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Suspected Ivdd In A Dog

by sophiek - March 31, 2023 View Case Report

Hi Steve,

I have a question specifically about the pulses in this case, and would love some guidance on herbal formula selection.

"Coco" is a 9 year old FN Maltese X - diagnosed in Nov 2022 with T3-L3 myelopathy after an acute onset episode of back pain, ataxia and hindlimb proprioceptive deficits. radiographs were unremarkable, no further imaging performed. Treated with opioid analgesia and rest. She has had 2 flare ups of back pain since this time

She also has a history of IBD (strict dry food hypoallergenic diet, Tylan BID), anxiety (fluoxetine 5mg SID) and allergic skin disease (Cytopoint q4weeks). She also has Grade 2-3 LATERALLY locating patella bilaterally.

I saw Coco for the first time yesterday for acupuncture. She has some thoracolumbar pain, no ataxia or proprioceptive deficits. Patellas currently in correct position. No skin lesions currently, but owners describe when her skin flares she is itchy all over, especially at sides of chest and flanks, and she cleans her face and over her ears with her paws (like a cat). There are never moist, hot or oozy lesions - so presume this is more Blood Deficiency causing skin signs vs Damp Heat.

Active points BL 19, BL 25 > BL 28, GB 25, GB 27
Tongue pale lavender, slightly thin
Pulse - this is where I was getting confused -
RIGHT pulse was superficial, thin, soft, easily compressed
LEFT pulse was deep and slightly wiry

My TCM diagnosis for Coco is
Global Blood Deficiency with Blood Stasis
Liver Blood Deficiency
Liver Qi Stagnation
Secondary Spleen Qi Deficiency

Based on the right pulse, I also thought Wind Invasion was a possibility, whereas the right side indicated more Stagnation?
I was considering Du Huo Ji Shen Tang, but then wondered if this would be enough to address the Stagnation. Could the right pulse be Stagnation that is resolving (as she currently isn't in a back pain flare up, no proprioceptive deficits) OR that things are starting to become worse. Perhaps I should be considering Chai Hu Gui Zhi Tang first?

Do you occasionally find the left and right pulse differing so much? I'm certainly no expert on pulse, but I went back and checked these pulses several times as they were so different on each side.

Thanks for your help!
Sophie

by naturevet

April 2, 2023

Hi Sophie,

It's hard to imagine this is case of IVDD if the radiographs were clear off issues. I'm wondering instead if this is nerve impingement from something like piriformis syndrome, for example, where a fixation at the sacro-iliac joint can produce pain, that then causes piriformis muscle contracture, which then puts pressure on the sciatic nerve. Other vertebral fixations can produce other nerve pinches through other mechanisms. The result is you can see proprioceptive deficits without the cord being affected.

The Shao Yang can play a major role in the development of this type of problem, since it is the regulator of circulation to the dorsum. A hindrance can produce reduced muscle perfusion, that leads to tightness or outright spasm. In particular, GB 25 (one of your active points) plays a major role in facilitating circulation to the dorsum. At the same time, a Shao Yang disharmony can produce the skin issues you're seeing, with lesion distributions along the sides of the body or the ventrum (such as the chin).

Concomitant Blood and Yin deficiency can aggravate both the skin issues and the tendency to muscle tightness and nerve fixation. Often, if the Blood and Yin deficiency is significant, the Shao Yang pulse converts to something that is surprisingly weak, like what you palpated. The left pulse may be manifesting the expected secondary Stasis more than the right pulse. The right pulse might be manifesting pure deficiency without Stasis.

Based on the above, a chiropractic evaluation seems in order if you can access one. Meanwhile, I'd wonder about using Chai Hu Gui Zhi Tang and perhaps Bu Gan Tang (to relieve muscle spasm and tightness) or Yi Guan Jian (to relieve chin and ventral abdominal redness, and IBD). YGJ might be the safest place to start, and if the GI becomes very stable, then you could move to BGT

Hopefully this helps you out! An interesting case. Let us know how it goes!

Steve

by sophiek

April 2, 2023

HI Steve,

Thanks so much fort your reply - makes sense. I'm thinking that my diagnosis if Blood Stasis is probably incorrect - I was assuming this due to physical IVDD lesion.

A query though - with the radiographs, these were just plain rads, no contrast, so is it still possible to have IVDD and proprioceptive deficits due to a mild disc protrusion that isn't visible on the rads? Or would you still expect to see narrowing / some sort of degenerative change along the spine?

Is there any way I can confirm it could be the piriformis causing the issue - I'm guessing it's too deep to palpate externally? Chiro's are not easy to find where I am located.

And I was also thinking the locating patellas could be causing the low back pain / strain - holding her back legs oddly to keep the patellas in place and putting strain on muscles in this area? I'm not sure this would explain the intermittent proprioceptive deficits though.

With the pulse being superficial on the right - in this case it sounds like it's not indicating a Wind invasion. How do you know when a Wind invasion is a factor? - if Blood/Yin Deficiency is a major issue and circulation to dorsum is poor, does this not then make a Wind Invasion more likely? I'm just wondering the subtleties of when to try Shao Yang formulas vs when to try Wind Invasion formulas like Du Huo Ji Shen Tang? It makes sense though that a XCHT derivative fits more of the picture of IBD and skin issues too, vs DHJST which won't address those?

Could you also explain more about using Bu Gan Tang - YGJ is a safer bet because there are less tonics than BGT? And YGJ fits more with IBD signs (and actually she can also be reactive and snappy when she meets other dogs). I haven't used BGT much yet - so this would be indicated more for cases where underlying cause of Blood Stasis is Blood / Yin Deficiency vs formulas like Xiao Huo Lou Dan (Blood Stasis due to Cold / Yang Deficiency) or Xian Fang Huo Min Yin (Blood Stasis due to Dampness and Phlegm)?

Sorry for all the questions - your answer above brought up lots of other queries!
Thank you for your time,
Sophie

by naturevet

April 13, 2023

Hi Sophie,

Hopefully I can address all these follow up questions successfully. For sure you can have CP deficits with no degeneration. That's what type I disc disease is all about. Degeneration is minimal in these cases, but often the cord damage is severe, generally calling for a prolonged period of Minor Bupleurum derivatives to start the animal on the road to recovery.

As for piriformis syndrome, the muscle itself is hard to palpate. If you limit your acupuncture or acupressure to the region of BL 28 in the sacro-iliac joint, and GB 29 or 30, and the pulse improves, then you know it's not disc disease per se, but nerve compression from soft tissue causes.

Regarding DHJST, yes, it can fit with that pulse analysis. Almost invariably though, DHJST helps dogs with floating pulses. Taking the case in its entirety, I felt the need to mention the Shao Yang approach as well.

YGJ has more herbs for the GI, so it's better for GI cases such as IBD. Normally we think of IBD as Damp Heat, but the other big cause is Yang Ming Heat due to Shao Yang disharmony. YGJ counteracts that.

Bu Gan Tang is more about suffusing the musculature with blood to relieve spasms. It is potentially Dampening, but can be teamed with Blood movers such as XHLD or even XFHMY to help them work better. The latter two help water flow more effectively in the river. The former puts the water in the river so it can flow in the first place. So there are synergies there.

Hope this helps you out!

Steve

by sophiek

April 24, 2023

Hi Steve,

I had an update from Coco's owner today - her skin has flared despite having her regular Cytopoint injection last week (at the regular vet). She has a Malassezia overgrowth on her feet and is chewing at them madly, and has been dispensed Fluconazole. She also has developed a mild cough / clearing of her throat like she is trying to bring something up. The regular vet examined her today and thought she was painful over lower lumbar / pelvic area.

She has also had some episodes of back pain in the last week too, which she hasn't had for a few weeks - just when we thought she was really improving, and she seemed to be moving really well!

She has been on Chai Hu Gui Zhi Tang plus Yi Guan Jian for 2 weeks now. I am wondering in hindsight if perhaps she does have some Damp / Damp Heat issues (and she's still on kibble due to the IBD which owner is very reluctant to move her off). Skin was normal when examined initially, but she has Cytopoint monthly to control this. Is is possible the Yi Guan Jian is too cloying / dampening for her, perhaps increasing circulation to the skin on her feet causing inflammation (then leading to the secondary yeast overgrowth)? The cough / throat clearing makes me think of Damp too and I am wondering if San Ren Tang could be appropriate - some effects on Triple Burner, but deals with the Damp and I think it has some effects on the sacro-iliac area/lower lumbar area?

I've asked the owner to stop the herbs until I examine her again next week to recheck pulse and tongue etc, but for now my other idea was just to try XCHT or Chai Hu Gui Zhi Tang alone, without the Yi Guan Jian.

Thanks for your thoughts on this one.

Sophie

by naturevet

April 29, 2023

Sounds like a plan, Sophie. Also, I like your idea of San Ren Tang.

If the skin doesn't improve after coming off the herbs, then a real food diet may be needed to cure the skin problems. Minor Bupleurum treats IBD, so the dog may be well protected from a flare-up if you reinstitute the formula. Just a thought, if you continue to hit a wall

S

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