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Toader C, Ples H, Covache-Busuioc RA, Costin HP, Bratu BG, Dumitrascu DI, Glavan LA, Ciurea AV. Decoding Chiari Malformation and Syringomyelia: From Epidemiology and Genetics to Advanced Diagnosis and Management Strategies. Brain Sci 2023; 13:1658. [PMID: 38137106 PMCID: PMC10741770 DOI: 10.3390/brainsci13121658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 11/24/2023] [Indexed: 12/24/2023] Open
Abstract
Chiari Malformation and Syringomyelia are neurosurgical entities that have been the subject of extensive research and clinical interest. Globally prevalent, these disorders vary demographically and have witnessed evolving temporal trends. Chiari Malformation impacts the normal cerebrospinal fluid flow, consequently affecting overall health. Key observations from canine studies offer pivotal insights into the pathogenesis of Syringomyelia and its extrapolation to human manifestations. Genetics plays a pivotal role; contemporary knowledge identifies specific genes, illuminating avenues for future exploration. Clinically, these disorders present distinct phenotypes. Diagnostically, while traditional methods have stood the test of time, innovative neurophysiological techniques are revolutionizing early detection and management. Neuroradiology, a cornerstone in diagnosis, follows defined criteria. Advanced imaging techniques are amplifying diagnostic precision. In therapeutic realms, surgery remains primary. For Chiari 1 Malformation, surgical outcomes vary based on the presence of Syringomyelia. Isolated Syringomyelia demands a unique surgical approach, the effectiveness of which is continually being optimized. Post-operative long-term prognosis and quality of life measures are crucial in assessing intervention success. In conclusion, this review amalgamates existing knowledge, paving the way for future research and enhanced clinical strategies in the management of Chiari Malformation and Syringomyelia.
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Affiliation(s)
- Corneliu Toader
- Department of Neurosurgery, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (C.T.); (R.-A.C.-B.); (H.P.C.); (B.-G.B.); (D.-I.D.); (L.A.G.); (A.V.C.)
- Department of Vascular Neurosurgery, National Institute of Neurology and Neurovascular Diseases, 077160 Bucharest, Romania
| | - Horia Ples
- Department of Neurosurgery, Centre for Cognitive Research in Neuropsychiatric Pathology 6 (NeuroPsy-Cog), 300736 Timișoara, Romania
- Department of Neurosurgery, “Victor Babeș” University of Medicine and Pharmacy, 300041 Timișoara, Romania
| | - Razvan-Adrian Covache-Busuioc
- Department of Neurosurgery, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (C.T.); (R.-A.C.-B.); (H.P.C.); (B.-G.B.); (D.-I.D.); (L.A.G.); (A.V.C.)
| | - Horia Petre Costin
- Department of Neurosurgery, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (C.T.); (R.-A.C.-B.); (H.P.C.); (B.-G.B.); (D.-I.D.); (L.A.G.); (A.V.C.)
| | - Bogdan-Gabriel Bratu
- Department of Neurosurgery, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (C.T.); (R.-A.C.-B.); (H.P.C.); (B.-G.B.); (D.-I.D.); (L.A.G.); (A.V.C.)
| | - David-Ioan Dumitrascu
- Department of Neurosurgery, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (C.T.); (R.-A.C.-B.); (H.P.C.); (B.-G.B.); (D.-I.D.); (L.A.G.); (A.V.C.)
| | - Luca Andrei Glavan
- Department of Neurosurgery, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (C.T.); (R.-A.C.-B.); (H.P.C.); (B.-G.B.); (D.-I.D.); (L.A.G.); (A.V.C.)
| | - Alexandru Vlad Ciurea
- Department of Neurosurgery, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (C.T.); (R.-A.C.-B.); (H.P.C.); (B.-G.B.); (D.-I.D.); (L.A.G.); (A.V.C.)
- Neurosurgery Department, Sanador Clinical Hospital, 010991 Bucharest, Romania
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Sherif T, Twele F, Meller S, Müller-Anders A, Volk HA. Quantification of spinal ataxia in dogs with thoracolumbar spinal cord injury. Front Vet Sci 2023; 10:1183755. [PMID: 37614460 PMCID: PMC10442642 DOI: 10.3389/fvets.2023.1183755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 07/27/2023] [Indexed: 08/25/2023] Open
Abstract
The clinical sign of ataxia is related to several neurological diseases and is seen in conjunction with paresis in dogs with spinal cord injury (SCI). Endeavours to objectify canine spinal ataxia in SCI remain limited. The aim of this clinical study was to determine and quantify differences between gait characteristics of ataxic dogs with thoracolumbar myelopathy and healthy control dogs using a computer-and treadmill-based gait analysis system. Five dogs with spinal ataxia and six healthy dogs underwent video-and computer-assisted gait analysis while walking on a four-ground reaction force plate treadmill system (maximum speed of 0.7 m/s). Spatio-temporal and kinetic gait characteristics regarding the dogs' locomotion were analysed with a focus on the individual coefficient of variation (CV), as a potential measure for quantification of the level of ataxia. Ataxic dogs with thoracolumbar SCI showed no effect on symmetry indices but higher variability in spatio-temporal and kinetic gait parameters mainly in the pelvic, but also in the thoracic limbs. Double support phase of the individual limb was prolonged in SCI dogs at the cost of the single support and swing phase. Reduced peaks of ground reaction forces (GRF) could potentially be explained by reduction of muscle strength, as a strategy of avoiding falling by taking enthusiastic steps, or by alteration of the rhythmogenic spinal circuits between the pelvic and thoracic limb pattern generators.
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Affiliation(s)
| | | | | | | | - Holger A. Volk
- Department of Small Animal Medicine and Surgery, University of Veterinary Medicine Hannover, Hannover, Germany
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Sherif T, Twele F, Meller S, Müller-Anders A, Volk HA. Quantification of phenobarbital-induced ataxia in dogs with idiopathic epilepsy. Front Vet Sci 2023; 10:1168335. [PMID: 37275612 PMCID: PMC10232958 DOI: 10.3389/fvets.2023.1168335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 05/03/2023] [Indexed: 06/07/2023] Open
Abstract
Ataxia is a clinical sign seen in several neurological diseases and has been reported as an adverse effect of anti-seizure medication such as phenobarbital (PB). Efforts to objectify canine ataxia in order to provide appropriate treatment or monitor adverse effects of drugs remain limited. Automated quantitative gait analysis can be useful for the acquisition of objective data for the evaluation and monitoring of ataxia in dogs. The aim of this prospective clinical study was to examine the gait characteristics of dogs with PB induced ataxia and compare them with healthy dogs using a computer- and treadmill-based gait analysis system. Six healthy dogs and five dogs with idiopathic epilepsy (IE) with PB-induced ataxia underwent video- and computer-assisted gait analysis during slow walking (maximum speed of 0.7 m/s) on a treadmill with four ground reaction force plates (one plate per limb). Kinetic and spatio-temporal gait parameters of dogs' locomotion were analyzed, including individually calculated coefficients of variation. Dogs with IE treated with PB showed higher variability in spatio-temporal but not in kinetic gait parameters. Double support phase of gait cycles was increased on the cost of single support and swing phases. Body weight standardized ground reaction forces in vertical, craniocaudal, and mediolateral direction were severely affected by ataxia. Compensatory mechanisms in locomotion of dogs with PB-induced ataxia included spatio-temporal and kinetic gait characteristics, most likely in order to compensate imbalance caused by limb incoordination.
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Affiliation(s)
- Tamara Sherif
- Department of Small Animal Medicine and Surgery, University of Veterinary Medicine Hannover, Hannover, Germany
| | - Friederike Twele
- Department of Small Animal Medicine and Surgery, University of Veterinary Medicine Hannover, Hannover, Germany
| | - Sebastian Meller
- Department of Small Animal Medicine and Surgery, University of Veterinary Medicine Hannover, Hannover, Germany
| | - Alexandra Müller-Anders
- Department of Small Animal Medicine and Surgery, University of Veterinary Medicine Hannover, Hannover, Germany
| | - Holger A Volk
- Department of Small Animal Medicine and Surgery, University of Veterinary Medicine Hannover, Hannover, Germany
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Engelsman D, Sherif T, Meller S, Twele F, Klein I, Zamansky A, Volk HA. Measurement of Canine Ataxic Gait Patterns Using Body-Worn Smartphone Sensor Data. Front Vet Sci 2022; 9:912253. [PMID: 35990267 PMCID: PMC9386067 DOI: 10.3389/fvets.2022.912253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 06/09/2022] [Indexed: 11/13/2022] Open
Abstract
Ataxia is an impairment of the coordination of movement or the interaction of associated muscles, accompanied by a disturbance of the gait pattern. Diagnosis of this clinical sign, and evaluation of its severity is usually done using subjective scales during neurological examination. In this exploratory study we investigated if inertial sensors in a smart phone (3 axes of accelerometer and 3 axes of gyroscope) can be used to detect ataxia. The setting involved inertial sensor data collected by smartphone placed on the dog's back while walking in a straight line. A total of 770 walking sessions were evaluated comparing the gait of 55 healthy dogs to the one of 23 dogs with ataxia. Different machine learning techniques were used with the K-nearest neighbors technique reaching 95% accuracy in discriminating between a healthy control group and ataxic dogs, indicating potential use for smartphone apps for canine ataxia diagnosis and monitoring of treatment effect.
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Affiliation(s)
- Daniel Engelsman
- The Hatter Department of Marine Technologies, University of Haifa, Haifa, Israel
| | - Tamara Sherif
- Department of Small Animal Medicine and Surgery, University of Veterinary Medicine Hanover, Hanover, Germany
| | - Sebastian Meller
- Department of Small Animal Medicine and Surgery, University of Veterinary Medicine Hanover, Hanover, Germany
| | - Friederike Twele
- Department of Small Animal Medicine and Surgery, University of Veterinary Medicine Hanover, Hanover, Germany
| | - Itzik Klein
- The Hatter Department of Marine Technologies, University of Haifa, Haifa, Israel
| | - Anna Zamansky
- Information Systems Department, University of Haifa, Haifa, Israel
- *Correspondence: Anna Zamansky
| | - Holger A. Volk
- Department of Small Animal Medicine and Surgery, University of Veterinary Medicine Hanover, Hanover, Germany
- Center for Systems Neuroscience, Hanover, Germany
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Huenerfauth EI, Bien CG, Bien C, Volk HA, Meyerhoff N. Case Report: Anti-GABAA Receptor Encephalitis in a Dog. Front Vet Sci 2022; 9:886711. [PMID: 35812851 PMCID: PMC9262380 DOI: 10.3389/fvets.2022.886711] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 05/25/2022] [Indexed: 01/21/2023] Open
Abstract
Autoantibodies against neurotransmitter receptors detected in cerebrospinal fluid (CSF) and serum are increasingly recognized in people with human autoimmune encephalitis causing severe neurological deficits, such as seizures and behavioral abnormalities. This case report describes the first encephalitis associated with antibodies against the γ-aminobutyric acid-A receptor (GABAAR) in a dog. A young male intact Cavalier King Charles Spaniel was presented with recent onset of initial multiple generalized tonic-clonic seizures progressing into a status epilepticus. Interictally, he showed alternating stupor and hyperexcitability, ataxia, pleurothotonus and circling behavior to the left side. Magnetic resonance imaging (MRI) of the brain showed breed-specific anatomical abnormalities. Standard CSF analysis was unremarkable. Despite treatment with multiple antiseizure medications (ASMs) seizures and behavior abnormalities sustained. Immunotherapy with dexamethasone was started on the fifth day after disease manifestation. This led to rapid improvement of clinical signs. An extensive antibody search in CSF and serum demonstrated a neuropil staining pattern on a tissue-based assay compatible with GABAAR antibodies. The diagnosis was confirmed by binding of serum and CSF antibodies to GABAAR transfected Human Embryonic Kidney cells. The serum titer was 1:320, the CSF titer 1:2. At the control visit 4.5 weeks after start of immunotherapy, the dog was clinically normal. The GABAAR antibody titer in serum had strongly decreased. The antibodies were no longer detectable in CSF. Based on clinical presentation and testing for GABAAR binding antibodies, this describes the first veterinary patient with an anti-GABAAR encephalitis with a good outcome following ASM and corticosteroid treatment.
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Affiliation(s)
- Enrice I. Huenerfauth
- Department of Small Animal Medicine and Surgery, University of Veterinary Medicine Foundation, Hannover, Germany
- *Correspondence: Enrice I. Huenerfauth
| | | | | | - Holger A. Volk
- Department of Small Animal Medicine and Surgery, University of Veterinary Medicine Foundation, Hannover, Germany
| | - Nina Meyerhoff
- Department of Small Animal Medicine and Surgery, University of Veterinary Medicine Foundation, Hannover, Germany
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Bhattacharjee S, Ceri Davies D, Holland JC, Holmes JM, Kilroy D, McGonnell IM, Reynolds AL. On the importance of integrating comparative anatomy and One Health perspectives in anatomy education. J Anat 2022; 240:429-446. [PMID: 34693516 PMCID: PMC8819042 DOI: 10.1111/joa.13570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 08/24/2021] [Accepted: 10/05/2021] [Indexed: 12/02/2022] Open
Abstract
As a result of many factors, including climate change, unrestricted population growth, widespread deforestation and intensive agriculture, a new pattern of diseases in humans is emerging. With increasing encroachment by human societies into wild domains, the interfaces between human and animal ecosystems are gradually eroding. Such changes have led to zoonoses, vector-borne diseases, infectious diseases and, most importantly, the emergence of antimicrobial-resistant microbial strains as challenges for human health. Now would seem to be an opportune time to revisit old concepts of health and redefine some of these in the light of emerging challenges. The One Health concept addresses some of the demands of modern medical education by providing a holistic approach to explaining diseases that result from a complex set of interactions between humans, environment and animals, rather than just an amalgamation of isolated signs and symptoms. An added advantage is that the scope of One Health concepts has now expanded to include genetic diseases due to advancements in omics technology. Inspired by such ideas, a symposium was organised as part of the 19th International Federation of Associations of Anatomists (IFAA) Congress (August 2019) to investigate the scope of One Health concepts and comparative anatomy in contemporary medical education. Speakers with expertise in both human and veterinary anatomy participated in the symposium and provided examples where these two disciplines, which have so far evolved largely independent of each other, can collaborate for mutual benefit. Finally, the speakers identified some key concepts of One Health that should be prioritised and discussed the diverse opportunities available to integrate these priorities into a broader perspective that would attempt to explain and manage diseases within the scopes of human and veterinary medicine.
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Affiliation(s)
| | - D. Ceri Davies
- Human Anatomy UnitDepartment of Surgery and CancerImperial College LondonLondonUK
| | - Jane C. Holland
- Department of Anatomy and Regenerative MedicineRoyal College of Surgeons in Ireland University of Medicine and Health SciencesDublinIreland
| | | | - David Kilroy
- School of Veterinary MedicineUniversity College DublinDublinIreland
| | - Imelda M. McGonnell
- Department of Comparative Biomedical SciencesRoyal Veterinary CollegeLondonUK
| | - Alison L. Reynolds
- School of Veterinary MedicineUniversity College DublinDublinIreland
- Conway Institute of Biomolecular and Biomedical ResearchUniversity College DublinDublinIreland
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Pukale DD, Farrag M, Leipzig ND. Detection of locomotion deficit in a post-traumatic syringomyelia rat model using automated gait analysis technique. PLoS One 2021; 16:e0252559. [PMID: 34762669 PMCID: PMC8584658 DOI: 10.1371/journal.pone.0252559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 10/24/2021] [Indexed: 11/24/2022] Open
Abstract
Syringomyelia (SM) is a spinal cord disorder in which a cyst (syrinx) filled with fluid forms in the spinal cord post-injury/disease, in patients syrinx symptoms include loss of pain and temperature sensation or locomotion deficit. Currently, there are no small animal models and connected tools to help study the functional impacts of SM. The objective of this study was to determine the detectability of subtle locomotion deficits due to syrinx formation/expansion in post-traumatic syringomyelia (PTSM) rat model using the recently reported method of Gait Analysis Instrumentation, and Technology Optimized for Rodents (GAITOR) with Automated Gait Analysis Through Hues and Areas (AGATHA) technique. First videos of the rats were collected while walking in an arena (using GAITOR) followed by extracting meaningful locomotion information from collected videos using AGATHA protocol. PTSM injured rats demonstrated detectable locomotion deficits in terms of duty factor imbalance, paw placement accuracy, step contact width, stride length, and phase dispersion parameters compared to uninjured rats due to SM. We concluded that this technique could detect mild and subtle locomotion deficits associated with PTSM injury, which also in future work could be used further to monitor locomotion responses after different treatment strategies for SM.
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Affiliation(s)
- Dipak D. Pukale
- Department of Chemical, Biomolecular, and Corrosion Engineering, University of Akron, Akron, Ohio, United States of America
| | - Mahmoud Farrag
- Integrated Bioscience Program, University of Akron, Akron, Ohio, United States of America
| | - Nic D. Leipzig
- Department of Chemical, Biomolecular, and Corrosion Engineering, University of Akron, Akron, Ohio, United States of America
- Integrated Bioscience Program, University of Akron, Akron, Ohio, United States of America
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A double-blinded randomised dietary supplement crossover trial design to investigate the short-term influence of medium chain fatty acid (MCT) supplement on canine idiopathic epilepsy: study protocol. BMC Vet Res 2019; 15:181. [PMID: 31146740 PMCID: PMC6543566 DOI: 10.1186/s12917-019-1915-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 05/14/2019] [Indexed: 01/23/2023] Open
Abstract
Background Epilepsy is the most common brain disease in dogs. Recently, diets have been reported to have a positive impact on seizure activity and behaviour in various species including dogs with idiopathic epilepsy (IE). Historically, classic high fat ketogenic diets (KD) and medium chain triglycerides (MCT) KD have been successfully used to manage drug-resistant epilepsy. Similarly, an MCT enriched diet has been shown to improve seizure control and behavioural comorbidities in some dogs with IE. However, it is unknown whether an MCT dietary supplement (DS) may provide similar positive effects. Methods A 6-month prospective, randomised, double-blinded, placebo-controlled, crossover, multicentre dietary trial is designed comparing a 9% metabolic energy based calculated medium-chain triglyceride (MCT) oil supplement to a conventional ‘control’ DS. Only dogs which will have an International Veterinary Epilepsy Task Force Tier II level like diagnosis of IE which satisfied the following inclusion criteria are included: age between 6 months and ≤ 12 years; weighing between 4 and ≤ 65 kg; unremarkable interictal neurological examinations; no clinically significant findings on routine laboratory diagnostics; unremarkable brain MRI scan; have had at least 3 seizures in the previous 3 months prior to enrolment; treated with at least one ASD and being classified as resistant. All dogs are fed initially for 90 ± 2 days with either the control oil or the MCT oil alongside their normal diet, followed by 97 ± 2 days with the other supplement including a 7-day washout period. Overall, the aim is to recruit thirty-six patients at five different centres and to investigate the effect of MCTs as DS on seizure activity, tolerability, behavioural comorbidities and quality of life (QoL). Discussion Dietary interventions are rarely studied in a standardised form in veterinary medicine. The background diet, the cohort of animals and ASD received is standardised in this prospective diet trial to ensure representative data about the potential effect of MCT DS. If the study data confirms former findings, this would provide further evidence for the efficacy of MCTs as a management option for canine epilepsy. This publication should offer a repository of trial conditions and variable description with forecasted statistical analysis. Electronic supplementary material The online version of this article (10.1186/s12917-019-1915-8) contains supplementary material, which is available to authorized users.
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Nalborczyk ZR, McFadyen AK, Jovanovik J, Tauro A, Driver CJ, Fitzpatrick N, Knower SP, Rusbridge C. MRI characteristics for "phantom" scratching in canine syringomyelia. BMC Vet Res 2017; 13:340. [PMID: 29145838 PMCID: PMC5691609 DOI: 10.1186/s12917-017-1258-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2017] [Accepted: 11/07/2017] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND A classic sign of canine syringomyelia (SM) is scratching towards one shoulder. Using magnetic resonance imaging (MRI) we investigate the spinal cord lesion relating to this phenomenon which has characteristics similar to fictive scratch secondary to spinal cord transection. Medical records were searched for Cavalier King Charles spaniels with a clinical and MRI diagnosis of symptomatic SM associated with Chiari-like malformation (CM). The cohort was divided into SM with phantom scratching (19 dogs) and SM but no phantom scratching (18 dogs). MRI files were anonymised, randomised and viewed in EFILM ™. For each transverse image, the maximum perpendicular dimensions of the syrinx in the dorsal spinal cord quadrants were determined. Visual assessment was made as to whether the syrinx extended to the superficial dorsal horn (SDH). RESULTS We showed that phantom scratching appears associated with a large dorsolateral syrinx that extends to the SDH in the C3-C6 spinal cord segments (corresponding to C2-C5 vertebrae). Estimated dorsal quadrant syrinx sizes based on the perpendicular diameters were between 2.5 and 9.5 times larger in dogs with phantom scratching, with the largest mean difference p-value being 0.009. CONCLUSION SM associated phantom scratching appears associated with MRI findings of a large syrinx extending into the mid cervical SDH. We hypothesise that damage in this region might influence the lumbosacral scratching central pattern generator (CPG). If a scratching SM affected dog does not have a large dorsolateral cervical syrinx with SDH involvement then alternative explanations for scratching should be investigated.
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Affiliation(s)
- Zoe R Nalborczyk
- School of Veterinary Medicine, Faculty of Health & Medical Sciences, Daphne Jackson Road, Guildford, Surrey, GU2 7AL, UK
| | | | - Jelena Jovanovik
- Fitzpatrick Referrals Orthopaedics and Neurology, Halfway Lane, Eashing, Godalming, Surrey, UK
| | - Anna Tauro
- Fitzpatrick Referrals Orthopaedics and Neurology, Halfway Lane, Eashing, Godalming, Surrey, UK
| | - Colin J Driver
- Fitzpatrick Referrals Orthopaedics and Neurology, Halfway Lane, Eashing, Godalming, Surrey, UK
| | - Noel Fitzpatrick
- School of Veterinary Medicine, Faculty of Health & Medical Sciences, Daphne Jackson Road, Guildford, Surrey, GU2 7AL, UK.,Fitzpatrick Referrals Orthopaedics and Neurology, Halfway Lane, Eashing, Godalming, Surrey, UK
| | - Susan P Knower
- School of Veterinary Medicine, Faculty of Health & Medical Sciences, Daphne Jackson Road, Guildford, Surrey, GU2 7AL, UK
| | - Clare Rusbridge
- School of Veterinary Medicine, Faculty of Health & Medical Sciences, Daphne Jackson Road, Guildford, Surrey, GU2 7AL, UK. .,Fitzpatrick Referrals Orthopaedics and Neurology, Halfway Lane, Eashing, Godalming, Surrey, UK.
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