Species: dog
Breed: French Bulldog
Sex: m, not neutered
Weight: 13.4 kg
Birth date: 2016-05-26 00:00:00
Primary diagnosis: Intervertebral disc herniation C2/3 (chronic), C3/4 (chronic) and C4/5 (acute or chronic)
Situation: consultation follow-up
Medical history: The dog has a history of chronic neck pain. He was presented to the clinic for this problem the first time in march 2019. In march-april 2024 he started going intermittently lame on the left forelimb, x-rays were taken at the private vet but there were no severe changes. The dog also has episodes of sudden screaming, where he seems to be painful. Therapy with Gabantin PO was started (doaage depending on the pain, usually 4 mg/kg PO SID). At the beginning of may the dog was presented to the clinic because of this lameness and they had the suspicion of a left-lateralised cervical disc herniation. Therapy with Carprofen 4 mg/kg PO SID and Gabapentin 7.5 mg/kg PO TID was started. After a week Carprofen was stopped and the dog was still doing well. Gabapentin therapy went on. After two weeks (end of may) the situation was still the same, with no worsening but also no improvement, so it was decided to do an MRI. MRI Report 06.06: Chronic intervertebral disc degeneration of the cervical spine; Chronic mild interverbetral disc herniation C2/3 with mild spinal cord flattening; Chronic mild intervertebral and left foraminal disc herniation C3/4 with mild spinal cord flattening and mild left foraminal stenosis; Acute or chronic mild intervertebral disc herniation C4/5 with mild spinal cord flattening; Mild syringomyelia C2/3 and C3. After the MRI also Paracetamol 18.7 mg/kg PO TID was started. Today (11.06.2024) Leroy was presented to the clinic for a cervical infiltration with corticosteroides (C3/4).
Medication: Before presentation on 11.06.2024: Paracetamol 18.7 mg/kg PO TID, Gabapentin 7.5 mg/kg PO TID (probably TID, not clear if reduced to BID/SID).
Orthopedic exam: Othopedic examination of 02.05.2024. Gait: Grade 1/4 lameness of the left forelimb and grade 1 lameness vs. good-walking monoparesis of the left hind limb. Stance: even weight bearing on all 4 limbs with straight back line and normal head carriage. Palpation orientating: unremarkable on all 4 limbs. Deeper palpation: normal on all 4 limbs.
Neurologic exam: Neurologic examination of 02.05.2024. Mentation: normal (aggressive depending on manipulation). Posture: unremarkable. Gait: unremarkable during neurological evaluation incl. walking up and down stairs, on video brought along severe lameness of the left forelimb and lateral slipping of the left hind limb under load. Postural reactions: Left hind limb mass intermittently delayed, others unremarkable. Cranial nerves: not examined due to aggressiveness. Spinal reflexes: Flexor reflex left forelimb minimally reduced compared to right or can only be triggered with stronger manipulation, patellar reflex left hind limb greatly exaggerated. Sensitivity: no dolence can be triggered on neck flexion and palpation, forced head movements not dolent (slight defence only on ventroflexion), thoracolumbar gruesome skin twitching and evasion on palpation. Neuroanatomical localisation: C6-Th2.
Pain type: chronic, nociceptive, somatic
Pain origin: neck
Pain duration: More than 7 days
Estimated pain severity: 40