Physiotherapy as an Alternative Treatment for Cauda Equina Compression.

INTRODUCTION

The cauda equina is the bundle of nerves and nerve roots arising from terminal spinal segment from L7 to Cd1 - Nd5, where the following nerves originate: sciatic, obturator pudendal, femoral, pelvic and coccyx. The lumbosacral articulation includes the L7 vertebra, sacrum and connective tissue (joint capsules, ligaments) surrounding the cauda equina. (SANTOSCOY, 2006)

Its primary movement is flexion, although minimal extension and rotation is also present. The instability secondary to abnormal motion results in skeletal changes such as spondylosis deformans, proliferation of osteophytes and hypertrophy of ligaments and joint structures. Among the most significant causes of abnormality is bad joints and L/S malformation, nevertheless different disorders can be combined including:

• Stenosis of the spinal canal (congenital or acquired)
• Type II lumbar disc disease between 7 and sacral
• Spondylosis deformans
• Instability and misalignment between 7 and lumbar sacral (congenital or acquired)
• Alterations in the blood supply
• Sacral Osteochondrosis
• Discospondylitis
• Hypertrophy of ligamentous or capsular structures

ANATOMICAL CONSIDERATIONS

The sacrum in dogs and cats is formed by five fused vertebrae and thus they do not possess intervertebral discs, the front part is articulated to the vertebra L7 through an amphiarthrosis joint (vertebrae are bound with fibrous cartilage). The L/S articulation is a transference site of forces whose extension is limited mainly by the ventral longitudinal ligament, the ventral part of the intervertebral ring and by the facet joint capsules. Flexion (primary movement), is limited by the supraspinous, interspinous, interarcuales and dorsal longitudinal ligaments. (WENDELBURG, 1998)

FIGURE 1. L / S joint anatomy (sagittal section).

The cauda equina is surrounded by the medullary canal, which its dorsal part is formed by the vertebral lamina, the flavum ligamentum and the facets with their joint capsules; laterally by the pedicles; and ventrally by the vertebral bodies, dorsal longitudinal ligament and the annulus fibrosus. On the floor of the spinal canal, above the vertebrae, a pair of sinus venous move caudally, taking a divergent lateral direction as they approach the intervertebral space. (TAYLOR, 2010)

The lumbosacral spinal stenosis (L / S) is a term that covers a range of disorders that results in the decrease of the medullary canal at the L / S level, with subsequent compression, displacement, inflammation, vascular compromise or destruction of the spinal nerves and nerve roots forming the cauda equina.

The L / S articulation is the transfer point of most biomechanical forces, which subjects it to bending and anomalous rotations often resulting in degeneration and fractures, despite the strong ligaments supporting it (JACOBO, 1999); the cauda equina tolerates deformation and injuries better than the spinal cord, but if a serious injury occurs there is little chance of recovery. It is important to remember that the affected nerve structures are the spinal nerves and nerve roots, as the spinal cord ends at the "conus medullaris" (sacral and coccygeal spinal segments) in the lumbar 6 in most breeds (in others it may be the L5), in cats it ends in L7.

Clinical signs vary from flacid weakness to paralysis of the lower limbs and tail. The patellar reflex and withdrawal (as well as the gastrocnemius and tibial reflexes) may be depressed or absent in the lower limbs, as well as the perineal reflex (anal) and bulbocavernosus (in male dogs). The tone of the pelvic muscles may be reduced or absent, the perception of pain in the pelvic limbs, tail and perineal region may be decreased or absent. Postural reactions in the pelvic limbs as well as the jump response and placing of the legs may be reduced. (BRAUND, 2003)

PATIENT EVALUATION

ANAMNESIS

A patient with the following characteristics enters the clinic on October 3, 2010:

Name: Polly

Breed: Doberman

Age: 10 months

Gender: Female

Weight: 1.2 kg

The patient has difficulty standing, considerable pain when trying to walk and prostration after having suffered a trauma by falling down the stairs.

Figure 2. Patient with proprioceptive deficits and spastic hindlimb paralysis.

CLINICAL EXAMINATION

During the examination while standing, hindlimb proprioceptive deficits, prostration and difficulty standing was observed, while dynamically an ataxic gait, wide base and greater burden of the weight on the forelegs was observed.

From the neurological examination the following was observed:

Table 1. Neurological examination findings.

The orthopedic examination observed pain upon palpation in the L / S joint, when performing flexion and extension of the hip joint and palpation of the sciatic nerve.

With the clinical findings the problem suspected is Cauda Equina Compression or spinal trauma in this region and as such a decision is made to do a radiological study, in which a fracture of the dorsal arch and the articular facets of L7, espodilolistesis L / S, are found.

Figure 3. Rx Plate L / L view, where lumbosacral espondilolistsis and fracture of the L7 facets is evident.

TREATMENT

Initially a medical treatment was prescribed in which tramadol and carprofen were administered for a period of eight days while the patient was sent to physical therapy and made to rest.

Physical therapy is decided on according to two general areas:

1. Patient condition: An improvement is evident from the moment the first medical treatment and physical therapy session was administered to the day of post trauma control.
2. Imaging findings: According to the theory of the two or three compartments, useful for determining the degree of stability and need for stabilization of vertebrae fractures, it is determined that the patient has a stable fracture in which only the dorsal compartment is affected.

Figure 4. Theory of two or three compartments.

When a compartment is fractured, this being the case here, it is a stable fracture despite the fact that by generating a lesion in the articular facets, minimal instability is caused due to the participation of these in the rotational stabilization. (PELLEGRINO, 2003) In the event that two of three compartments are affected we must then proceed to surgically stabilize because the fracture is unstable and may aggravate the symptoms presented by the patient. (SHARP, 2006).

1. Mild Compression: No further displacement of bone fragments and at the time of examination the patient presented anal and tail reflex, showed no fecal or urinary incontinence, which indicates no severe compression of the nerve endings that innervate the bladder and anal sphincter (pudendal nerve). (SANTOSCOY, 2007)

PHYSIOTHERAPY AND REHABILITATION

Once referred to physical therapy, a zookinésico examination was carried out, which is necessary for establishing the treatment plan. This consists of a full neurological and orthopedic examination to locate the areas of pain being treated and the site of injury in order to speed the healing process, reduce swelling and relax the muscles.

The goal of physical therapy and rehabilitation is to improve weight reloading, strength, fitness, joint mobility, proprioception, eliminate the cause of physical alteration, improve clinical symptoms to return to normal functioning, decrease the use of NSAIDs, decreased pain and prolong and improve the animal's quality of life. Upon doing the zookinésico test the following was found:

Table 2. Zookinésico static examination

Three types of strengths are used when palpating the spine, with (1) mild; (2) moderate; and (3) strong, which is indicative of the level of pain that the patient has in the examined region.

Table 3. Pain scale by the spine's anatomical regions.

Muscle contracture was observed in the forelimbs due to an increased weight burden and the hindlimb presented pain upon palpation of the gluteal muscles, gastrocnemius, hamstring, knee and quadriceps. Surface and deep sensitivity were not affected. In examining the spinal reflexes, the sciatic and patellar were reduced while the flexor reflex was absent.

According to the results of the zookinésico examination, the protocol established for this patient was 10 therapy sessions with magnets, laser, massage therapy, thermotherapy and cryotherapy.

Table 4. Physical therapy treatment protocol

A positive evolution of the patient was achieved between each session, meeting the objectives set at the beginning of therapy.

The distribution of the weight on all four limbs improved, as well as muscle relaxation, muscle mass was recovered, joint mobility and there was no pain or proprioceptive deficit.

Below the mechanism of action of these physical means is carefully explained so you can understand the changes that can be generated at the muscular, cellular, bone, joint and metabolic level.

1. LASER

Strut arsenurio diode gallium, included in non-ionizing radiation, ie, it cannot degrade or alter molecules or biological tissues.

It operates by processes:

- Thermal: temperature increases intracellularly for short periods of time.

- Chemical: increases ATP synthesis, protein synthesis and mitosis.

- Bioelectric: restores the membrane's potential.

-Mechanical: local pressure due to collision of sonic and ultrasonic waves.

Clinical effect: produce analgesia, anti-inflammatory, anti-edema, stimulation of microcirculation and healing.

Indications: wounds, contractures, post surgical edema and disc disease.

Contraindications: pregnancy, infections, tumors, never apply directly to the eye and fractures. (PELLEGRINO, 2003)

2. MAGNET

Low frequency currents that, unlike high frequency, cause a much stronger magnetic field than the electric.

Magnetic fields produce biochemical, cellular, tissue and systemic effects.

The main effects at the biochemical level are the following:

a) Deviation of electrically charged particles in motion.

b) Provoke induced, intracellular and extracellular currents.

c) Piezoelectric effect on bone and collagen.

d) Increased solubility of substances in water.

At the cellular level, the effects indicated by the biochemical field determine

the following effects:

a) Overall stimulation of cell metabolism.

b) Standardization of altered membrane's potential.

On one hand, the currents induced by the magnetic field produce a direct stimulus of cellular mass, as evidenced by the stimulation in the synthesis of energy required by the body for its functioning at the cellular level, thus favoring cell propagation, protein synthesis and the production of prostaglandins (anti-inflammatory effect).

Clinical effect: three overall effects resulting from this treatment.

1. Anti-inflammatory or antiphlogistic effect.

2. Tissue regenerating effect.

3. Analgesic effect.

Indications: fractures, contractures, muscle spasms, ischemia.

Contraindications: pregnancy, tumors, bleeding and pacemakers.

(CORDERO, 2000)

3. THERAPEUTIC MASSAGE

Natural component of physiotherapy.

This is indicated for decreasing muscle tension secondary to a spinal injury, improving the function of joints and muscles, reducing and preventing venous and lymphatic stasis, mobilizing adhesions, regulating muscle tone and preparing the muscles for rehabilitation and accelerating recovery after physiotherapy.

The main effects are an increased blood flow, release of endogenous endorphins, reduced pain, facilitated muscle recovery, increased venous and lymphatic return, mobilized adhesions and the production of physical and mental relaxation.

 - Contraindications: local inflammation of the skin, local infection of the region, tumor, fever, coagulopathies, shock and viral diseases.

4. THERMOTHERAPY

Produces vasodilation, increased oxygen delivery and tissue metabolism. Produces moderate analgesia, relaxes muscle spasms and increases the viscosity of collagen fibers.

- Surface Heat: applied through packs, heating pad or heat lamp.

Indicated for muscle spasms.

- Deep Heat: by ultrasound that produces heat at a depth of 7 - 12 cm, generating heat at the tissue level.

(RUIZ, 2007; PELLEGRINO, 2003)

5. CRYOTHERAPY

Indicated for acute and peracute inflammation. It promotes analgesia and prevents the formation of edema.

Contraindicated in sensibility  and anesthesia disorders. (RUIZ, 2007; PELLEGRINO, 2003)

PROGNOSIS 

The patient's condition must be taken into account from the beginning, seeing as how the compression of the nerve roots was mild and presented surface and deep sensitivity, the recovery percentage is high in comparison with patients that have suffered severe compressions in which during the clinical examination there is no anal or tail reflex and fecal and urinary incontinence. (SHARP, 2006)

CONCLUSIONS

-The combination of an allopathic or homotoxicological treatment and physiotherapy (integral analgesia) accelerates recovery time, healing, well-being and quality of life of patients.

- Physiotherapy manages to improve the correct allocation of the animal's own weight, endurance, fitness, joint mobility, proprioception, eliminate the cause of physical alteration, improve clinical symptoms in order to return to normal functioning, decrease the use of NSAIDs, pain reduction and improve and extend the animal's quality of life.

- Physiotherapy in patients with deep sensitivity, anal and tail reflex and that do not have fecal or urinary incontinence, fully recover from the pathology they present as long as the compression is not severe, because the nerve roots of the cauda equina tend to be more resistant to spinal cord trauma and recover easily from minor injuries, however in the case of serious injury there is little chance of recovery. (SHARP, 2006)

Angelica B. Ortega Vásquez

Ortocanis.com Collaborator