Background on Leben's spinal problem and paralysis

THIS POSTING IS STILL UNEDITED.

March 29, 2001 – Leben’s birthdate (in Germany).

May 31, 2001 – I adopted Leben (and his sister).

July 2001 – 45-day, 14,500 mile road-camping Leben and Erde to Prudhoe Bay, Alaska, to SF, Ca. then to DC. At Inuvik, Northwest Territories, Canada, Leben started limping in his right front leg. I called vet Jodi Kroch and she gave potential diagnosis of united anconeous. Vet in North Pole, Alaska, also said the same.

September 2001 – At home, vet Rich Bradley (Manassas) diagnosed Leben with uninvited anconeous and performed an ulnectomy. Six months later, x-ray shows it was successful...

August 2002-September 2002– 50-day, 10,000 mile road-camping journey with Leben and Erde. In Nova Scotia, Leben showed signs of limping again.

September 2002 – At home, Rich Bradley diagnosed Leben with fractured correnoid process and OCD (loose cartilage) resulting from ulnectomy and performed surgery to repair.

2006 – Leben shows signs of limping again. Vet Tom Walker (Friendship Animal Hospital) removed loose cartilage in both elbows.

2007- Leben still shows sign of limping in front leg.

2008? - Over the last several years, Leben was sometimes unable to urinate. He was also very difficult to express (his bladder). Dr McConnell of Friendship diagnosed him with enlarged prostate. I decided to continue with my successful remedy of walking him around until he urinates on own. 

May 2010 – I took Leben to Dr Sherman Canap at VOSM for his limping; he put Leben on Previcox. I set up appointment to return in the first week in June.

May 26, 2010 – Leben’s left leg was entirely swollen. Vet at Friendship did nothing; advised me to wait to see VOSM vet the following week. 

May 31, 2010- Leben’s bladder was extremely full and I was unable to express it. I also could not walk him around because of his swollen leg. I rushed him to Friendship. They kept him overnight to see Dr. McConnell next day. Dr McConnell aspirated his leg and diagnosed the cause as a spider bite. He also neutered him to resolve enlarged prostrate problem that led to difficulties in urinating in past.

June 2010 – Returned to Sherman Canap at VOSM to deal with continued limping and whatever the new problem was. An MRI shows more loose cartilage in elbows, stretched left carpus ligament, and some kind of a tear problem with his left shoulder. 

July 2010 – Canap performed laser fusion surgery on left shoulder and removed loose cartilage in both elbows.

September 2010 – Canap performed Stem cell injections on left shoulder and carpus and both elbows.

October 2010 – Just after his recovery from surgery, Leben showed signs of his rear legs splaying on smooth surfaces. He also seems to be hitting the deck (lying down sternum) at every opportunity and reluctance to go on walks. I took him into VOSM about this but they could not find anything wrong orthopedically.

October 2011 – I noticed that returned again to VOSM since the splaying and other symptoms continued. Dr Deb Canap performed several tests (including testing for DM, Degenerative Myelopathy) and all were negative. Since they could find nothing orthopedically wrong, Dr. Christopher recommended seeing their neurologist. (I was reluctant to do that because of the two unsuccessful experiences I had with neurologists with Montag and Sonntag.)

Until now, three signs that something was wrong with Leben are: splaying of rear legs on slippery floors, hitting the deck at every opportunity, and reluctance to go for long walks. There were also signs of wear on the middle toes of both rear legs and occasional signs of fecal incontinence.

May 2012 – Although Leben was not running as fast and as long as he had in the past, he was still able to run. All of a sudden, one day, after running a few steps, he showed signs that something was wrong with his right rear leg and then stop. This continued thereafter. I then made an appointment for July 3^rd to return to VOSM for their opinion.

July 3, 2012 – VOSM did not have me down for the July 3^rd appointment and had no openings for weeks but recommended seeing Dr Ryan Gallagher (their neurologist) that day. Dr Gallagher exiled Leben in his spinal area and noticed some issues. X-rays reveal nothing of significance. He recommended an MRI.

July 11, 2012 – MRI at Vienna Clinic.

July 12, 2012 – I returned to VSOM to review Leben’s MRI with Dr Gallagher. The MRI showed two disc ruptures and serious compression in mid-spine (L2) and very serious compression in lower-spine (L4) (You could not see the spinal column). Dr. Gallagher could not tell if they had calcified, which, if they had, would make the chances of a successful operation less. We discussed the chances of at least preventing further decline because I was convinced that if Leben continued his normal activities, he would become paralyzed (like Montag or Sonntag) over next year. Dr. Gallagher says, “we don’t experiment on dogs”, meaning there is a good chance of success even if ruptures had calcified. Even just opening a window in the bone onto the spine could offer some decompression relief; removing some of calcified stuff might help too by allowing additional room for decompression. Dr. Gallagher offered two options: “conservative management” or surgery to remove the debris from the ruptures. I asked about the recovery period for the surgery because of the road trip I had planned with my dogs and was told that in four weeks he Leben would be back to normal activity and would b able to make the trip. I asked what the downside of the surgery would be and Dr. Gallagher said “he could be worse”. With regard to the timing of the surgery, I told Dr. Gallagher I had three choices: do it now and postpone the trip until at least four weeks after the surgery; do it in October after I came back from the trip; or no surgery at all and just wait and see what happens and decide then. The meeting had to be cut short because Dr Gallagher had another appointment.

July 13, 2012 – The next day, after watching Leben running after he got out of the pool at Middleburg (he stopped abruptly after three or four steps); I decided to go ahead with surgery now. If “conservative management” meant no running at all or climbing up steps, etc., I knew that that was not a possibility. I also thought that if nothing was done now to at least prevent further decline, Leben would take another step down sometime over the next year, and if I left for the trip and he took another step down on the trip, I would want to rush back for the surgery. Although I was not optimistic that Leben’s situation would be improved by the surgery, I was convinced that either further decline could be avoided or the operation would not produce any benefits at all, which a risk worth was taking. Except for that one statement, made almost as a footnote, that “he could be worse”, I was not aware of any downside risks associated with the operation. In Montag’s case, he was lame going into his operation and lame coming out; in Sonntag’s case, he as paralyzed going into his operation and paralyzed coming out. Going into his operation, Leben was walking okay and able to climb steps, and I expected that he would be the same after the operation, that is, until he took another step down if the operation was unsuccessful in avoiding that.

July 17, 2012 – Gallagher performed surgery on Leben. Dr. Gallagher called me after and said that the operation took 4.5 hours. The good news was that the right L4 area was a fresh rupture and he was able to clean it out pretty well. The left side, however, was calcified and he was able to chip away a good amount. He also said he went ahead with surgery at the L2 area, which was less serious than L4, although still serious, but both sides were completely calcified and he could only chip away at a little. Gallaher said he did not want to go any further as he did not want to manipulate the attached nerves too much.

July 18-19 2010 – I visited Leben in hospital. He was able to get up on his own but was in bad shape otherwise. He could not walk without support. Dr. Gallagher says it was not a matter of if there would be wobbling, but how much. He could not urinate on his own and was leaking. Although Dr. Gallagher said I could pick Leben up the next day, I decided to wait until Friday, July 20, to pick him up because he could not urinate on his own yet and I knew that his bladder is extremely difficult to express. The techs agreed to it were difficult to express his balder and so they were cauterizing him.

July 20, 2012 – I picked Leben up. Although he was more alert then he had been the previous two days, he was still in very bad shape. He could get up on his own but his wobble was so terrible he needed to be supported when walking. He still cannot urinate on own. He is leaking all the time. Dr. Gallagher said he had never seen a case where this urination problem continued this long. 

July 22 – Dr Gallagher prescribed Bethanachol and Phenoxybenzamine for Leben’s bladder control issues.

On July 22^nd, I moved to Karen Hamrick’s cottage in Virginia where it was easier to manage Leben than at home in condo where walk outside means long walks and up steps. I stayed in the cabin for three weeks until Leben was able to walk on his own.

On August 1^st, I started Leben on once-a-week therapy at VOSM (laser, massage, then underwater treadmill when his skin infection cleared up). I also took him to acupuncture once a week at Southpaws (Dr. Hoary and Dr. Cogency), and swimming twice a week (for 15 minutes or more) at the Animal Swim Center in Middleburg. I also gave him home therapy three times a day as prescribed, keep him confined, and took him only on short leash walks. I continued the VOSM, swimming and acupuncture therapy until the first week in September.

I took Leben back to Dr. Gallagher for rechecks two and four weeks after surgery.

During Leben’s rehab, I kept a “scorecard” on at how Leben was doing compared to where he was when he went in for the surgery. He was not improving very rapidly. At the two week point, Leben was nowhere near 25% of where he was before the surgery and his bladder control problem was controllable only by the medicines. (Once, when I took him off the meds, his bladder problem returned.)

August 1, 2012 – At the first recheck at 2 weeks at VOSM, Dr. Gallagher said that he thought Leben was doing better than he expected. I was still concerned because I do not see any serious recovery and because of his urination problem and Dr. Gallagher said that it could be eight weeks before he recovered (to where he was before the operation). Because of Leben’s slow recovery and his urination problem, I started to get concerned that the operation chipped away at too many critical nerves, including Leben’s bladder control nerves. Dr. Gallaher admitted that the L2 area does control bladder functions.

During one of my acupuncture sessions, after Leben was walking on his own, poorly, but walking, Dr. Hoary pointed out that Leben’s left rear leg was in worst condition than his right. Since I had not seen that for myself since both looked in bad shape, I was surprised to hear that at that since it was his right leg that I thought was problematic. As I watched this carefully after that, I saw that she was right. He would only bring his left leg up to the front only so far and then would abruptly stop. This was in addition to the terrible wobble to both legs that persisted.

 

Ageist 15, 2012 – Second/final rechecks at VOSM. Dr Gallagher advised an eight-week recovery period before resuming normal activity, and also said that recover of strength could take many months. (Of course, had I known that that was a possibility, I would not have gone ahead with the surgery as Leben’s life expectancy is 12, and that would surpass it?) Leben was still not even at the half-way point of recovering to where he was going into the operation. Dr Gallagher did not advise against the upcoming trip but suggested I not let him chase any moose, bear, or wolves.

At the end of the revised recovery period of 8 weeks, Leben was able to get up on own, walk without support, climbs steps and stay standing. But he had not made any progress that I could see since week four. Both legs were still very wobbly.

September 17, 2012 – I left on road-camping trip with Leben and Erde. Knowing that the operation was probably unsuccessful since the disc ruptures had calcified, my plan was to manage Leben conservatively.

September 20, 2012 – After the first few days on the trip, I determined that Leben was able to take walks, so I took him for a 1.7 mile walk up a grassy jeep trail. He was able to do on his own without difficulty. Up and back took six hours, with a two-hour break in between. I supported him with a sling the last portion of the trip to make sure he did not fall. The next day, he was fine, and he continued that way for the next three weeks. But he was not improving. It was easier to manage him on the road than it would have been at home because he did not have to walk as much. He was able to take steps, and slight slopes. I kept all his walks short. For longer walks, I put him in the dog stroller I had brought along.

October 3, 2012 – At Killarney Park, Leben took a short step down to the beach area. When he went to climb back up what should have been an easy step for him, he fell down. He could not get back up on his own. After I helped him up, he continued on his own with no trouble, although our walks were short.

October 6, 2012 – I noticed that Leben was no longer scratching himself to show me where his skin allergy was bothering him. I did not know it at the time but he was not scratching himself because he actually was no longer able to, at least with his left rear leg. He was also showing signs of having difficulty maneuvering himself on the tent mattress.

October 7, 2012 - Leben started to fall when walking, always the left leg. He would always fall to his left. At that point, I started to support him with a sling or take him in his stroller. He was getting less activity on the trip than he would have at home so I knew that just normal activity or less was getting to him. But he was still able to get up on his own, albeit slowly.

October 8, 2012 – Leben was no longer able to get up on his own. I decided to end the trip and head fiord Thunder Bay and started the return trip from there to get him into swim therapy. I stayed in Kolas the entire trip home as it was easier to

October 12, 2012 – I sent e-mail to Dr Gallagher asking has advice on what to do about Leben.

October 13, 2012 – I arrive home and started to take Leben swimming 3x weekly the next day.

October 17, 2012 – I sent another e-mail to Dr. Gallagher.

October 19, 2012 – After I had not heard from Dr Gallagher, I emailed Sherman Canap. Dr Gallagher responds within few hours. He asked me to bring Leben in on Monday, October 23.

Leben’s left leg situation seemed to be deteriorating by the day. He showed no signs of strength in it at all and was unable to tend on it even when propped up.

October 22, 2012 – I took Leben to Dr. Gallagher at VOSM. X-rays showed that there were no bone factures or infections, the inflammation from which could cause the problem we were seeing. He agreed that the fall on Oct 3^rd occurred outside the healing period (Leben had taken similar falls during the early healing period with no resulting problems) and so that should not have been a problem. He advised steroids (with side effects) to reduce any inflammation or an MRI to see if something else occurred. He agreed that an MRI would be useful if I intoned to go ahead with surgery to fix any underlying problem, a new problem, scar tissue, etc... He has no explanation for what is going on but agrees that Leben’s neurologic signs are worse.

Since the last visit to VOSM, Leben’s left rear leg has deteriorated more. He cannot place his toes, he cannot stand on it, when swimming he uses it very little, when walking in the harness or wheelchair he hardly uses it . He can move his right leg somewhat when walking in the harness or wheelchair and when swimming, and he can scratch himself with it, but his toe placement is poor. Whatever happened to him affected is left leg significantly and his right leg somewhat. He is, to all intents and purposes, now paralyzed. So the operation I subjected Leben to in order prevent him from becoming paralyzed eventually, might actually have caused his paralysis in 11 weeks.

What happened to Leben?

While I have no idea what caused Leben’s two disc ruptures, there are four possibilities for what contributed to his paralysis.

1- This is that next step down that I was hoping to avoid by putting Leben through the surgery. That is, the surgery was not only unsuccessful in improving his situation, but it was unsuccessful in preventing any further decline.

2- Something traumatic happened (a fall, etc.) at some point in or after the healing period that caused this paralysis, i.e., next step down.

3- Inflammation of some kind. Inflammation from an infection or fracture has been ruled out, leaving inflammation from scar tissue from the operation.

4- The surgery was too aggressive and chipped away at too many critical nerves and made the remaining nerves vulnerable to simply normal activity.

I know my dog. I knew his movements before the surgery and knew every movement he took after the surgery as I was with him for, literally, 24/7 after that. What happened was not (#1) the next step down that I was hoping to avoid with the surgery. Likewise, nothing traumatic happened (#2) during healing (recovery) period or afterwards that caused this. Leben got nothing more than normal activity after the surgery. When he fell on October 3^rd, that was the first sign that the recovery had failed and not the cause of the failure. His left leg is now the major part of his paralysis. It was fine going into the surgery. Dr. Khoury noticed weeks after the surgery that his left leg was problematic. Something happened during the surgery started this chain of events that led to this. 

In retrospect, Leben was not a good candidate for this surgery. The signs of a problem started to show up two years before the surgery, more than enough time for the calcification to take place. The surgery was not supposed to be heroic. I am not too sure what I would have done if I had been told that Leben was not a good candidate for the surgery because of when the symptoms first started to show up and other things, but I was not interested in heroic surgery. Either the surgery was too aggressive in chipping away at critical nerves, which would explain Leben’s immediate loss of bladder control, failure to recover significantly, and new left rear leg problem, or created scar tissue which is causing inflammation. Had I been aware of either of these risks, I would not have gone ahead with the surgery given Leben’s age and other things. The only reason it is helpful to understand these things is to determine where I go from here, a routine of prednisone to reduce inflammation, another MRI and maybe surgery, or put Leben in a wheelchair. In retrospect, I should have opted for waiting for the next step down to take place on its own and put Leben in a wheelchair immediately if it did instead of subjecting Leben to the weeks of hell he and I went through during his recovery period. His paralysis and accompanying problems (no bladder control) now is probably worse than it would have been had it occurred on its own, although I will never know that for sure. All of this is no longer of concern to me because now I have to make do with the dog I have and give him as full a life as I can, and I will. But the bottom line, for which I take full responsibility, is that the surgery itself brought on Leben’s paralysis faster than it would have occurred on its own over the next year or so. This is the first time in my own personal experience, with my dogs or myself, where an operation or medical procedure caused or contributed to a worse outcome than going in.