).
Onset for the majority of dogs who develop myelomalacia is usually within 2 days of presentation and these patients are usually euthanised within another 3 days. However, onset can be delayed up to 5 days after presentation with progression to euthanasia taking as long as 2 weeks. Mid‐to‐caudal lumbar discs might be associated with an increased risk of PMM.
The clinical signs indicative of PMM reflect the involvement of extensive regions of the spinal cord gray matter, producing coincidental lower motor neuron signs in the pelvic limbs (such as lower tone) and cranial advancement of the cutaneous trunci reflex (used as an indicator for the level of the lesion).
As the disease progresses, loss of anal and abdominal tone, paralysis of the thoracic limbs and of the respiratory muscles develops. Most dogs are humanely euthanized before respiratory failure results in their death.
PMM occurs in approximately 11 to 17.5% of dogs presenting paraplegic with loss of pain perception in pelvic limbs and tail following IVDE. There is some evidence that this number may differ between breeds, with the rate of occurrence reported to be as high as 33% in French Bulldogs with paraplegia and loss of pain perception.
Nursing care for patients that are at risk of PMM should include regular pain scoring (patients may be in profound pain – analgesia will usually not help in these cases).
Patients can become hyperthermic with PMM, so regular temperature checks should be carried out. As the disease progresses respiratory muscles are affected so respiration requires careful monitoring -rate and effort should both be checked frequently.
Intervertebral Disc Protrusion - Hansen Type II
Hansen type II disc protrusion typically affects older (>7 years), non-chondrodystrophic breeds.
It occurs because the collagen content in the disc increases in a process known as fibroid metaplasia, which leads to the thickening of the annulus – and over time protrusion into the spinal canal. These patients will often have multiple protrusions.
If the patient is ambulatory, physiotherapy or hydrotherapy along with gentle exercise (to ensure the muscles can support the spine appropriately), may be enough.
However, if the patient is non-ambulatory, then surgery is the treatment of choice. As multiple protrusions are typically present, the surgeon will often decide which disc(s) are causing the most compression and operate only on those protrusions.
Hydrated Nucleus Pulposus Extrusion (HNPE)
Hydrated nucleus pulposus extrusion or HPNE is a condition where partially- or non-degenerate nucleus pulposus material enters the spinal canal, causing varying degrees of spinal cord compression or bruising.
This condition is typically, non-painful, however most cases occur within the cervical spine meaning patients often present being tetraplegic.
This means that respiratory compromise is common in these cases. Where this is the case, patients may require ventilation support and tend to need surgery due to those respiratory symptoms.
If there is no respiratory compromise present, conservative treatment with a good physiotherapy regime is often a viable treatment option.
Acute Non-compressive Nucleus Pulposus Extrusion (ANNPE)
Acute non-compressive nucleus pulposus extrusion, or ANNPE, occurs when non-degenerated nucleus pulposus material extrudes into the spinal canal.
This can be either traumatic or non-traumatic in origin, and leads to contusion (bruising) of the spinal cord but not compression, as the name suggests.
The spinal cord contusion causes neurological deficits which are typically lateralised, affecting one side of the body, or worsened on one side.
Surgery is not often recommended with this condition, because the extruded material disperses along the spinal canal and does not cause significant compression. Instead, conservative management and a good physiotherapy regime is indicated.
Traumatic Intervertebral Disc Extrusion
Traumatic intervertebral disc extrusion (TIDE) occurs due to a rupture in the annulus fibrosis, resulting in an extrusion of nuclear material into spinal cord.
As the name suggests, it often occurs secondary to spinal cord trauma. It can also cause contusion and compression of spinal cord.
These patients may have surgery depending on the level of spinal cord compression and if there is extruded disc material within the canal.
Fibrocartilaginous Embolic Myelopathy (FCEM)
The precise pathophysiology of FCEM is still unknown at this point.
It is hypothesised that fibrocartilaginous embolised material blocks arterial supply to spinal cord causing a disruption in the oxygen supply to that area. It is more common in middle-aged non-chondrodystrophic dogs.
Typically, the condition is non-progressive after 24 hours, and these patients are managed conservatively with good-quality nursing care and physiotherapy.
OK, so those are the different types of IVDD we see. But how do we decide which patients are managed surgically and which are managed conservatively?
Although it is probably assumed that if a patient presents to practice non-ambulatory and is diagnosed with IVDD they will then go straight for surgery, this is not always the case.
If a patient is non-ambulatory paraparetic the odds of recovery are actually similar for conservative management compared with surgery.
The decision must be made with the client, and they need to be fully aware that if conservative treatment fails, surgery is the next option.
Patients being managed conservatively still require a lot of the same nursing care as the post-operative patients while hospitalised, it is important that the client is therefore fully committed to ensuring cage resting at home.
The aim of rest is to ensure no further disc material is extruded and give the tear in the annulus time to heal, so this needs to be emphasised.
What diagnostic tests are required in our spinal patients?
To start with, a basic blood panel is appropriate in most cases. We run this to ensure there is not a metabolic or systemic inflammatory cause of weakness, or a concurrent disease or change that may alter further work-up or treatment plans.
After this, advanced imaging is required for a more accurate diagnosis.
There are a few different imaging options used, each with their own benefits and considerations.
Magnetic resonance imaging (MRI)
This imaging provides excellent detail of the spinal cord. Assessing the spinal cord on MRI can help give a more accurate diagnosis and prognosis.
Computed Tomography (CT)
CT can be a viable option for IVDD cases, especially in chondrodystrophic breeds, as allows the spine, disc and vertebrae to be assessed. Since it is most useful for assessing bone, CT is particularly handy if a fracture is suspected. One advantage is that CT is a lot quicker than MRI, which can help reduce time under anaesthesia if this is a concern. This modality can also be used for surgical planning, as allows for 3D reconstruction, if required.
Radiography
This imaging modality is more limited, allowing for more chronic calcified discs to be seen. Although radiography is still useful for patients suffering from discospondylitis, or in an emergency to assess if there is a fracture, the downside with radiography is the inability to assess the spinal cord.
And after all of that, it’s time to talk about the most important aspect: nursing care.
Each patient should have their needs assessed, to determine what they can and cannot do, and to thoroughly plan their nursing care. Post-operative care for spinal patients and medically managed recumbent patients is similar. The aim of nursing care is to ensure the patient does not develop any other conditions/complications due to inadequate nursing care.
Let’s start by looking at bedding.
Bedding should be absorbent and wick any urine away from the patient, especially those who are recumbent and unable to move away. These patients need bedding that is comfortable, non-slippery and provides adequate support.
We also need to consider their general hygiene.
Patients should be kept clean and dry to prevent complications such as urine and faecal scalding. Patients with skin folds (i.e. brachycephalics) should be checked daily and cleaned as required. Surgically wounds should be monitored for oedema, oozing or any signs of infection.
And then we need to think about exercise.
Taking a patient out for controlled exercise provides an opportunity to assess their neurological status, allow them an opportunity to toilet outside, as well as providing much needed mental stimulation.
Patients should be handled gently, always provide the patient with a good level of support. Try and keep the spine straight whenever you’re lifting or turning the patient, and provide the appropriate amount of support (i.e. via pelvic pants or slings) to ensure there is no additional strain put on their spine.
Next up is hydration and nutrition.
Each patient should have their individual nutritional needs calculated and they should be fed accordingly. Patients that are non-ambulatory may not be able to reach bowls and require feeding by hand. Ensure that recumbent patients are placed in sternal recumbency for feeding, to reduce the risk of aspiration pneumonia.
Patients may also struggle to reach water bowls, so it’s important to monitor hydration status and water intake. By offering water regularly these patients can have a better opportunity to stay hydrated. If patients are not staying adequately hydrated, they may require intravenous fluid therapy.
It is important to remember that good nutrition and hydration are necessary for a good recovery. It is worth noting that patients with neck pain (or post-ventral slot surgery) may need soft food rather than dry, and should also be offered food and water from a height to prevent discomfort.
Opioids can also make patients nauseous so they may not be as willing to eat.
Another essential consideration is bladder management.
Spinal patients often have a degree of bladder dysfunction needing careful management.
Urination is controlled by complex reflexes involving both voluntary and involuntary components of the nervous system. A patient will either have what is referred to as an upper-motor neuron bladder or lower-motor neuron bladder.
Upper-motor neuron bladder (UMN); The bladder and urethra have increased tone and are difficult to express. Patients may require drugs to relax the sphincters.
Lower-motor neuron bladder (LMN); The bladder and urealthral tone is reduced and the bladder will feel flaccid on palpation. This generally makes them easier to express but can be difficult to fully empty.
Patients should have their bladder checked every 4-6 hours, to ensure the bladder does not become too full and distended.
Leaving a patient’s bladder to become distended for prolonged periods may cause irreversible damage or a urinary tract infection to develop. If the patient is unable to urinate themselves, their bladder should be expressed manually if possible.
If this is not possible a patient may be intermittently catheterised to drain the bladder, or have an indwelling catheter placed if expression is not possible and bladder management is going to be required for several days.
Both in-and-out and indwelling urinary catheters carry a high risk of hospital-acquired UTI, so this must be performed aseptically regardless of the method of catheterisation used.
It is important not to assume that a patient (with little or no movement) which has urine in their bed, has done so voluntarily; this may be overflow (which can be a significant volume).
IVDD patients often develop urinary tract infections (possibly due to the increased contact with the floor) and need to be properly managed to reduce the risk. Monitoring the urine for signs of infection is vital.
And this is another area where we as veterinary nurses play an essential role - we can be placing these catheters, appropriately maintaining them, checking for signs of infection, and reporting those findings to the vet promptly so they can make treatment decisions earlier.
We also need to think about patient stimulation, rest, and sleep.
TLC and other forms of mental stimulation is an important consideration for all patients, but especially those that are recumbent.
Being hospitalised is a stressful experience for patients, and stress reduces the body’s ability to recover, and can delay healing.
Sleep can also play a large part in recovery and should ideally be part of our patient treatment plans. By planning hours where there are no treatments taking place to allow our patients to sleep, we can help aid their recovery.
And lastly, we need to think about at-home nursing, too.
It is likely that these patients will be discharged still having some additional needs that the client will need to assist with, whether it be walking with a sling for some support or manually expressing their pet’s bladder.
As nurses we need to ensure they are fully prepared to care for their pet at the time of discharge, so that it is not too stressful for them.
The intensiveness of this homecare depends on how severely affected the patient is.
Family circumstances can limit if this is possible and can affect the treatment options the family may opt for, and when making treatment decisions, we must consider the quality of life for both the patient and their family.
Research has shown that, where circumstances allow, there is an increase in the bond between clients and patients that do require bit more extra care at home.
Therefore, it is vital our clients are fully prepared at the time of discharge, so they can enjoy caring for their pet rather than this becoming a stressful experience.
In addition to the patients’ needs for recovery it is important to promote a good overall patient health. This will help not only the patient during recovery, but for the rest of their life.
So to sum up everything we’ve discussed, although there are several different conditions under the IVDD title, which may seem daunting, treatment options are similar.
This means that once we’ve mastered the basics of their disease, planning care and implementing a successful nursing care plan should be straightforward.
There is no right or wrong answer when it comes to treatment and it is very much dependant on the individual patient and the client, as to which option is the best.
As nurses, we can support our clients fully whether their pet is managed conservatively or surgically. For any patient, it is imperative that a good overall quality of life (e.g. weight control) is promoted, both to aid recovery and ensure the patient is as healthy as possible.
Did you enjoy this episode? If so, I’d love to hear what you think. Take a screenshot and tag me on Instagram (@vetinternalmedicinenursing) so I can give you a shout-out and share it with a colleague who’d find it helpful!
Thanks for learning with me this week, and I’ll see you next time!
References and Further Reading
Fenn, J., Olby, N.J. & The Canine Spinal Cord Injury Consortium (CANSORT-SCI) 2020, "Classification of Intervertebral Disc Disease", Frontiers in veterinary science, vol. 7, pp. 579025-579025.
Olby, N.J., Moore, S.A., Brisson, B., Fenn, J., Flegel, T., Kortz, G., Lewis, M. & Tipold, A. 2022, "ACVIM consensus statement on diagnosis and management of acute canine thoracolumbar intervertebral disc extrusion", Journal of veterinary internal medicine, vol. 36, no. 5, pp. 1570-1596.
Moore, S.A., Early, P.J. & Hettlich, B.F. 2016, "Practice patterns in the management of acute intervertebral disc herniation in dogs", Journal of small animal practice, vol. 57, no. 8, pp. 409-415.
Freeman, P. & Jeffery, N. 2022, "Is decompression in acute thoracolumbar intervertebral disc herniation overvalued?", Frontiers in veterinary science, vol. 9, pp. 1049366-1049366.
Castel, A., Olby, N.J., Ru, H., Mariani, C.L., Muñana, K.R. & Early, P.J. 2019, "Risk factors associated with progressive myelomalacia in dogs with complete sensorimotor loss following intervertebral disc extrusion: a retrospective case-control study", BMC veterinary research, vol. 15, no. 1, pp. 433-433.
Freeman, P.M., Holmes, M.A., Jeffery, N.D. & Granger, N. 2013, "Time requirement and effect on owners of home-based management of dogs with severe chronic spinal cord injury", Journal of veterinary behavior, vol. 8, no. 6, pp. 439-443.
Granger, N, 2024. A review of intervertebral disc disease classification in dogs: a fast-changing field! https://www.veterinary-practice.com/article/intervertebral-disc-disease-classification-dogs
Haskey, E. 2020, "Nursing the recumbent patient", In practice (London 1979), vol. 42, no. 5, pp. 268-278
Bell, S. 2015, "Recumbent patients: is turning enough?", The veterinary nurse, vol. 6, no. 9, pp. 542-547
McDonald, C. 2017, "Nursing the recumbent patient", The veterinary nurse, vol. 8, no. 9, pp. 506-511
Greenfield, S. 2012, "Mental stimulation as a tool to enhance canine patient mental wellbeing", The veterinary nurse, vol. 3, no. 9, pp. 554-561
About Zoe Hatfield, RVN, VTS(IM-Neurology)
Zoe qualified as a registered veterinary nurse in 2012. After spending her first year as a RVN working in first opinion practice, she moved to referral joining the University of Glasgow Small Animal Hospital nursing team in 2013.
Since joining the nursing team, Zoe has developed her passion for neurology and in 2019 gained the VTS certificate in Neurology.
Working within the vet school she enjoys using her extensive experience in neurology to teach and educate students and newer members of staff.
She also presents CPD on a wide variety of neurological topics, including at BSAVA Alba, ExcelCPD, VetTrust, AIMVT and BVA Live.
Watch Zoe’s excelCPD webinar series here.
