Early vs Delayed Surgery in Dogs with Intervertebral Disk Extrusion

犬椎间盘突出的早期vs延迟手术

Martin S, Liebel FX, Fadda A, Lazzerini K, Harcourt-Brown T. 

Same-day surgery may reduce the risk of losing pain perception in dogs with thoracolumbar disc extrusion. 

J Small Anim Pract. 2020;61(7):442-448.

Surgical timing for suspected intervertebral disk extrusion (IVDE) cases is controversial in veterinary medicine. Clinicians often attempt to maximize outcomes by promoting expedient referral for emergency surgery when necessary. This decision-making process becomes more complicated in after-hours situations. In paraparetic and paraplegic dogs, presence of deep pain is a clear prognostic indicator for improved outcomes after surgery, with 88% to 96% of dogs regaining ambulation; once deep pain is gone, the patient’s ability to regain voluntary ambulation lowers significantly (50%-60%).1-3 When surgery is indicated for an after-hours patient, the clinician must determine whether surgery is needed overnight or can wait until the next day. Spinal surgery requires precise therapy by the surgical team, and precise therapy may not be maximal in the middle of the night. In human medicine, it has been well-documented that after-hours surgery is a risk factor for development of complications.4,5

疑似椎间盘突出(intervertebral disk extrusion，IVDE)病例的手术时机在兽医界有争议。

临床医生经常试图在必要时通过促进急诊手术的应急转诊来最优化结果。

在下班后的情况下，这个决策过程会变得更加复杂。

在后肢轻瘫和后肢麻痹的犬中，

深部疼痛是手术后结果改善的一个明确的预后指标，

88%到96%的犬可以恢复运动;

一旦深部疼痛消失，病患恢复自主行走的能力显著降低(50%-60%)。1-3

如果是下班后的病患需要手术，临床医生必须确定是需要尽快手术还是可以等到第二天。

脊柱手术需要外科团队的精确治疗，而精确的治疗在半夜可能不是最好的。

在人类医学中，有充分的证据证明，下班后的手术是发生并发症的一个危险因素。4,5

This study retrospectively examined the effect of surgical decompression timing for IVDE on dogs’ ability to regain ambulation. Dogs with paraparesis or paraplegia with deep pain were included in the study. Dogs were admitted and had surgery either the same day or after an overnight delay; 273 dogs qualified for the study. Dogs with earlier surgery (ie, between days 0 and 1) had decreased hospitalization times and better odds for recovery to voluntary ambulation. Seven of 151 (5%) dogs in the early surgery group lost deep pain postoperatively; 15 of 122 (12%) dogs in the delayed surgery group lost deep pain. Five of 7 (71.4%) dogs in the early surgery group that lost deep pain perception regained ambulation within 3 weeks; 8 of 15 (57.1%) dogs in the delayed surgery group that lost deep pain perception regained ambulation. This suggests that an overnight delay may decrease the odds of regaining ambulation.

这项研究回顾性地研究了IVDE减压时机对犬恢复行走能力的影响。

后肢轻瘫或后肢麻痹伴有深部疼痛的犬被纳入研究。

犬入院并接受手术，

要么是在同一天，

要么是在晚了一夜之后;

273只犬符合这项研究的条件。

早期接受手术的犬(例如，在第0天到第1天之间)住院时间减少，恢复到自主运动的几率更高。

早期手术组151只犬中有7只(5%)术后深部疼痛消失;

延迟手术组122只犬中有15只(12%)失去了深部疼痛。

早期手术组7只失去深部疼痛感知的犬中有5只(71.4%)在3周内恢复行走;

延迟手术组15只犬中有8只(57.1%)丧失了深部疼痛感，恢复了行走能力。

这表明一晚的延迟可能会降低恢复行走的几率。

The biggest weakness of this study is its retrospective nature. Case selection for which cases were to have same day surgery versus delayed surgery provides an unknown bias. In addition, return to voluntary ambulation was based on a pet owner survey, not evaluation by a clinician. Prospective studies would be beneficial to investigate the effects of early versus delayed surgery in IVDE cases.

这项研究最大的缺点是它的回顾性性质。

同一天手术和延迟手术的病例选择存在未知的偏见。

此外，自主运动是基于宠物主人的调查，而不是临床医生的评估。

前瞻性研究将有助于调查IVDE病例中早期与延迟手术的影响。

TO YOUR PATIENTS 对于病患

Key pearls to put into practice:

临床关键点：

1

Presence of pain perception remains the best prognostic indicator for eventual voluntary ambulation in dogs with IVDE.

疼痛感的存在仍然是IVDE犬最终自主运动的最佳预后指标。

2

Performing surgery in nonambulatory dogs prior to loss of deep pain perception is ideal; however, this can create a difficult situation after hours with regard to balancing expedient care with a potentially compromised surgical team. This study data suggest that only a small percentage of surgically delayed cases experience detrimental long-term outcomes.

在不能运动的犬丧失深部痛觉之前进行手术是理想的;

然而，这可能会造成一个困难的情况，

即几个小时后，要平衡的应急护理与潜在的妥协的外科团队。

这项研究数据表明，

只有一小部分百分比的手术延迟的病例经历了有害的长期结果。

3

Paraplegic cases should be prioritized for surgical decompression so surgery may occur before loss of deep pain. It is important to note that even with expedient surgery not all dogs maintain or regain deep pain sensation.

后肢麻痹病例应优先进行手术减压，以便在深部疼痛消失前进行手术。

值得注意的是，即使进行了适当的手术，也不是所有的犬都能保持或恢复深部疼痛感受的。

4

A small percentage of dogs deteriorate neurologically despite surgical decompression, suggesting timing of surgery in these dogs may be less clinically imperative.

尽管进行了手术减压，仍有一小部分犬的神经系统状况恶化，

这表明对这些犬进行手术的时机的选择在临床上可能没有那么必要。

5

Early referral can help promote improved outcomes due to optimal planning and timing. Ideally, surgery should occur during the day, when the surgical team is fully supported and may demonstrate the greatest procedural acumen, and on a patient that has not lost deep pain sensation.

由于最佳的计划和时机，早期转诊有助于促进结果改善。

理想情况下，手术应该在白天进行，这样手术团队就能得到充分的支持，

并且可以表现出最大的手术敏锐度，

但是需要病患还能保持深部疼痛感受。

REFERENCES 参考文献

Ruddle TL, Allen DA, Schertel ER, et al.

Outcome and prognostic factors in non-ambulatory Hansen type I intervertebral disc extrusions: 308 cases.

Vet Comp Orthop Traumatol. 2006;19(1):29-34.

Brisson BA.

Intervertebral disc disease in dogs.

Vet Clin North Am Small Anim Pract. 2010;40(5):829-858.

Langerhuus L, Miles J.

Proportion recovery and times to ambulation for non-ambulatory dogs with thoracolumbar disc extrusions treated with hemilaminectomy or conservative treatment: a systematic review and meta-analysis of case-series studies.

Vet J. 2017;220:7-16.

O’Loughlin E, Smithies WJ, Corcoran TB.

Out-of-hours surgery--a snapshot in time.

Anaesth Intensive Care. 2010;38(6):1059-1063.

Bertram A, Hyam D, Hapangama N. (2013)

Out-of-hours maxillofacial trauma surgery: a risk factor for complications?

Int J Oral Maxillofac Surg. 2013;42(2):214-217.