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Lola is an 8-year-old, female, spayed chihuahua who presented to The Ralph’s Neurology + Neurosurgery team with a one year history of recurrent severe neck pain and left thoracic limb lameness. Before presenting to us, Lola was tried on several analgesic treatments including NSAIDS, prednisolone, paracetamol, gabapentin, pregabaline, amantadine and diazepam without long standing resolution of the clinical signs. 

At the time of presentation, cervical discomfort and a mild left thoracic limb lameness were confirmed, and further investigations were pursued. The MRI of the cervical spine only revealed two small protrusions at C5-C6 and C6-C7 which initially appeared to be too small to be causing such pronounced and recurrent signs (figure 1). Further investigations were performed with CSF analysis revealing the presence of mild inflammation potentially compatible with meningitis. Having excluded infectious diseases via serology, an immunosuppressive treatment with prednisolone at higher doses was initiated.

Unfortunately, this was again not successful in controlling her signs and a second MRI with dynamic assessment of the cervical spine was performed. This revealed similar findings, with still similar degree of protrusion at C5-C6 and C6-C7 which were only mildly worsening on cervical extension (figure 1). Although the clinical signs would fit very well with the localisation of these two protrusions, we were unable to prove the presence of a dynamic compression of spinal cord or nerves, therefore still making it difficult to justify major surgical intervention. In this scenario, we elected to perform-ultrasound guided perineurial injections of methylprednisolone at the sites of protrusion, bilaterally. For the first time, a clearer improvement of the clinical signs was achieved confirming that the origin of the discomfort was indeed from these nerves. However, this improvement was not sustained. A dynamic form of foraminal stenosis was ultimately suspected and surgical intervention with spinal stabilisation was elected. 

Figure 1: Sagittal T2W images of the (top) position, showing the mild C5-C6 and C6-C7 protrusions and (bottom) post operative lateral radiograph of the surgical stabilisation

A C5 to C7 stabilisation was performed with ventral approach using two parallel 2.0mm titanium reconstruction plates (ABM affordable best movements), with 3 screws per vertebral body (figure 2). The post-operative radiographs and CT confirmed perfect position of all screws with no violation of the vertebral canal.    

Figure 2: intraoperative
picture of the surgical
stabilisation

Since then, Lola became pain-free and we were able to wean her off from all medications. To date, one year after the surgery, Lola has never had any relapse of her clinical signs. 

This case presented many challenges. As we saw, dynamic spinal cord or nerve compressions can be difficult to diagnose even with advanced imaging, and some diagnostic findings such as mild inflammation on the CSF can be misleading. The ultrasound-guided perineurial injections of methylprednisolone as local analgesic treatment have proved to be an excellent tool with high diagnostic value in this case to give to our diagnosis the support that we need before proceeding with surgical intervention. Also, this surgical procedure is generally performed in large breed dogs such as Dobermans and it is rarely performed in toy breeds, leading to the challenges to find implants that were small enough to achieve solid stabilisation avoiding large bulking masses of surgical cement in such a small neck.  

Our technique proved to be highly effective in this case with long term resolution of the clinical signs and a return to pain-free, medication-free and restrictions-free life, and we will happily apply it to other cases in the future.