Opinion: A Different Approach to Spinal Cord Injury—Acupuncture and Rehabilitation as an Alternative to Surgery

by Narda Robinson, DVM, DO, MS, FAAMA, and Michael C. Petty, DVM, CCRT, CVPP, DAAPM

When do we cut and when do we find an alternative? Recently, a cat owner from England reached out to us because she had read an article by Narda Robinson, DVM, DO, about the value of medical acupuncture for the treatment of intervertebral disc disease (IVDD) as a nonsurgical option. The 15-year-old cat had a suspected spinal cord injury (SCI) and her veterinarian gave her only two choices: surgery or euthanasia. He advised the latter owing to the cat’s age. Heartbroken, the cat’s owner desperately began seeking alternatives, thinking that there should be other options. While the cat did not ultimately receive treatment from us, the owner’s instincts were right—there are other options.

Many animals with neurologic compromise from SCI can recover just as well, or better, without surgery. The problem, as we see it, is that too few veterinarians—especially those in the surgical specialties—know the science and evidence of medical acupuncture and related techniques. Instead, many rapidly dismiss these effective, neuromodulatory approaches as worthless woo-woo. As such, they not only fail to communicate vital information about nonsurgical options to clients but also deprive their patients of the value of an integrative rehabilitation program that could save animals’ lives and avoid breaking the hearts of those who love them.

The mounting empirical and experimental evidence in favor of spinal cord stimulation for neurologic recovery, in combination with integrative rehabilitation, raises the question of whether surgical intervention should even remain the de facto treatment of choice for small animals (typically dogs) with para- or tetraparesis due to IVDD, or even SCI in general.

Science-based treatments such as medical acupuncture and photomedicine stimulate spinal cord repair noninvasively, accelerating return to function and restoration of a pain-free existence without the high cost of surgery and ensuing complications. Surely, given that scientific, rational, and effective alternatives exist and already show evidence of value, our clients should hear about them and have the option to pursue them.

The Case for Nonsurgical Treatment

Surgery causes pain and trauma even under the best circumstances. However, perioperative complications of surgery for IVDD or other causes of SCI include poliomyelomalacia and other life-threatening complications from anesthesia, priapism, hemorrhagic myelomalacia, surgical site infections, discospondylitis, recurrence of neurologic signs or disc protrusion, pneumorrhachis, clot emboli, long-term postoperative pain, pyogranulomatous inflammation, and more. Considering that IVDD surgery may not even result in the removal of compressive disc material; may not deliver significant, eventual improvement; and may require further invasive procedures to remedy complications it causes, this commonly touted “gold standard” remains far from a slam dunk.

Furthermore, decades of research on SCI have verified that central nervous system tissue can, and does, heal, thereby restoring neurologic communication between peripheral nerves and the brain. However, the likelihood that a para- or tetraplegic individual regains the ability to ambulate increases with access to treatment that addresses the key source of long-term morbidity for patients—i.e., secondary SCI. While surgery targets the initial, traumatic, mechanical impact of IVDD leading to primary SCI, is disrupting the structural integrity of the spine and its supporting soft tissues, in order to find and remove disc material, actually in the patient’s long-term interests?

Human research has shown that even patients with massive disc herniation, where extruded disc material occupies 50% or more of the anteroposterior diameter of the spinal canal, can achieve favorable outcomes. First documented in 1984, spontaneous regression of herniated nucleus pulposus not only happens, but a study in the Annals of the Royal College of Surgeons of England by Benson et al. indicates “that the largest lumbar intervertebral disk herniations have the greatest ability to regress over time.” Thus, for more than 10 years, human findings have shown the following: A “wait and watch” approach for massive disc herniation constitutes a reasonable approach if there are early signs of clinical improvements; when clinical improvement is apparent, massive prolapses do not raise the risk of major nerve damage or cauda equina syndrome; and massive disc herniations typically reduce in size to a third of the original volume after six months.

Going Forward

So how do we achieve clinical improvements? Those of us in the integrative rehabilitation community have found that medical acupuncture and related techniques (e.g., photomedicine) lead to profound improvements (e.g., ambulation and analgesia) in dogs with IVDD in the majority of cases. Time after time, we find that dogs with SCI who receive these techniques, especially when provided promptly after onset, demonstrate remarkable capacity to recover in the absence of surgery. This then shifts the paradigm from “cut to cure” to “protect to cure” and encourages the institution of rational, science-based integrative medicine, coupled with carefully instituted rehabilitation, without delay.

Modern research indicates that the bulk of long-term morbidity as a consequence of SCI arises because of the secondary pathophysiologic changes following a traumatic event such as disc herniation. While a surgical approach may address the primary insult of mechanical compression, it does not avert or address secondary injury. And with the information that disc material may spontaneously regress, turning our focus to lessening, eliminating, or even reversing secondary injury paves the way to greater possibilities to regain function and resume normal activities of daily living.

The heterogeneity of secondary SCI ensues after the initial insult, leading to multifaceted pathological changes involving circulatory compromise, neuroinflammation, oxidative stress, neuronal injury and death, glutamatergic cytotoxicity, demyelination, and disruptive changes in the functional neural network. From an integrative medicine standpoint, medical acupuncture and the related approach of photomedicine (i.e., therapeutic laser and light-emitting diodes) counter inflammation, edema, spinal cord wind-up, and circulatory compromise. By including careful, patient-tailored rehabilitation in these physical medicine measures, individuals recovering from SCI can achieve a return to function and pain-free existence, even in the absence of surgery.

In the Literature

Several studies in the veterinary literature reinforce our observations. Studies reported in the Journal of the American Veterinary Medical Association have shown, for example, that electroacupuncture (i.e., acupuncture coupled with electrical stimulation) was more effective than decompressive surgery for the recovery of ambulation and alleviation of neurologic deficits in dogs, even those with long-standing and severe neurologic compromise from thoracolumbar (TL) IVDD (Joaquim et al. 2010). Electroacupuncture hastened recovery from TL IVDD as compared with conservative measures alone (Hayashi, Matera, and de Campos Fonseca Pinto 2007), and electroacupuncture lessens the severity of pain, even in dogs who did receive surgery (Laim et al. 2009).

Electroacupuncture is a noninvasive version of targeted electrical stimulation. While much of the human research on SCI recovery involves the implantation of epidural electric stimulators, electroacupuncture avoids the tissue trauma and disruption of neurosurgery. Additional advantages include stimulation of somatic afferent fibers supplying muscles and their enveloping or investing fascial tissues, thereby contributing to improved spinal column integrity through enhanced neuromotor control over joint integrity.

While canine SCI patients also appear to benefit by coupling therapeutic rehabilitation with acupuncture, rehabilitation without acupuncture may not provide similar benefits, as indicated by a 2018 study on dogs with and without intensive rehabilitation after surgical decompression of acute TL intervertebral disc herniation (Zidan et al. 2018). Human research reinforces the value of this sort of multimodal approach.

Conclusion

One of the best things I (Michael Petty) learned during veterinary school at Michigan State University was to question everything: not only things like presenting signs, diagnosis, lab work that doesn’t fit with what you are seeing, and more, but also more basic things like accepted therapies. The reality is that there is probably a different way of doing things. And that different way may be better or even the same in terms of outcome but with less cost to the owner, and less impact on the animal.

For example, the American Veterinary Dental Society had one treatment for something called a base-narrow defect wherein the canine teeth were destined to grow into the roof of the mouth because they were pointed that way. They advised a complex orthodontic device called an inclined bite plane. This gradually moved the teeth into their proper alignment. Then someone realized that if you simply encouraged the dog to bite on rubber balls of ever-increasing sizes, then the teeth would shift to a normal position. And what were the only costs? The rubber balls and some playtime with your dog, compared with anesthesia and an expensive oral device.

We can all improve the science of veterinary medicine by always asking whether there might be a better way to do something. Better because it is more affordable, better because it avoids possible comorbidities brought on by the treatment, and better because it serves the animal in a reliable and less painful method.

References

Hayashi, A. M., J. M. Matera, and A. C. Brandão de Campos Fonseca Pinto. 2007. “Evaluation of Electroacupuncture Treatment for Thoracolumbar Intervertebral Disk Disease in Dogs.” Journal of the American Veterinary Medical Association 231, no. 6 (September): 913–918. avmajournals.avma.org/doi/abs/10.2460/javma.231.6.913?journalCode=javma.

Joaquim, J. G. F., S. P. L. Luna, J. T. Brondani, S. R. Torelli, S. C. Rahal, and F. de P. Freitas. 2010. “Comparison of Decompressive Surgery, Electroacupuncture, and Decompressive Surgery Followed by Electroacupuncture for the Treatment of Dogs with Intervertebral Disk Disease with Long-Standing Severe Neurologic Deficits.” Journal of the American Veterinary Medical Association 236, no. 11 (June): 1225–1229. avmajournals.avma.org/doi/abs/10.2460/javma.236.11.1225.

Laim, A., A. Jaggy, F. Forterre, M. G Doherr, G. Aeschbacher, and O. Glardon. 2009. “Effects of Adjunct Electroacupuncture on Severity of Postoperative Pain in Dogs Undergoing Hemilaminectomy Because of Acute Thoracolumbar Intervertebral Disk Disease.” Journal of the American Veterinary Medical Association 234, no. 9 (May): 1141–1146. pubmed.ncbi.nlm.nih.gov/19405884/.

Zidan, N., C. Sims, J. Fenn, K. Williams, E. Griffith, P. J. Early, C. L. Mariani, K. R. Munana, J. Guevar, and N. J. Olby. 2018. “A Randomized, Blinded, Prospective Clinical Trial of Postoperative Rehabilitation in Dogs After Surgical Decompression of Acute Thoracolumbar Intervertebral Disc Herniation.” Journal of Veterinary Internal Medicine 32, no. 2 (May–June): 1133–1144. ncbi.nlm.nih.gov/pmc/articles/PMC5980307/.

Narda Robinson, DVM, DO, MS, FAAMA, is a leading authority on scientific integrative medicine. In 1998, she launched Colorado State University’s (CSU’s) first integrative medicine service and for eight years directed CSU’s Center for Comparative and Integrative Pain Medicine. Robinson now teaches through CuraCore Vet and CuraCore Med as founder and president. Robinson holds a bachelor of arts degree from Harvard University/Radcliffe College, a doctorate in osteopathic medicine from the Texas College of Osteopathic Medicine, and a doctorate in veterinary medicine and master’s degree in biomedical sciences from the CSU College of Veterinary Medicine and Biomedical Sciences. She is a fellow of the American Academy of Medical Acupuncture (AAMA). She also serves on the American Board of Medical Acupuncture, the board-certifying organization for physician medical acupuncturists, and the AAMA Board of Directors.

Michael C. Petty, DVM, CCRT, CVPP, DAAPM, is in private practice in Canton, Michigan. He is a frequent national and international lecturer on topics related to pain management. Petty provides commentary on the Trends Pain Case of the Month (and occasionally writes one himself). He was also a member of the task force for the 2015 AAHA/AAFP Pain Management Guidelines for Dogs and Cats.

 

Photo credits: Photo courtesy of Kimberly Nelson, ©AAHA/Robin Taylor, zilli/iStock via Getty Images Plus, ~User5f9db551_246/iStock via Getty Images Plus