C10016701 / invoice 10000

11/03/2026 NURSE: LM

REASON: referral from Lindisfarne Vet - suspect IVDD

HISTORY:
Sudden onset crying out and hesitation to move on friday, shaking and panting
Seen at AES - mild proprioceptive deficit left hind and not placing hind feet well.
Has since improved 
CURRENT MEDICATIONS: prednsiolone 5mg BID (ceased saturday morning), gabapentin 200mg BID, amanatdine SID, paracetamol 135mg BID, fentanyl patch 

CLINICAL EXAMINATION
Mentation: BAR
MM: Pink
CRT: 1 sec
HR: 120
RR: panting

NEURO:
Sensorium and behaviour
- Normal
Cranial Nerves
-  NAD
Posture and Gait
- Ambulatory - hind limb ataxia 
Postural Reactions
- Mild proprioceptive delay in L hind
Spinal reflexes & muscle tone
- Muscle tone/mass - NAD
- Patella reflexes - exagerated 
- Withdrawal reflex - normal 
- Perineal reflex - normal
- Cutaneous Trunci - 
Sensation and Pain
- Deep pain present 
- Superficial sensation present

ASSESSMENT:
Grade 2/5 spinal, suspect T3-L3 

DISCUSSION:
Spinal diseases that cause ataxia/paresis 
- Disc disease Type I,II and ANNPE
- FCE, focal meningitis, neoplasia, haemorrhage and trauma 
Disc disease in detail 
Diagnostics including CT, myelogram, CSF analysis (+/- MRI)
Higher risk GA in brachycephalics 
Hemilaminectomy surgery to decompress depending on CT results 


PLAN:
CT scan +/- myeolgram today 
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REASON: CT Myelogramme

NURSE: LM

LABORATORY:
PreGA - ALT 142 10 - 125 U/L
PCV - 52

SEDATION:
Methadone: 0.5mls IM
Medetomidine: 0.06mls IM + 0.02ml IV in recovery 

Level of sedation: Profound

ANAESTHESIA: 
Induction: I/V Alfaxan    
Maintenance: Isoflurane
Fluids (Surgical rates 5-10ml/kg): 67ml/hr

CT SCAN: (performed at VIT-NH)
Helical scan of spine - C1-sacrum
Bone and soft tissue algorithms performed

TREATMENT:
IV contrast administered
Omnipaque 300mg/ml (2mls/Kg) - 28mls

Helical scans repeated post contrast administration
IV fluids maintained @ 10ml/Kg post contrast for 10 minutes

MYELOGRAM:
Lumbarpuncture L5/6
CSF collected for analysis
Omnipaque - 4mls (0.3mls/kg) injected into subarachnoid space 

CT Scan post Myelogram:
Helical scan repeated

L2/3 - extradural non-mineralised lesion causing mild L sided compression 
T... - Vertebral malformations including hemivertebrae, butterfly and wedge vertebrae causing moderate kyphosis (typical for the breed)

ASSESSMENT:
L2/3 - disc extrusion causing mild L sided cord compression

PLAN:
Conservative management at this stage
RV with Zoe in 1 week 
RV with GHS in 2 and 4 weeks