Nala ' s clinical signs were indicative of a worsening compression of her spinal cord, particularly lesions that affect the C1 – C5 segments of the spine; these can result in tetraparesis, primarily of the thoracic limbs, with minimal deficits in the pelvic limbs [ 9 ]. A repeat MRI was performed to rule out any possible comorbidities, as neck pain and neutrophilia are not typical signs of an SAD [ 2 ]. The MRI revealed that she had hyperintensity cranially in the cervical spine but no other changes to the thoracolumbar region.
Due to these findings, surgical intervention was required, and a dorsal laminectomy and durotomy procedure was performed. Nala had a stable general anaesthetic and the surgical procedure went well. There was a substantial amount of retained CSF with significant pressure in the diverticulum evident; this could be an indication of why her ataxia deteriorated to tetraplegia in a short amount of time [ 9 ].
Nursing care analysis
Due to the invasive nature of this surgical procedure, postoperative nursing considerations can have a significant impact on how a patient recovers [ 8 ]. Postoperative spinal patients require continuous monitoring, especially in terms of pain management, and this was integrated into Nala ' s postoperative plan.
Nala was placed on a constant-rate infusion( CRI) of ketamine( Ketaset, Zoetis, 100 mg / ml) at 2.5 µ g / kg / min post surgery, plus methadone( Comfortan, Dechra, 10 mg / ml) 0.2 mg / kg IV every 4 hours. She was pain scored using the Glasgow Composite Pain Scale between each dose. If her pain score was greater than 4, an additional dose of methadone could be given at 0.1 mg / kg, and if her pain score was greater than 6, a top-up of 0.2 mg / kg was given.
Pain scoring is integral to a veterinary nurse ' s( VN ' s) role as it affects the patient ' s care plan [ 10 ]. Nala was displaying signs of pain in the first 24 hours of her recovery: her neck carriage was low and she yelped when moving her head, alongside paroxysms of screaming, which may be common in patients with cervical spinal pain [ 11 ].
Monitoring deep pain following a spinal procedure is important, as an absence of pain could indicate a poor prognosis [ 11 ]. To assess deep pain, the periosteum is stimulated by using forceps to pinch the skin between the digits; a behavioural response should be observed( turning towards the digit) and not solely a withdrawal reflex [ 11 ]. However, as Nala ' s pain scores rose, her ketamine CRI was increased to 5 µ g / kg / min; this not only made her more recumbent but also made assessing her pain a challenge, due to her more depressed demeanour.
Due to Nala having become recumbent, her postoperative care plan was adjusted to include turning her every 4 hours to reduce the risk of hypostatic pneumonia and decubitus ulcers [ 12 ]. Bladder management was an important consideration; although Nala was able to urinate and defaecate voluntarily, she was not able to stand to void her bladder outside the kennel. Therefore, her bedding was checked and changed regularly to reduce the risk of urine and faecal scalding [ 13 ].
Physiotherapy was implemented as it aids muscle elasticity, joint mobility and nerve health [ 14 ]. Modalities included coupage to reduce the build-up of lung secretions, effleurage to improve circulation, and passive flexion and extension movements starting from the carpus / tarsus and working through all the joints of the limbs. Passive range-of-motion exercises alongside active movements through supported exercises were also integrated into Nala ' s nursing plan [ 14 ]. When she was taken for walks, she was supported with a sling to encourage her to move without causing herself injury [ 13 ]. Thomovsky and Ogata [ 14 ] state that physical rehabilitation can also aid in improving the psychological state and mental health of spinal patients; eventually this proved to be true with Nala, although initially it was a challenge.
Interactions with Nala were minimal, as actively turning her and assessing her pain caused her to become increasingly anxious when a staff member entered her kennel, as she was anticipating pain. Her anxiety meant that assessing her for pain and implementing appropriate analgesic plans became more challenging.
Anxiety and pain have similarities in their neurochemistry; they share physiological responses that can look similar enough that one could be interpreted as( or mistaken for) the other [ 15 ]. Nala ' s ketamine CRI was gradually reduced from 5 µ g / kg / min to 2.5 µ g / kg / min and then she was placed solely on methadone at 0.1 – 0.2 mg / kg administered IV every 4 hours, with the dose dependent on her pain score.
However, the nursing team noticed inconsistencies in Nala ' s behaviour. Although deterioration can occur postoperatively, it appeared that Nala was anticipating a painful stimulus that had not been introduced. She would flinch when approached in her kennel unless food was introduced as a distraction; this demonstrates the importance of assessing a canine patient ' s psychological wellbeing as well as their physical state [ 14 ].
Nala had a prolonged period of hospitalisation and had lost her sense of independence, as she needed assistance with walking and urinating in some cases. This can be a cause of stress for many patients and could have been considered more in Nala ' s recovery [ 14 ].
Nala was naturally a very anxious dog, and this was taken into consideration when analysing the behavioural traits she displayed, especially in correlation to a pain response. It was found that throughout the course of her hospitalisation, offering food helped to improve interactions with Nala, as it is a good form of positive
52 Veterinary Nursing Journal