Kaiser Can't Walk! What Next?

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Dr Caroline Fallon and our ECC team collaborated on a patient that was suddenly unable to walk! In this Case Chronicle, we will explore the systemic method our team took to diagnose Kaiser, and we hope to provide you with some key learning points on how to deal with similar presentations in the future.


Kaiser is a 5 year old male neutered Toy Poodle that presented to our ECC department over a hectic weekend for acute paraparesis. According to the owners, Kaiser had been behaving completely fine, when he was seen to suddenly “apply the brakes” in the midst of running around. Thereafter, he started to hunch, and progressively became weaker in the hindlimbs. The owner then decided to bring Kaiser into VES for an emergency consult.

On physical examination at VES, Dr Steph from our ECC team found multiple abnormalities, including:

  • Pyrexia (39.8C)
  • Only able to stand with support, weakly ambulatory with ataxia and crossing over in the hindlimbs
  • Pain on thoracolumbar (TL) palpation
  • Resented neck manipulation

At this stage, Kaiser was determined to have a neurological issue causing his weakness and pain. He was admitted into our hospital for pain relief, strict cage rest, and close monitoring for progression of neurological signs.

Referral to Neurology

The next morning, following rounds between all our departments, Kaiser was internally referred from the ECC department to our Neurology department.
Once transferred to the Neurology department, Dr Caroline Fallon, our neurologist, repeated the neurological examination.


  • When in doubt: always start with a neurological examination.
  • Create a system for your neurological exam, and be consistent with how you perform your neurological exam.
  • A thorough neurological exam can reveal a lot about a patient, and the key is that it will allow you to neuro-anatomically localise.

Dr Caroline went through the following neurological examination in systematic fashion:

  1. Mentation
    1. Alert and responsive
  2. Posture and gait
    1. Sitting with pelvic limbs stiff and extended in front of the body
    2. Non-ambulatory severe paraparesis with no voluntary motor function on the left and minimal voluntary motor function on the right
    3. Left hindlimb knuckled when supported to stand and walk, right intermittently placed correctly.
  3. Cranial nerves (the following should be assessed as part of a cranial nerve exam); all were normal for Kaiser:
    1. Vision
    2. Menace response
    3. Direct PLR
    4. Indirect PLR
    5. Palpebral reflex
    6. Physiologic nystagmus
    7. Facial sensation
    8. Pinnae sensation
    9. Swallowing/gag
    10. Tongue movement
  4. Postural reactions
    1. Knuckling: Absent in both hindlimbs
    2. Hopping: Absent in both hindlimbs
  5. Segmental reflexes
    1. Forelimb withdrawal reflex: Normal
    2. Patellar reflex: Mildly increased bilaterally
    3. Hindlimb withdrawal reflex: Normal bilaterally
  6. Other reflexes
    1. Panniculus reflex: cut off at L1-L2
    2. Tail tone and anal tone: normal
    3. Muscle tone: increased in both hindlimbs
  7. Conscious responses
    1. Hyperaesthesia: painful on spinal palpation at thoracolumbar junction
    2. Nociception: assessed on left due to lack of voluntary motor function and present; not examined on right or in front limbs as patient had voluntary motor function

Given the above results, are you able to come up with a neuro-anatomical localisation?

Click here for Dr Caroline's neuro-anatomical localisation for Kaiser.

If you have guessed T3-L3 myelopathy, you are absolutely correct!

Next, can you come up with some potential differentials for Kaiser? (Hint, there is more than just the very obvious one!)

Click here to see a list of differentials that Dr Caroline came up with.

Here are all the differentials that Dr Caroline will have to rule out in further investigations:

  • IVDD (Intervertebral Disc Disease)
  • Inflammatory disease (non-infectious vs infectious)
  • ANNPE (Acute Non-compressive Nuclear Pulpous Extrusion)
  • FCE (Fibrocartilaginous emboli)
  • Neoplasia

Next Steps

At this stage, we were highly suspicious Kaiser has, you guessed it, IVDD. An MRI was recommended to determine if IVDD was the root cause – and it was. Due to Kaiser being unable to walk and having progressive clinical signs, surgery was recommended. (If IVDD had not been the cause, then CSF analysis would be indicated.)


When is the right time to send a patient over for referral or consider advanced imaging?

The short answer is: if you are worried about anything at all – it is NEVER wrong to refer a patient for a further opinion, and referral is always an appropriate choice.
We should definitely refer and consider advanced imaging if the patient has the following:

  • Any neurological deficits
  • Progressive neurological symptoms
  • Inability to walk/Non-ambulatory

MRI Results

On the MRI – compressive disc material was found on the left side at T11-T12 and T12-T13, a diagnosis consistent with the physical exam findings, and indicative of IVDD Type I. A hemilaminectomy was indicated to remove the disc material causing compression in the region of T11 – T13.

a) T2 sagittal T2 image. The orange lines indicate where the transverse images were acquired and the three green lines indicate where the image b) is located
b) T2 transverse image. The blue arrow points at the spinal cord. The purple arrow is pointing to disc material which is T2 hyperintense (brighter) compared to the spinal cord. This material is causing the compression and shifting the spinal cord to the right side.


On confirmation of the diagnosis, consent was obtained from the owners and the patient was immediately taken to surgery with Dr Caroline. Over the course of surgery, Dr Caroline removed a significant amount of disc material from T11-T12 and a smaller amount of disc material from T12-T13, as well as diffuse haemorrhagic clots throughout both sites.


The surgery went without a hitch and Kaiser was hospitalised overnight with our ECC team. On a recheck the next morning, 12 hours post-surgery, Dr Caroline performed a repeat neurological examination and found multiple improvements in Kaiser’s condition, including:

  • Improved motor function in both hindlimbs.
  • Panniculus reflex: Normal on the right and L3 on left, as opposed to cut off at L1-L2 prior to surgery.
  • Spinal palpation: now comfortable, with normal cervical ROM – Kaiser was painful on TL palpation and resented neck manipulation prior to surgery.

Kaiser was kept one more night, with continued improvement noted on the parameters above, and was discharged 36 hours after surgery, to the delight of his owners!

Prognosis after IVDD Surgery

IVDD cases that end up having to undergo surgery can have very satisfying outcomes when approached in the right manner and when quick intervention is taken. Statistically, patients with voluntary motor function and paraplegic patients with nociception (deep or superficial pain sensation) in either hindlimb or the tail have an excellent prognosis with surgery – 85-95% of these patients are able to return to normal function.

If a patient is paraplegic and has lost nociception, the prognosis is still excellent with rapid intervention (i.e. surgery in the first 24 hours after loss of nociception). However, if they have been paraplegic with absent nociception for greater than 24 hours, the chance for recovery with surgery decreases to 50%. Additionally, cases that are paraplegic without nociception are at risk for myelomalacia.

Recent publications have also revealed that French Bulldogs do not always follow the rules, and there are published reports of French Bulldogs developing myelomalacia even with immediate surgical intervention. Owners of rapidly progressive French Bulldogs and those with no voluntary motor should be counselled on the risk of myelomalacia.

Recovery Post-Surgery

After surgery, patients need to have strict cage rest for 4 weeks. Increased activity post-operatively can lead to complications including: seroma, incisional infection, additional disc herniation and severe complications such as vertebral subluxations or fractures. Healing can occur rapidly, but in some patients we can continue to see improvements months after surgery.

It is impossible to predict the timeline of recovery even with diagnostic tools such as MRI. Post-operatively, the goal is to see steady and consistent improvement every 1-2 days. In some patients like Kaiser, this can be appreciated immediately by veterinarians and owners. In other patients, improvements are subtle and often only appreciated by a veterinarian. In either category, excellent nursing care and strict rest are needed after surgery.


When in doubt, it is never wrong to refer to a neurologist to get a full neurological examination! Often times, a full neurological examination by a neurologist is the best way to start a diagnostic plan.

If you have a tricky case on your hands, you may certainly contact VES directly for any advice – our neurologist and ECC team are ready at hand to assist our fellow veterinary colleagues!

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