The essential publication for BSAVA membersThe essential publication for BSAVA members

companionJUNE 2013

How ToApproach the dog with neck painP16

Nick StaceInterview with CEO of RCVSP8

Clinical ConundrumA recurrent UTIP12

Are we producing too many vets?

01 OFC June.indd 1 16/05/2013 16:46

2 | companion

CT assessment of the in uence of dynamic loading on physiological incongruency of the canine elbowIn this study, signi cant changes in humero-radio-ulnar congruency occurred, suggesti ng pronati on of the radius with respect to the ulna was induced during loading. The authors conclude that this movement may in uence the load experienced by the medial coronoid process and could play a role in the aeti opathogenesis of medial coronoid process disease.

Transverse secti oning for histological assessment of sebaceous glands in healthy dogs and canine sebaceous adeniti sThe authors conclude that transverse secti oning of canine skin specimens to allow visualizati on of the follicular isthmus or deep porti on of the common infundibulum enhances the histological assessment of sebaceous glands in both health and disease.

Prevalence, outcome and risk factors for post-operati ve pyothorax in 232 dogs undergoing thoracic surgeryThis study shows that idiopathic chylothorax, intrathoracic biopsy and prior thoracocentesis are independent risk factors for postoperati ve pyothorax.

companion is published monthly by the British Small Animal Veterinary Association, Woodrow House, 1 Telford Way, Waterwells Business Park, Quedgeley, Gloucester GL2 2AB. This magazine is a member-only bene t. Veterinary schools interested in receiving companion should email companion@bsava.com. We welcome all comments and ideas for future articles.

Tel: 01452 726700Email: companion@bsava.com

Web: www.bsava.com

ISSN: 2041-2487

Editorial BoardEditor Mark Goodfellow MA VetMB CertVR DSAM DipECVIM-CA MRCVSCPD Editor Simon Tappin MA VetMB CertSAM DipECVIM-CA MRCVSPast President Mark Johnston BVetMed MRCVS

CPD Editorial TeamPatricia Ibarrola DVM DSAM DipECVIM-CA MRCVSTony Ryan MVB CertSAS DipECVS MRCVSLucy McMahon BVetMed (Hons) DipACVIM MRCVSDan Batchelor BVSc PhD DSAM DipECVIM-CA MRCVSEleanor Raffan BVM&S CertSAM DipECVIM-CA MRCVS

Features Editorial TeamAndrew Fullerton BVSc (Hons) MRCVSMathew Hennessey BVSc MRCVS

Design and ProductionBSAVA Headquarters, Woodrow House

No part of this publication may be reproduced in any form without written permission of the publisher. Views expressed within this publication do not necessarily represent those of the Editor or the British Small Animal Veterinary Association.For future issues, unsolicited features, particularly Clinical Conundrums, are welcomed and guidelines for authors are available on request; while the publishers will take every care of material received no responsibility can be accepted for any loss or damage incurred.BSAVA is committed to reducing the environmental impact of its publications wherever possible and companion is printed on paper made from sustainable resources and can be recycled. When you have finished with this edition please recycle it in your kerbside collection or local recycling point. Members can access the online archive of companion at www.bsava.com .

3 BSAVA NewsLatest from your Association

46 Are We Producing Too Many Vets?Undergraduate veterinary training consultation results

810 A Year at the TopNick Stace CEO of the RCVS

11 Medicines Guide UpdateDetails about recent revisions

1215 Clinical ConundrumA Golden Retriever with recurrent urinary tract infection and suspected urinary incontinence

1623 How ToApproach the dog with neck pain

2425 All Go for SAVSNETSurveillance scheme set up and ready

26 Cost of Illness can Make You SickKeep your practice safe from the cost of long-term sickness absence

27 PetSaversPassive smoking and pets

2829 WSAVA NewsThe World Small Animal Veterinary Association

3031 The companion InterviewFreda Scott-Park

33 Letters from the RegionsNews from your local groups

3435 CPD DiaryWhats on in your area

Additional stock photography:www.dreamstime.com Andres Rodriguez; Angel Luis Simon Martin; Anton Starikov; Antonio Guillem; Cammeraydave; Christos Georghiou; Edyta Pawlowska; Ewa Walicka; Hong Chan; Isselee; Kirill Zdorov; Vladischern

Whats in JSAP this month?

Here are just a few of the topics that will feature in your June issue:

E cacy and safety of cimicoxib in the control of perioperati ve pain in dogsIn this study, cimicoxib demonstrated stati sti cal non-inferiority compared to carprofen. Both drugs were well tolerated.

Relati onships between heart rate and age, body weight and breed in dogsBody weight, age, breed and disease status all in uence heart rate in dogs, although these factors account for a relati vely small proporti on of the overall variability in heart rate.

Stati sti cs: using regression modelsThe latest in our series of arti cles helping practi ti oners with stati sti cs asks How are we related?, and will demonstrate the stati sti cal techniques required to reach a conclusion.

Log on to www.bsava.com to access the JSAP archive online.

EJCAP ONLINE

Dont forget that as a BSAVA member you are enti tled to free online access to EJCAP register at www.fecava.org/EJCAP to access the latest issue.

Find FECAVA on Facebook!

www.fecava.org/EJCAP to access the

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Dont miss a thing. If you are not already following the BSAVA on Twitter and Facebook, but would like to receive up to the minute updates on all things BSAVA, such as association news, membership benefits, CPD, publications, Congress and events, then sign up to Follow us on Twitter and Like us on Facebook.

The annual report from the RSPCA Prosecutions Department was issued on 30 April and its contents are shocking, even to those familiar with seeing cases of abuse.

The latest report from the RSPCA makes grim reading indeed, particularly for members of the veterinary profession, said Professor Michael Day, BSAVA President. It demonstrates all too clearly that our nation of animal lovers sadly also includes those who carry out acts of wilful cruelty, or are at least negligent in their duty of care.

BSAVA did find one positive aspect of this report however in the 78,090 welfare improvement notices that have been dispensed. As Professor Day commented, These are seen as being extremely effective in changing poor conditions for pets if steps are taken early enough, before welfare has been seriously compromised avoiding suffering for the animal and at the same time offering advice and education to a

pet owner who might otherwise become neglectful.

As some of the cases in the report illustrate, where animals are abused there may also be people at risk of violence in that household, this correlation is not uncommon and requires multi-agency involvement, which The Links Group has promoted for over 12 years.

Dr Freda Scott-Park of The Links Group said: Although many of the cases described were not presented to veterinary practices, veterinary colleagues should be aware that if they are presented with a case of animal abuse, then there may also be violence against vulnerable humans in the same household.

Dr Scott-Park was joined by Detective Inspector Linda Borland and vet Paul Roger to give a talk on dealing with cases of animal abuse at BSAVA Congress. Members of the Association can download the talk as a Congress podcast from www.bsava.com. See the interview with Dr Scott-Park on pages 3031.

RSPCA prosecutions report

Be social with BSAVA

The Frank Beattie scholarship was established in 1988 in memory of Frank, a well respected veterinary surgeon and a long-standing member of the BSAVA. It is awarded annually from a generous gift given by Franks widow, Annie. The scholarship, worth 2000, is to help a BSAVA member undertake a trip abroad to study a particular aspect of veterinary practice. To apply for this scholarship email h.field@bsava.com. The deadline for application is 26 September.

Apply for travel scholarship

The prestigious BSAVA Awards give you the chance to acknowledge the inspiring work of colleagues who have made their own exceptional contributions to our profession people we work alongside every day or those whom we admire from afar.

All members of BSAVA are eligible to vote you can choose to select just one, or nominate in multiple categories. It takes just a few minutes to encourage and honour a colleague visit www.bsava.com/awards for details. The Awards Ceremony will take place at BSAVA Congress 36 April 2014.

The prestigious BSAVA Awards give you the chance to acknowledge the inspiring work of colleagues who have made their own exceptional contributions to our profession people we work alongside every day or those whom we admire from afar.

All members of BSAVA are eligible to vote you can choose to select just one, or nominate in

Nominate now please

03 Page 03 June.indd 3 16/05/2013 16:44

Are we producingtoo many vets?

Since the announcement that the University of Surrey would be opening a new veterinary school in 2014, and rumours of other universities considering to do so, there has been a great deal of discussion about the potential consequences for the veterinary profession.

The recent consultation with BSAVA members revealed that the majority of respondents considered that another veterinary school is not a good idea, with concerns about the overproduction of new graduates, the problems of maintaining teaching standards and accessing sufficient good quality extramural studies (EMS). However, there were also some positive comments, with increased opportunities for prospective students and more opportunities for academics being mentioned as possible benefits.

ConcernsConcerns about the number of veterinary graduates being produced are not new. Similar concerns were expressed when the new veterinary school at Nottingham was announced and until recently the veterinary profession was classed as a shortage occupation. Although Nottingham is now producing graduates this is not the only reason for the recent increase in graduate numbers, as one respondent noted:

Overproduction of students is mostly attributable to the huge increase in numbers of vet students in the current schools e.g. Edinburgh almost doubling from 100 to 160170 in 10 years. If the new vet school poses such a threat to the profession, why has no one made such a fuss about the ever increasing number of students in the current systems? Its ridiculous as far as I can see its a free market, let them compete on a level playing field.

BSAVA recently ran a consultation with members about undergraduate veterinary training. Scientific Policy Officer Sally Everitt reviews the results

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A recent analysis of the veterinary profession produced by the RCVS for the Migration Advisory Committee shows that RCVS membership continues to increase year on year with no drop off so far recorded. These figures show that the RCVS is registering around 600 veterinary surgeons from overseas (EUand non EU) on top of the 800 UK veterinary registrants every year. The RCVS figures suggest that there is still a shortfall of 422 vets per year, with the forecasts indicating a requirement for 1222 vets per year to replace those retiring and the apparent increased demand for veterinary surgeons.

Although the RCVS has not yet noticed any change in registrations, responses to our member consultation suggest a rather different picture with reports of an increasingly difficult job market.

We cannot get jobs! I have friends who are working at bars as they cannot get jobs. A practice near me has recently employed x2 new grads as VNs! Ridiculous those places should be taken by qualified VNs not new grads how is that fair to VNs who have worked hard for their qualification to now have to fight with Vets for the same position, totally unsuitable for all concerned.

Yes it took myself and several friends from my graduating year (2009) several months to find a job, with several interviewers telling me they were getting around 30 applicants for one position, Itherefore had to sign on for jobseekers allowance and move in with my parents which I found very demoralising after 6years of study and obtaining a professional degree.

Support from practicesThe increasing number of students is producing another problem for the profession in providing suitable opportunities for EMS. Problems

reported in our survey related both to the practices and the students. Several practices reported being inundated with requests for EMS and work experience and having waiting lists to 2015. The problems seemed to be most acute in, though not confined to, mixed, farm and equine practices. However there are also reports of practices that would be willing to take students if contacted.

The practices feel that more is expected of them, with one respondent saying the vet schools have recently had to start practice-specific alliances with vet practices in order to ensure provision of EMS as local practices are tired of giving their skills, services, time and patience for nothing especially when they have to pay 250600 per day themselves for CPD at the same universities. Also, with competition increasing between practices, vet students are effectively commercial espionage.

There were also comments about the variability of EMS and the increasing demands of students who are paying for their degree, frequently paying for accommodation when seeing practice, as this cannot always be arranged close to home, and in a few cases even paying for EMS itself, with one respondent saying that practices are starting to charge up to 200 per week. There was also mention that there are an increasing number of qualified but as yet unemployed vets seeing practice.

Specifically SurreyIn response to a specific question about the suitability of the location of Surrey as the site for a new veterinary school, only 17 out of 118 respondents considered the location appropriate. Those that did cited as reasons that this is an area of high population density and has proximity to the Veterinary Laboratories Agency at Weybridge. In contrast, those that gave

specific reasons against the location (as opposed to general comments that there shouldnt be a vet school anywhere) cited that it was too close to other vet schools, especially the RVC, and that the location did not provide easy access to livestock.

Asked whether they thought the stated emphasis on One Health is appropriate, the most frequent comment was that this is not a unique selling point for Surrey and is already being promoted in other schools. This was seen to be a trendy term which wouldnt translate into anything different in reality since all schools have to fulfil the curriculum requirements of RCVS and EAEVE, and students are predominantly looking for training forpractice.

Too many graduatesAlthough one, or more, new veterinary schools will increase choice and access for the many prospective students, it will also inevitably increase the number of graduates. With changes to the mechanisms of funding higher education, limits on student recruitment except for those with high grades and a high demand for places, veterinary courses would still appear to be an attractive proposition for a university. Australia has increased the number of veterinary schools from four to seven in recent years and there are plans for a further four veterinary schools to open in the USA, showing that this problem is not confined to the UK.

However, as one respondent put it:I am a recent graduate and quite

simply there arent enough opportunities for those leaving University. Given the debt students are taking on, it is morally unacceptable to throw them into a market where we already know there is over supply of labour and due to the number of young vets and limited career development opportunities.

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Are we producing too many vets?

A lthough the UK job market for veterinary graduates appears to be becoming more difficult, the prospects still look reasonable compared to both graduates in other subjects and to veterinary graduates in some other countries. It is yet to be seen how long this will continue and whether the profession is able to adapt by expanding into other areas of work, or whether the overproduction of vets will drive down pay

and conditions and ultimately the numbers and calibre of applicants for veterinary courses.

The RCVS are likely to be conducting another survey of the professions (veterinary and veterinary nursing) in 2014; it will be interesting to see what changes it shows, and what effect the economic climate and increasing number of veterinary surgeons registered are having on those within the professions.

Consultation results

MORE ABOUT THIS SUBJECT

We plan to follow up on this consultati on with a feature in a future editi on of companion that explores the experience of vets in practi ce and how they view the potenti al impact of more vet schools on the profession.

If you would like to contribute email Kay Colquhoun k.colquhoun@bsava.com or call 01452 726718.

Q1

Do you think that the opening of a new veterinary school at the University of Surrey isa good idea?

No 111 Yes 6 Blank 1

Q3

What do you see as the disadvantages of having another veterinary school?

A range of responses were given to thisquestion but the main issues raisedwere:

Overproduction of new graduates (97responses) Reduced resources for research and teaching leading

to falling teaching standards (17responses) Pressure on EMS (14 responses) Debt burden (6 responses)

Q5

Are you aware of any problems relating to the provision of EMS (seeing practice) in the UK?

Yes 78 No 22 Variable 1

Q7

Do you think that the emphasis on One Health is appropriate?

Yes 41 No 22 Other 39 (no comment, not sure, and mixed responses) Blank 17

Q6

Do you consider the location of the new veterinary school appropriate?

Yes/OK 17 No 55 26 provided ambivalent responses/dont know these were

mostly negative opinions or doesnt matter where its placed; again many of these were negative about the prospect of a new vet school

20 people didnt answer this question (all bar one of these did not think the opening of the new vet school was a good idea)

Q4

Are you aware of any problems relating to over- or underproduction of veterinary surgeons in the UK?

77 replied yes, although 5 of these stated that their evidence was onlyanecdotal

10 replied no 5 others thought that there would be problems in the future 6 raised concerns about the effect of foreign graduates entering

the UKmarket 4 respondents mentioned that there are still problems recruiting

for farmpractice and public health

Q2

What do you see as the benefits of having another veterinary school?

60 said they did not see any benefits and one went so far as to say Genuinely NONE! = a terrible idea

42 positive responses divided into the following broad themes 20 made reference to an increase in choice or

access for prospective students 9 respondents made reference to increasing the

number of UK graduates 10 noted that it would increase jobs for academics

and opportunities for research 1 hopeful respondent suggested it could result in

smaller class sizes

04-06 University Consultation.indd 6 16/05/2013 16:44

For more information or to book your coursewww.bsava.comAll prices are inclusive of VAT. Stock photography: Dreamstime.com. Andersastphoto

Imaging the abdomen20 JuneThis course is designed to cover imaging of the abdomen, with particular emphasis on radiological and ultrasound findings, and includes points of interest for both general practitioners and nurses with an interest in diagnostic imaging.

SPEAKERS

Andrew Parry and Lizza BainesVENUE

Willows Veterinary Centre and Referral Service, Solihull B90 4NHFEES

BSAVA VN Member: 167.00Non BSAVA VN Member: 250.00BSAVA Member: 233.00Non BSAVA Member: 350.00

This course is designed to cover imaging of the

Split Course

for vets and VNs

VN Merit Award Surgical Nursing

FEES

BSAVA VN Member 494.00Non BSAVA VN Member: 741.00

Day I: 27 September 2013SPEAKERS

Laura Owen and Hayley CarneThe first day will look at preoperative assessment of surgical patients, including triage and stabilisation of the emergency patient, principles of fluid therapy, assessment of anaesthetic risk, analgesic options and principles of antibiotic prophylaxis.

Day II: 28 September 2013SPEAKERS

Laura Owen and Hayley CarneThe second day will look at the nurses role during surgery, including optimising the role of a surgical assistant, use of advanced surgical equipment, indications for and placement of drains and monitoring blood loss.

Webinar I: 15 October 2013SPEAKER

Laura OwenWound healing: understand the biological processes and how to optimise your management of traumatic wounds (includes case examples).

Day III: 9 November 2013SPEAKERS

Laura Owen and Hayley CarneThe final day will look at monitoring and care of the postoperative patient, including assessment and treatment of pain, nutritional requirements and tubes/catheters/drains

Webinar II: 3 December 2013SPEAKER

Laura OwenBlood products: when and how should we use them in surgical patients?An online assessment will follow these attendance and online activities and at the end of the award you will receive a certificate and a badge. Holders of the award will be expected to complete a refresher course in 5 years.

VN Merit Award Surgical Nursing

NEW

for

Autum

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From well birds to I am trying to die fast17 SeptemberThis mixed session will include anaesthesia, diagnostic work-up and clinical pathology. We will also cover some of the welfare and behavioural needs of well psittacine birds. In the afternoon, vets will cover topics such as therapeutics, orthopaedics and soft tissue surgery, whilst nurses will take on catching and handling, nutrition and fluid support.SPEAKERS

Neil Forbes and Matthew RendleVENUE

Lismoyne Hotel, Fleet, Hampshire GU51 4NEFEES

BSAVA VN Member: 167.00Non BSAVA VN Member: 250.00BSAVA Member: 233.00Non BSAVA Member: 350.00

From well birds to I am trying to die fastThis mixed session will include anaesthesia, diagnostic

Split Course

for vets and VNs

New courses for Autumn 2013Look out for your copy of the new BSAVA CPD Brochure coming soon? Cant wait? Why not take a sneak peak here: www.bsava.com/CPD/ChooseaCourse/tabid/1383/Default.aspx

07 CE Advert June.indd 7 16/05/2013 16:43

8 | companion

Taboo words exist for the members of most professions. For actors, it is any quotation from that part of Shakespeares canon which they like to call the Scottish play. For veterinary surgeons, it is in using the term customers to describe the people on whom their living depends.

Nick Stace, the Chief Executive of the Royal College of Veterinary Surgeons, has either never heard of this convention or (as seems more likely) he chooses to ignore it. As far as he is concerned, the Royal College is an organisation providing services to two separate groups veterinary staff and the general public and they are both his customers.

Mr Stace was appointed in June 2011, and quickly acquired a reputation for honesty, plain-speaking and a willingness to push the RCVS in new directions in the way that it engages with the outside world. That was clear from his first public appearance in the role at the November meeting of the Royal College Council, where he rebuked unnamed members for discourtesy in their dealings with both college staff and each other.

Fact findingPrevious occupants of the chief administrators post at the RCVS have come from either a legal or military background. Nick is neither, having served as a

A year at the topMany have come to think of the RCVS as an aloof and rather stuffy institution; it has certainly received its fair share of criticism in the last few years. That shouldnt be the case anymore, according to the Chief Executive Nick Stace, who has been seen by some to be a breath of fresh air at the 169-year-old regulatory body. John Bonner went to meet him a year on from his initial appointment

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communications specialist in government service, and more recently as the head of the Australian consumer protection agency CHOICE. So it is not surprising that with this background in working for the antipodean equivalent of Which?, his first priority was to carry out some market research.

You come into a job like this with some ideas and the thing you need to do is to find out if it is likely that they will work. So my initial task was to reach out to the profession and the public to hear what they have to say about the ways that we operate, what we do well and what we dont do quite so well.

He wrote to the veterinary press, giving his email address, and asked for comments which he promised would receive a reply within 24 hours. In the first week he had around 60 messages and he is still getting an average of 6 per week, with a mixture of regular and new correspondents. Meanwhile, he estimates that around one-fifth of the UK veterinary profession has responded to an online questionnaire.

Nick also wanted to know the views of other organisations which have regular dealings with the Royal College, including BSAVA and he has carried a series of interviews with senior officials. In addition, he took an in-depth look at the way that other bodies with similar functions both at home and abroad carry out their work.

All this research feeds into what Nick is calling the First Rate Regulator initiative, a project designed to improve the structure and function of the RCVS and ensure that both sets of customers are happy with the service that they get.

Complaints processOf course, one of the main responsibilities of the RCVS is to listen to and investigate complaints from one set of customers about the behaviour of the other. Nick asked his staff to follow up every complaint made against an MRCVS over the past three years to find out how the complainant felt that the issue had been dealt with.

What he found was that there is little correlation between the outcome of the process and the feelings of the complainant. Many would be dissatisfied that the RCVS was unable to deal with their grievance, often because it was a case for the civil court system and didnt involve professional misconduct. However, even some of those whose complaints were upheld in the disciplinary committee process were unhappy with the process. Often that was because of time taken to reach a decision, and no doubt the respondent in the case would have similar concerns.

On average it takes just under two years for a case to go through the whole process from initial

complaint to a final decision. Compared with other regulators that isnt too bad but I do think that we can do a lot better, he says.

Part of the solution is already in hand, with parliamentary approval in April for the legislative reform order that modernises the RCVSs disciplinary structures and will create preliminary investigation and disciplinary committees that are independent of Council and contain roughly equal numbers of veterinary surgeons and lay people.

The College has appointed an independent recruitment firm and selection panels to sift through the 170 or so applicants. Previously, when having to draw solely on RCVS Council members, meetings of the full disciplinary committee have sometimes struggled to remain quorate. Nick hopes that with a larger pool of potential members, the committee will be able to meet more frequently and process cases much faster.

Yet it isnt just the time that cases take which creates dissatisfaction; many complainants felt that they werent kept informed and when they were, the reports were delivered in legal language that they often couldnt understand. So part of the reform process that Nick has introduced will be the allocation of a case officer for each complaint to keep both sides informed on what is happening.

As an extension of this concept, the College has appointed a new senior staff member Nicola South to be Customer Experience Manager, with responsibility for ensuring that all those contacting Horseferry Road feel that their enquiry has been dealt with properly.

A philosophical approachAs well as these relatively simple practical changes, Nick also wants the First Rate Regulator project to look at some broader philosophical issues. One task is to examine the RCVSs joint role as a statutory body and as a Royal College required by its charter to try to progress the art and science of veterinary medicine. Few if any of the other statutory bodies have this dual function, he points out.

Between 90 and 95 per cent of the money we spend is on regulation, only a tiny percentage goes into being a Royal College. I think there is a real appetite to have a fully functioning Royal College as well as a regulator. So we will be exploring what people mean by and want from a Royal College. We want to look at the different models of college to see which one we should adopt. In this process we will want to involve the BVA, BSAVA and other stakeholders. They have nothing to fear from this; our role will be complementary to what they are already doing in professional education, etc.

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A year at the top

One logical conclusion to this line of thought is that changes may be needed in the Colleges council system to separate the two functions, particularly as no other organisation with purely statutory duties would be run by an unwieldy 42 member committee like the existing Council. A report on options for the next steps in the reform process will be discussed at the June Council meeting and Nick insists that the debate and any subsequent decision-making will be conducted entirely under public view.

A team effortChanges on this scale in any organisation would normally be expected to make the permanent staff rather anxious. While three posts have been made redundant, those beavering away at Horseferry Road appear to be fully supportive of Nicks programme. That is probably because he has taken every opportunity to communicate with his team and tried to assess their morale through a staff engagement study. That scored 59 on a scale of 1 to 100 really happy and effective organisations generally score in the 80s and those with serious management issues as low as 40, he explains.

The middling satisfaction rating for RCVS staff is a little disappointing but not that surprising for a first-time study as people will naturally remember issues that have cropped up at any time that they have worked there. What matters, Nick says, is to carry out regular reviews to make sure that the necessary steps have been taken to ensure that the trajectory of staff morale is heading in the right direction.

Staff engagement is not some fluffy peripheral issue. I think it is central to being a good or possibly even a great organisation. If we want to give our customers the best service and to constantly improve what we do, then we need highly engaged staff to do that. It will also help us in the long run by ensuring that we can recruit and retain the best staff.

Not just vets and petsUnlike most of his predecessors at the Royal College, Nick also has responsibility for regulating a group of people who are not themselves veterinary surgeons but for whom the College has become an essential part of their working lives. Nick says there needs to be further debate about whether veterinary nurses should be integrated more closely within the RCVS structure, or whether they should achieve greater autonomy in setting their own professional goals.

One key step is to ensure that the meaning of the term veterinary nurse is clearly defined and he says the RCVS has persuaded Defra to agree to a proposal for a Bill to make this a protected title. The next stage

is to persuade an MP to take this on as a Private Members Bill, and as the legislation is likely to be uncontroversial there is every chance that it will succeed, he says.

Transparency on every levelOne immediate and tangible change at Horseferry Road has been the building work to convert what was formerly a rabbit warren of corridors and small offices into an airy open-plan workspace. At the centre of each floor there is a pod a small glass cubicle in which staff, members and visitors can hold impromptu meetings. The concept was borrowed from one of the buildings used by the Home Office and, while the idea is to reduce the amount of time spent in unnecessary meetings, the see-through glass walls may be viewed as a reflection of the new management style.

We are trying to repair some of the damage caused by the McKelvey report, he says (referring to the investigation into the cost overrun from a previous building project which ultimately led to the resignation of his predecessor and Staces appointment as Chief Executive).

It was a mistake to redact parts of the report before it was made public. That looked as though we were trying to conceal something. We have got nothing to hide but if we are entirely open about what we are doing then that does involve some risks. I want the profession to get used to the idea that we will tell them all there is to be told, whether that news is good, bad or indifferent. All I ask is that they take that in the right spirit and to help us get on with the job. n

08-10 Nick Stace.indd 10 16/05/2013 16:42

companion | 11

The BSAVA Guide to the Use of Veterinary Medicines provides a comprehensive and authoritative guide to the safe and legal use of veterinary medicines in companion animals in the UK, for all members of the veterinary team. Everyone who uses veterinary medicines has a legal, ethical and moral responsibility to use them appropriately. Many infringements of the law relating to the possession, use and disposal of veterinary medicines are criminal offences and this Guide helps practitioners stay on the correct side of the law in an area where this can sometimes be problematic.

The Medicines Guide is updated on a regular basis, whenever the Veterinary Medicines Regulations are reviewed and at other times if legislation or recommendations for good practice change. In April of this year, a comprehensive review and update was completed; a couple of the revised sections are detailed here.

Suitably Qualified PersonSuitably Qualified Person (SQP) is a phrase used in the veterinary medicines legislation in relation to the prescription and supply of medicines. In practical terms this means a person registered with the Animal Medicines Training Regulatory Authority who is permitted by the regulations to prescribe and/or supply medicines classified as POM-VPS or NFA-VPS.

An SQP can orally or in writing prescribe a POM-VPS medicine for a client. They do not need to see the animal.

They may not diagnose disease but can identify infestation (e.g. lice). They may not treat disease but can advise on prevention and control of disease. Most of the medicines in the VPS categories do have preventive uses, e.g. antiparasitic medicines, farm animal vaccines, nutritional supplements, antiseptic medicines and some local anaesthetics.

When prescribing and supplying a product within the POM-VPS category or supplying a product within the NFA-VPS category, the SQP must always:

Be satisfied that the person who will use the product is competent to use itsafely

Advise on any warnings or contraindications on the label or product leaflet

Provide advice on the safe administration of the product

Supply the product specified in that prescription

Take all reasonable steps to ensure that the product is supplied to the person named in the prescription.

PharmacovigilancePharmacovigilance is the monitoring of unwanted or adverse events in response to medicines and vaccines. For veterinary surgeons, veterinary nurses and animal owners, this monitoring is done through the Suspected Adverse Events Surveillance Scheme. The reporting of suspected adverse events is a key part of the process of ensuring the safety of medicines, and

also plays a part in keeping existing medicines on the market and available.

Adverse events are harmful and unintended reactions to a medicine when administered to an animal at its recommended dose and route of administration. Adverse events in animals that should be reported to the Veterinary Medicines Directorate (and also to the manufacturer or distributor of the medicine where known) include:

Lack of efficacy, including resistance to antimicrobial or antiparasitic agents

Events not mentioned in the datasheet Events mentioned in the datasheet but

occurring more frequently or more severely

Events arising during clinical use of a new medicine under development

Any reaction to a medicine which has been authorized for less than a year

Events arising during off-licence use (i.e. under the prescribing cascade)

Environmental problems.

Reports are collated by the manufacturer and used as part of the ongoing safety monitoring of all medicines. Information on serious adverse events and events in humans in response to veterinary medicines must be reported to the VMD within 15 days. Reports from all European Union countries are collated by the European Commission. Quarterly summaries of the reports received are published in Veterinary Record and MAVIS.

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Medicines Guide updates

11 Publications Medicines Guide.indd 11 16/05/2013 16:42

Case presentationAn 18-month-old female neutered Golden Retriever presented with a history of recurrent urinary tract infection (UTI) and suspected urinary incontinence. Over a 14-month period she had demonstrated intermittent episodes of stranguria and haematuria, responding on each occasion to symptomatic therapy with amoxicillin/clavulanate and meloxicam. Prior culture and sensitivity of the urine documented an E. coli and Proteus infection. She had also been noted to suffer from episodes of suspected urinary incontinence, most commonly coinciding with excitement, where she passed large volumes of urine without apparent awareness. During the 2 weeks prior to presentation the patient was reported to have a slightly reduced appetite although she had remained bright in other regards and there had been no change in water intake.

On presentation she was overweight, with a body condition score of 7/9. Her vulva was recessed within a perineal fold and she had matted, urine-stained hair surrounding it, with erythema of the underlying skin. The remainder of the physical examination was unremarkable.

Case presentationAn 18-month-old female neutered Golden Retriever presented with a history of recurrent urinary tract infection (UTI) and suspected urinary incontinence. Over a 14-month period she had demonstrated intermittent episodes of stranguria and haematuria, responding on each occasion to symptomatic therapy with amoxicillin/clavulanate and meloxicam. Prior culture and sensitivity of the urine documented an E. coli and Proteus infection. She had also been noted to suffer from episodes of suspected urinary incontinence, most commonly coinciding with excitement, where she passed large volumes of urine without apparent awareness. During the 2 weeks prior to presentation the patient was reported to have a slightly reduced appetite although she had remained bright in other regards and there had been no change in water intake.

On presentation she was overweight, with a body condition score of 7/9. Her vulva was recessed within a perineal fold and she had matted, urine-stained hair surrounding it, with erythema of the underlying skin. The remainder of the physical examination was unremarkable.

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Clinical conundrum

Fran TaylorBrown, a previous intern at the Royal Veterinary College, invites companion readers to consider a Golden Retriever with recurrent urinary tract infection and suspected urinary incontinence

Create a problem list based on the patients history and physical examination

n Inappropriate urination n Recurrent UTI n Recessed vulva n Urine scald and staining n Overweight

What differential diagnoses should be considered based on the problem list?For the first two problems the possible differential diagnoses can be organised into three main categories.

n Inappropriate urination Structural abnormalities Lower urinary tract inflammation or infection Neurogenic disorders

n Recurrent UTI Structural abnormalities Lower urinary tract inflammation e.g. urolithiasis Systemic disease

Given the patient was young, structural abnormalities were high on the list of differential diagnoses. A prioritised list of differential diagnoses for this case would be:

1. Congenital structural abnormality, e.g.ectopic ureter, vulval hypoplasia

2. Urethral sphincter mechanism incompetence (USMI)

3. Urolithiasis

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What diagnostic procedures would you perform in this case?Routine haematology and biochemistry were performed to investigate systemic causes which could be responsible for recurrent UTI; these results were unremarkable. Urinalysis and culture were performed on a sample obtained by cystocentesis with particular interest in the urine sediment, pH and specific gravity. The urinalysis revealed only mild haematuria, and urine culture was negative.

In order to investigate structural abnormalities of the urinary tract, abdominal ultrasonography was performed. This revealed that both kidneys were small with an irregular contour; this was more severe on the left side. These changes were thought to be consistent with a chronic nephropathy. The patient was nonazotaemic (creatinine 102 mol/l; reference interval 50110 mol/l) with adequate urine concentrating ability documented repeatedly (specific gravity 1.036). However, changes identified on ultrasound examination supported International Renal Interest Society (IRIS) stage one, nonazotaemic, chronic kidney disease (CKD).

Systolic blood pressure was assessed using the Doppler technique (124 mmHg), a result considered low risk in accordance with the American College of Veterinary Internal Medicine Hypertension Guidelines. The patient was proteinnegative on urine dipstick with well concentrated urine and therefore urine protein:creatinine ratio assessment was not performed at this stage. Further assessment of proteinuria was postponed due to the presence of haematuria.

The patient was anaesthetised and plain radiographs were obtained to assess general anatomy and positioning of organs within the abdomen. The images were unremarkable and showed a normally positioned bladder. Following this, an intravenous urogram was obtained to assess kidney and ureteric structure and positioning; a left ectopic ureter was documented (Figure 1). Subsequently, retrograde vaginourethrocystography was performed in order to assess for the presence of caudal structural abnormalities in the urogenital tract. It demonstrated normal filling of the vestibule, vagina and urethra, and confirmed a normally positioned bladder within the abdomen.

What techniques are available for the diagnosis of ectopic ureters?

n Urethrocystoscopy n Computed tomography (CT) n Excretory urography n Ultrasonography n Retrograde vaginourethrocystography

Urethrocystoscopy is considered the gold standard for diagnosis of ectopic ureters in female dogs and is the only technique which allows accurate detection of the point of termination of the ectopic ureter or identification of multiple openings. CT ( contrast) is considered the gold standard for diagnosing ectopic ureters in male dogs. It is a superior diagnostic technique to excretory urography as it allows threedimensional reconstruction, which can aid in following the course of ureters and their distal insertion. The diagnostic success of using conventional radiographic

Figure 1: Slightly oblique ventrodorsal view of an excretory urogram with negative contrast in the bladder. it demonstrates a left ectopic ureter. (black arrows highlight the course of the left ectopic ureter and white arrows show the course of the right ureter)

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Clinical conundrum

excretory urography can be enhanced by combining it with negative contrast within the bladder and also performing oblique views.

Ultrasonography can be used to diagnose ectopic ureters, especially in cases where the affected ureter is dilated. However it can be challenging even for highly skilled ultrasonographers to detect ectopic ureters in the absence of ureteral dilation, and the detection of an appropriately positioned ectopic opening does not preclude the presence of multiple openings.

Obtaining a retrograde vaginourethrogram can be very useful to diagnose ectopic ureters, as the ectopic ureter often readily fills during contrast injection. The technique is also useful for identifying the bladder neck and assessing bladder positioning, which is important for the diagnosis of common concurrent conditions such as USMI or shorturethra syndrome.

What are the options available for treating ectopic ureters?

n Surgical correctionIn order to correct intramural ectopic ureters a new ureteral opening is created from the bladder lumen after performing a ventral cystotomy. Success rates of 2259% have been reported, as defined by resolution of urinary incontinence.

n Cystoscopic laser ablationCLA is a more recent technique appropriate for the treatment of intramural ectopic ureters and involves ablation of the tissue separating the ureter from the bladder lumen at the point where a typical ureter would terminate into the bladder. Success rates, with respect to resolution of urinary continence, are reported to be comparable to that of more traditional surgical correction techniques. However, due to the minimally invasive nature of the procedure there is less postoperative pain and the need for hospitalisation is reduced.

In this patient it was elected to perform CLA. Theright ureteral orifice was visualised in the bladder trigone region (Figure 2) and the left ureter was observed to enter into the proximal urethra (Figure 3); urine jets were observed coming from both ureters. Acatheter was placed via a guidewire into the left

Figure 2: Cystoscopic image of the bladder trigonal region, showing the right ureteric orifice in a normal position (asterisk marking the bladder lumen and the arrow identifying the ureterovesicular junction)

ureter in order to outline the ureter clearly and a Holmium:YAG laser was then used to carefully cut the abnormal ureteral wall in a continuous manner from a caudal to cranial direction. The laser treatment was completed level with the right ureteral orifice (Figure 4).

OutcomeThe patient had an uneventful recovery from the CLA and was discharged from the hospital.

The presence of chronic bilateral nephropathy was thought to be either a developmental abnormality or to reflect chronic pyelonephritis. Despite the negative urinary culture and the absence of pyelectasia, the history of ectopic ureter and recurrent UTI raised the suspicion for pyelonephritis, prompting treatment with a prolonged course of antibiotics.

Weight loss was recommended, to help with perivulval conformation and improve allround health. It was discussed with the owner that if weight loss alone failed to improve perivulval conformation, surgical resection of excess perineal skin could be pursued if recurrent UTI remained a persistent feature.

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Contribute a CliniCal Conundrum

If you have an unusual or interesting case that you would like to share with your colleagues, please submit photographs and brief history, with relevant questions and a short but comprehensive explanation, in no more than 1500 words to companion@bsava.comAll submissions will be peer-reviewed.

Figure 3: urethroscopic image showing the left ectopic ureter opening abnormally within the urethra (asterisk marking the urethral lumen and the arrow identifying the ectopic ureter)

Figure 4: Cystoscopic image of the ectopic ureter following Cla. the ureteric catheter is still in place

What possible complications should you make the owner aware of?Following any treatment for ectopic ureters there remains a risk of persistence or deterioration of urinary incontinence. In this case, concurrent signs compatible with USMI were not present, although this would not preclude a future diagnosis of this condition. Furthermore, an underlying pyelonephritis can result in or exacerbate renal damage, which would be detrimental to the outcome of the patient.

Follow-upOne month following CLA the patient developed a UTI which was resistant to amoxicillin/clavulanate and she was treated with a 6week course of enrofloxacin. Two months after discharge the patient was continuing with her weight loss and had a body condition score of 6/9. There had been no further episodes of inappropriate urination and there was minimal urine staining of the perivulval hair.

Four months after discharge the patient was diagnosed with a further UTI and after treating the UTI

it was elected to commence therapy with phenlypropanolamine to optimise control of a possible lowgrade persistent urinary incontinence and to perform vulvuloplasty to improve the patients conformation. Since surgery the patient has had no further episodes of inappropriate urination or UTI, although some degree of perivulval hair staining has persisted. Following the diagnosis of CKD it is necessary to initiate regular monitoring of the patient with the frequency dependent on IRIS stage. Biochemistry, urinalysis, urine protein:creatinine ratio assessment and blood pressure measurement are performed at 6month intervals in this patient. n

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How to approach thedog with neck pain

Neck pain or cervical hyperaesthesia is a common presenting sign in canine patients and can be associated with many different conditions. As with all other neurological conditions, a systemic approach to the patient with cervical hyperaesthesia is essential, with a general physical examination giving important information for example about pyrexia, enlarged lymph nodes or swollen and painful joints.

Cervical hyperaesthesia is an important factor when considering the most likely differential diagnoses in cases that are showing neurological deficits. It is important to remember that the severity of the hyperaesthesia is not predictive for the disease nor its potential severity.

CausesAnatomical structures that can be responsible for cervical hyperaesthesia are vertebrae, meninges and nerve roots. Spinal cord parenchyma does not contain nociceptors and therefore purely intramedullary lesions do not cause signs of cervical hyperaesthesia. Other potential sources of the cervical hyperaesthesia are the vertebral articulations and surrounding soft tissue in the neck area. Any condition affecting one of these structures can produce any degree of cervical hyperaesthesia.

An important cause of cervical hyperaesthesia is intracranial disease. Space-occupying intracranial lesions can stretch the meninges and therefore produce pain. Lesions in the thalamus can produce the signs of pain, so-called thalamic pain. With intracranial lesions other neurological signs are usually present and can either be observed by the owners or are detected on neurological examination. It should be mentioned that cervical hyperaesthesia is very commonly persistent, however intermittent the clinical signs may appear. Occasionally these cases are misdiagnosed as having epileptic seizures especially when the clinical signs are very paroxysmal.

Clinical signsThe clinical signs of cervical hyperaesthesia are often very obvious (Figure 1), although in many cases only thorough neurological assessment, neck palpation and assessment of neck movement can pick up signs of hyperaesthesia. Patients with nerve root involvement can also show signs of lameness of the thoracic limb or may hold the limb up (nerve root signature; Figure2) as well as neurogenic muscle wastage on the affected limb.

Affected patients are reluctant to bend their neck and will turn their body instead. They are reluctant to flex the neck ventrally to eat or drink from their bowl. It is not uncommon that the owner described inappetence. If neurological deficits are present, the most common clinical signs are gait abnormalities or tetraparesis. Very specific signs are usually seen with the Chiari-like malformation and associated syringomyelia. These clinical signs are attributed to the neuropathic pain syndrome: phantom scratching and spontaneous yelping are the most commonly encountered.

Occasionally patients with thoracolumbar pain appear to have low neck carriage as they shift their weight to the thoracic limbs. This changes posture and it can often be mistaken for a sign of cervical hyperaesthesia. Very rarely, painful orthopaedic diseases of scapula, shoulder and proximal humerus can mimic cervical hyperaesthesia without obvious lameness. If the patient shows signs of lameness, orthopaedic conditions should be excluded before evaluating for causes of nerve root signatures.

Viktor Palus, of Dick White Referrals, talks us through this painful presentation

Figure 1: A Miniature Schnauzer with C3C4 intervertebral disc extrusion, showing the typical posture associated with cervical hyperaesthesia

Figure 2: A Lurcher with C6 vertebral body tumour showing a nerve root signature

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DiagnosisDefinitive diagnosis in these cases is usually very difficult to achieve without further specialised investigation. However a few hints can be found from careful history taking and on physical examination; as a result the diagnosis can be very straightforward in some cases. Anexample of such a case would be a subcutaneous or subfascial abscess in the cervical area due to previous subcutaneous injection, migrating foreign material or previous dog or cat bite wounds.

Thorough palpation of the cervical area should be performed to rule out soft tissue masses; also palpation of the temporomandibular joint and periaural area needs to be performed. Thoracic lesions, for example pleuritic pain, can also present in a similar way to cervical hyperaesthesia.

The differential diagnosis list should be formed before further investigation is undertaken. Table 1 lists the most common differential diagnoses associated with cervical hyperaesthesia. A logical approach to investigation is important in these cases as some of them require costly and specialised evaluation. For example, if there is a suspicion of a vertebral tumour spinal radiographs can be useful but this is not true for cases with suspected meningitis.

Haematology can be helpful in narrowing down possible inflammatory or infectious diseases. For example, cases with steroid-responsive meningitisarteritis (SRMA) can have very marked neutrophilia, although caution is needed as other inflammatory diseases cannot be excluded on this basis. Biochemistry can be helpful to confirm an inflammatory process or raise the suspicion of bone tumours or multiple myeloma that can invade the vertebrae. However, results of blood tests can be completely normal in

cases of a severe inflammatory process in the central nervous system. Survey radiographs can reveal marked osteolysis, caused by bone tumours and the changes associated with discospondylitis.

Radiography should be strongly considered in cases of suspected spinal fractures and atlanto-axial instability (Figure 3), but should be performed with extreme care. Myelography is an invasive diagnostic procedure and should be contemplated only in cases when the surgical management can be pursued under the same general anaesthesia. Myelograms can reveal an extradural compression (Figure 4), intraduralextramedullary compression of the spinal

cord or an intramedullary lesion in the spinal cord.

Advanced imaging is preferable in most cases of cervical hyperaesthesia and magnetic resonance imaging (MRI) is usually superior to computed tomography (CT) as regards soft tissue resolution. MRI and CT are non-invasive diagnostic procedures and MRI can also assess the soft tissue surrounding the spinal cord.

Cerebrospinal fluid (CSF) analysis is an important part of the diagnostic work-up, especially if inflammatory central nervous system causes are suspected. Additional tests such as arthrocentesis need to be considered, as dogs with

Neurological conditions

Meningomyelitis (SRMA, granulomatous meningoencephalitis, meningoencephalitis of unknown aetiology, etc.)

Intervertebral disc disease Chiari-like malformation and syringomyelia Cervical spondylomyelopathy Atlanto-axial instability Pathological vertebral fractures and

vertebral tumours Discospondylitis Facet joint pain (DJD) Polymyositis Mid-thoracic spinal lesions Intracranial lesion Spinal cord haematoma or haemorrhage Synovial cyst

Non-neurological conditions

Abscess in the soft tissue in the cervical area

Otitis media Soft tissue tumour in the neck Bicipital bursitis Polyarthritis Temporomandibular joint or

oropharyngeal pain Thoracic lesion, e.g. pleuritic pain Proximal humerus or scapula lesions

Table 1: Differential diagnoses for cervical hyperaesthesia

Figure 3: Lateral radiograph with mild flexion of a 1-year-old Yorkshire Terrier. There is an increased gap between the dorsal lamina of C1 and dorsal spinous process of C2. This is a typical finding in atlanto-axial instability

Figure 4: Lateral myelogram of the cervical area of 6-year-old English Springer Spaniel with cervical hyperaesthesia and ambulatory tetraparesis, showing the presence of an extradural compressing lesion at the level of C4C5. This was confirmed at surgery to be extruded intervertebral disc material

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How to approach the dog with neck pain

immune-mediated polyarthritis can have concurrent cervical hyperaesthesia and an inflammatory picture on CSF analysis. Urinalysis, urine culture or blood cultures can be potentially useful in cases of discospondylitis.

Common neurological causes of cervical hyperaesthesiaSteroid responsive meningitis-arteritis (SRMA)This condition is also known under different names such as juvenile polyarteritis syndrome, necrotising vasculitis, aseptic suppurative meningitis, Beagle pain syndrome and several others. It can affect any breed but medium to large breeds, particularly Beagles, Bernese Mountain Dogs, German Pointers, Weimaraners and Nova Scotia Duck Tolling Retrievers, seem to be predisposed to this condition.

The age of onset is usually between 6and 18 months but cases have been reported in dogs as old as 7 years. The major clinical signs are cervical hyperaesthesia, stiffness, depression and pyrexia. Two forms of this disease are commonly observed. The acute form is characterised by stiffness and pyrexia, whereas the chronic form is commonly associated with neurological deficits that can be very severe, mainly in cases of spontaneous subarachnoid bleeding.

The chronic form can rarely cause obstruction of the normal cerebrospinal flow and can produce obstructive hydrocephalus. Extension of SRMA to the brain has also been reported, though is rare, and intracranial neurological signs (various cranial nerve deficits, seizures or vestibular signs) might also occur.

The pathogenesis of SRMA is unknown, but it is likely due to dysregulation of the immune system. This hypothesis is supported by elevated IgA in CSF and serum, increased CSF and blood

B cell:T cell ratio and increased levels of interleukin8 in CSF. A neutrophilic infiltration commonly targets the subarachnoid space, arteries, spinal cord and, uncommonly, the brain.

Peripheral neutrophilia with left shift is commonly seen. Final diagnosis is made on the basis of CSF findings and by excluding other causes of cervical hyperaesthesia. The CSF analysis usually reveals severe neutrophilic pleocytosis (Figure 5) and elevated protein content. The neutrophils are usually not degenerate and culture of the CSF is negative.

In the chronic form mononuclear pleocytosis can be found. Measurement of IgA from CSF and serum, as well as measurement of C-reactive protein in the serum, can be helpful in confirming the diagnosis, but care must be taken with interpretation as these parameters can be elevated in other systemic inflammatory or infectious processes. MRI is useful to rule out other causes of cervical hyperaesthesia

and this is important from the therapeutic point of view, especially if an infective process such as discospondylitis is suspected. Meningeal enhancement of the spinal cord is commonly found on MRI in cases with SRMA.

New MRI features (Figure 6) have recently been identified in dogs with suspected SRMA and most likely represent secondary changes in the adjacent paraspinal musculature due to the inflammatory process in the meninges and nerve roots.

Figure 5: CSF with marked neutrophilic pleocytosis from a 13-month-old Bernese Mountain Dog with SRMA. Note that the neutrophils are not degenerate and there are no signs of microorganisms

A

BFigure 6: (A) Sagittal and (B) transverse STiR images from a 1-year-old Border Collie with severe cervical hyperaesthesia and pyrexia due to SRMA. The images highlight increased fluid content of the paraspinal cervical muscles, findings very commonly associated with SRMA

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The prognosis is good, with long-term remission seen in up to 80% of cases. Treatment is long term and consists of immunosuppressive corticosteroids. Other immunomodulatory drugs such as azathioprine can be used in refractory cases or those that show severe side effects from corticosteroid use.

Intervertebral disc diseaseCervical intervertebral disc disease is a common disorder, especially of chondrodystrophic dogs. It is very common in small breeds, although any breed can be affected. In large dogs, the condition is very commonly a part of cervical spondylomyelopathy, discussed later. The mean age of small dogs with cervical intervertebral disc problems is about 6 years.

The clinical signs range from severe acute or chronic cervical hyperaesthesia and low head carriage to nerve root signature or differing degrees of tetraparesis. Extrusion of intervertebral disc material is more common in small breeds and protrusion is more common in large breeds. C2C3 is the most common site of the extrusion, especially in small breeds, whereas large breeds commonly have more caudal sites affected.

In the cranial cervical area extrusion can be very prominent and the dogs exhibit only cervical hyperaesthesia, whereas with more caudal sites the extrusion might not be that prominent and dogs can have severe neurological deficits. This is due to the larger vertebral canal to spinal cord ratio in the cranial cervical area. For this reason the spinal cord does not need to be that severely compressed in the cranial cervical area. Cervical hyperaesthesia is usually very severe with characteristic low head carriage and spontaneous screaming when only small movements of the head are attempted. Interestingly, dogs with neurological deficits do not show as severe pain as the dogs without.

Survey radiographs very commonly show no abnormalities with this condition. However, narrowing of the intervertebral space and presence of mineralised radiopaque material in the vertebral canal can be suggestive of intervertebral disc disease (Figure 7). Myelography should be performed, as a minimum, to confirm the compression of the spinal cord or presence of extradural lesion (see Figure4).

In some cases, especially when the extruded material is located in the

intervertebral foramen, this can be difficult to interpret correctly. Therefore CT, CT myelography or MRI are superior in localising the extruded site and the extension of the affected area. MRI (Figure8) especially is very sensitive and a non-invasive method to diagnose intervertebral disc disorder in dogs, especially if the intervertebral disc material is not mineralised.

Ultimately, treatment for intervertebral disc extrusion is surgical decompression. The method of achieving this is chosen according to the position of the affecting intervertebral disc material to the spinal cord either ventral or dorsal decompression. A ventral slot procedure is very challenging to perform because many peri- and postoperative complications can occur. However, it allows removal of the intervertebral disc material and provides rapid resolution of the clinical signs. It is therefore the preferred surgical option. Dorsal laminectomy or cervical hemilaminectomy are less commonly performed unless indicated by a dorsal or foraminal location of the extruded intervertebral disc material.

Prognosis for surgically treated dogs is excellent. If surgical treatment is not an

Figure 7: A survey radiograph of the dog in Figure 4. This radiograph reveals narrowing of the C4C5 intervertebral space with radiopaque material within the vertebral canal

Figure 8: A sagittal T2-weighted MR image of the cervical area of a middle-aged Miniature Schnauzer with cervical hyperaesthesia. This image shows an extrusion of the C2C3 intervertebral disc with a deviation of the spinal cord dorsally

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How to approach the dog with neck pain

option then conservative management can be tried, especially in cases with cervical hyperaesthesia without neurological deficits. Although successful in many cases, the recurrence rate of the clinical signs in dogs with conservative management can be more than 30%. If conservative management is undertaken, then controlled exercise should be pursued for at least 6 weeks. In addition, either non-steroidal anti-inflammatory drugs or low-dose corticosteroids with narcotics can be used. If, however, there is a lack of improvement or a progression of the clinical signs in 12 weeks, surgical treatment should be strongly recommended.

Cervical spondylomyelopathy (Wobbler syndrome)This condition is predominantly seen in large and giant breed dogs. Dobermann and Great Dane are classic examples of breeds predisposed to this condition. However, a very similar condition has been recognised in Bassett Hounds and was described in small breed dogs such as Chihuahua and Yorkshire Terrier.

The most common presentation is abnormalities in gait, though cervical hyperaesthesia and low head carriage can also be present. Care must be taken to assess the gait correctly in these cases because the pelvic limbs are usually more severely affected than the thoracic limbs, especially in cases with caudal cervical lesions. This can lead to a mistaken consideration that the problem is either in the lower portions of the spine or even in the hips.

Lameness of the thoracic limbs and atrophy of the supraspinatus and infraspinatus muscles is common when there is a nerve root compression of the one of the nerves of the cervicothoracic plexus. Another common sign of nerve root compression and neuropathic pain is

excessive licking and chewing of the thoracic limb paws (Figure 9). Dogs that have a lesion in the C1C5 spinal segment usually have a floating gait in addition to tetraparesis. In comparison, dogs with C6T2 lesions show so-called two-engine gait, with a short stride and stilted gait in the thoracic limbs and a long-stride gait in the pelvic limbs.

Pathogenesis is complex but stenosis of the vertebral canal and compression of the spinal cord or the nerve roots by the intervertebral disc protrusion, ligamentum flavum hypertrophy, enlarged articular facets, vertebral anomalies and vertebral instability are the main reasons for development of neurological signs.

As with other neurological conditions advanced imaging is superior in identifying the exact structure that is responsible for neurological signs. Survey radiographs can reveal the degenerative changes but these changes cannot be used to determine the site and degree of the spinal cord compression. Myelography or CT myelography are more useful, although linear traction views should be used to identify the compression (Figure 10). Stressed view studies should not be performed as these can worsen the neurological signs significantly. MRI can assess not only the lesion but also the effect on the spinal cord, and is less invasive (Figure 11).

Figure 9: A 4-year-old Dobermann which was diagnosed with cervical spondylomyelopathy. The owners reported that the dog had been chewing and licking his thoracic limbs excessively since they had acquired him. This sign can be due to the nerve root compression often seen with this condition.(Courtesy of Giunio Bruto Cherubini DECvN)

A

BFigure 10: Lateral myelograms of a middle-aged dog with progressive tetraparesis and cervical hyperaesthesia. (A) Multiple sites of ventral attenuation of the contrast column, more apparent in the caudal cervical area, which responded well to linear traction (B)

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Cervical spondylomyelopathy is a chronic and progressive disease; surgical treatment is therefore preferred. However medical management can be tried in some circumstances. Controlled exercise and anti-inflammatory drugs can be used, but it is important to monitor these patients very closely, because in case of further deterioration surgery should be strongly recommended. Around 3050% of affected dogs can be managed with conservative treatment.

If surgical treatment is chosen, multiple techniques have been described. Dorsal decompression is preferred in cases with dorsal or dorsolateral compression, and ventral approaches with stabilisation are

recommended in cases with instability and ventral compression (Figure 12). The prognosis is worse for dogs with severe neurological deficits but it appears that about 80% of surgically treated dogs have a good prognosis. There is a recurrence rate of about 20% and it is therefore wise to monitor the dogs after surgery for the rest of their lives.

Chiari-like malformation and syringomyeliaChiari-like malformation is also known as caudal occipital malformation syndrome. Chiari-like malformation occurs due to malformation of part of the occipital bone decreasing caudal fossa volume. This results in the herniation of the cerebellum through or into the foramen magnum or indentation of the cerebellum. This is more complicated because there are other potential structures that can alter the normal caudal flow of the CSF through the foramen magnum. Syringomyelia is a presence of the fluid-filled cavity in the parenchyma of the spinal cord; it is commonly associated with Chiari-like malformation but can be present alone.

Chiari-like malformation is very common in toy and small breeds. The most common breeds affected are Cavalier King Charles Spaniels and

Griffon Bruxellois. The most common clinical sign is pain or signs of neuropathic pain syndrome. The affected dogs may rub their face, chew their paws, or show spontaneous screaming and so-called phantom scratching. Less common signs are scoliosis of the cervical spine, tetraparesis and ataxia.

Facial paresis or other intracranial signs can be present in severely affected cases. Dogs of 6 months up to 10 years of age have been reported to have this condition, but the most common age on presentation is around 3 years. Dogs can be completely asymptomatic and this is noted in a significant number of Cavalier King Charles Spaniels.

Chiari-like malformation and syringomyelia is known to be a hereditary condition. It is also known that Cavalier King Charles Spaniels have simply too much brain parenchyma in the cranial vault for their relatively small skull, which causes overcrowding of the caudal fossa. This affects the normal and smooth caudal CSF flow, which becomes turbulent. The altered CSF flow is believed to be the main reason for the development of syringomyelia in the cervical spinal cord but also in more caudal areas of the spinal cord and in the syringomyelia, size and location of the

Figure 12: Postoperative radiograph of the cervical area of the dog from Figure 11. Pins and polymethylmethacrylate were used to stabilise the area

A

BFigure 11: Sagittal T2-weighted MR images of the cervical area of a middle-aged Dobermann with progressive tetraparesis. (A) Compression at the level of C6C7. The compression is more severe from the protruded and degenerated intervertebral disc. From the ventral aspect, however, there is also a mild compression dorsally, suspected to be hypertrophied ligamentum flavum. Note the hyperintensity in the spinal cord at the level of the compression that can be due to the chronic compression of the spinal cord. (B) There is significant improvement of the compression during the linear traction, confirming instability in that area

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How to approach the dog with neck pain

Figure 14: intraoperative picture of foramen magnum decompression and partial C1 dorsal laminectomy. The vermis of the cerebellum, cisterna magna and medulla oblongata are visible in the bone defect

syrinx are significantly associated with the discomfort and pain.

Diagnosis is unfortunately difficult to reach without MRI. However, it is important to rule out other diseases that can mimic the clinical signs, especially otitis externa or media in cases of scratching. It is crucial to rule out these conditions by thorough otoscopic examination. All the diseases discussed in this review should be considered as potential differentials and the work-up should be tailored to rule them out.

Caudal fossa height to length ratios on skull radiographs have been used to predict Chiari-like malformation in Griffon Bruxellois, with promising results. However, MRI is the gold standard for assessing the cerebellum and the size and extent of the syrinx. MRI features are very characteristic, with caudal fossa overcrowding or herniation of the cerebellum through the foramen magnum, kinking of the brainstem and a syringomyelia in the spinalcord (Figure13).

Treatment is still controversial and no consensus has been reached amongst neurologists, especially for cases with severe neurological signs and pain. Either medical or surgical treatment can be tried. The aim of the medical treatment is to decrease the production of the CSF and establish a good analgesia protocol.

Furosemide or prednisolone are commonly used, but other drugs such as omeprazole and acetazolamide can also be employed. Neuropathic pain is more complicated to treat but gabapentin or pregabalin are common drugs which are trialled. Anticonvulsants, tricyclic antidepressants, amantadine and non-steroidal anti-inflammatory drugs are usually a part of the analgesia protocol. The response to this treatment is good but rarely complete and as this is a chronic progressive disease the treatment does not stop progression.

If medical treatment is not successful, surgical treatment should be considered. Foramen magnum decompression (FMD) (Figure 14) is the most common procedure to be performed. Other techniques have been described with variable results. FMD success rate is about 80% but recurrence is not uncommon.

The prognosis depends largely on the severity of the clinical signs on presentation and response to treatment. Itis important to mention that the BVA has developed a screening and breeding scheme for breeders of Cavalier King Charles Spaniels. This is a logical approach to breeding that will hopefully decrease or eliminate the incidence of inherited Chiari-malformation and syringomyelia and should be strongly encouraged amongst breeders.

Atlanto-axial instabilityThe anatomy of the atlanto-axial area is very complex but, put simply, the dens of the axis along with its ligament are important to maintain cervical stability. This joint does not have an intervertebral disc, and ligaments largely maintain the position of the vertebrae. If the dens of the axis vertebra and/or the ligament are absent, underdeveloped or malformed, instability of the area occurs. This is most commonly a congenital abnormality, although traumatic fracture or damage to the ligament can cause the neurological signs.

Clinical signs are most commonly seen in immature animals but traumatic instability can occur at any age. Toy and small breeds with a predisposition are Yorkshire Terriers, Chihuahuas and Miniature Poodles; however cases have also been reported in large breeds.

Figure 13: Sagittal T2-weighted image of the cervical area and the caudal fossa of a 4-year-old Cavalier King Charles Spaniel with severe cervical hyperaesthesia. There is a cerebellar herniation (vermis) through the foramen magnum and syringomyelia of the cervical spinal cord within more dorsal localisation, this is consistent with the Chiari-like malformation and syringomyelia

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Cervical hyperaesthesia is very common, especially in dogs following trauma. The neurological dysfunction can range from mild proprioceptive deficits to tetraplegia with respiratory compromise. Occasionallyseizure-like episodes are described, but these can be a presentation of intermittent spinal cord compression with a sudden cervical hyperaesthesia and neurological deficits.

If this condition is suspected, the examination of the cervical area should exclude extension, flexion and lateral movement of the neck, as this can exacerbate the condition. In fact any young dog with cervical hyperaesthesia should be initially treated as having suspected atlanto-axial instability.

The diagnosis can be confirmed on survey radiographs (see Figure3) but extreme care must be taken when performing this on the anaesthetised animal and intubation needs to be done very carefully. Lateral views are the most useful, as they can reveal a misalignment on mild flexion. This must again be performed with care. The ventrodorsal view is useful to assess the dens and it is generally safe to position the dog for this view. CT and MRI can assess the area better.

The preferred treatment is surgical stabilisation of the joint. Ventral and dorsal approaches have been described, however the ventral approach is the treatment of choice. Ventral fusion with pins, screws, plates and bone cement has been described (Figure 15) and the choice of technique is mainly dependent on the surgeons preferences. The prognosis is good if the animal survives 48 hours postoperatively. The predictors of a successful outcome are: age of onset, with dogs younger than 2 years having better prognosis; and severity and duration of the neurological signs. Dogs with less severe and shorter duration of neurological signs

usually have a better prognosis. Cervical hyperaesthesia and ataxia can be still present in some cases after successful surgical treatment.

Medical treatment should only be attempted in cases of acquired atlanto-axial instability. Neck braces, appropriate analgesia and a resting regime are recommended. The prognosis can be good, but concerns arise for long-term prognosis and the possible complications of braces, as well as sudden deterioration with more dramatic consequences.

ConclusionCanine cervical hyperaesthesia is a common clinical presentation in veterinary practice. A logical approach to these patients can be very rewarding in determining the underlying cause. Thorough clinical and neurological examinations are essential and to have the list of differential diagnoses to hand can make it easier for the clinician to make correct decisions for further investigation or the necessity of referral. Rapidly progressing disease with severe neurological deficits should be considered an emergency, but with appropriate diagnosis and treatment these cases can have very successful outcomes.

Figure 15: Lateral postoperative radiograph of a young Cavalier King Charles Spaniel with atlanto-axial instability. Four pins and polymethylmethacrylate have been used to stabilise the area

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24 | companion

The Small Animal Veterinary Surveillance Network was at BSAVA Congress for the first time this year. Visitors were able to experience the demo version of the SAVSNET system and to talk to members of the team about how their practice can be involved.

Delegates were able to get details about all aspects of the project from the people at the heart of SAVSNET Professor Susan Dawson, Dr Phil Jones, Dr P-J Noble and Dr Alan Radford were joined by Suzanna Reynolds, Tarek Menacere and Fernando Snchez-Vizcano Buendia.

What will it mean in practice?There is a growing awareness of SAVSNET amongst the profession and now that the project is really taking off, visitors to the stand at Congress were keen to know more about how the data collection will work and about the aims and objectives for the coming year. Sothe demonstration version of the SAVSNET questionnaire was a real success, showing people that taking part in SAVSNET would generally add just a few seconds to consultation time, and that in only about 1in 15 consultations would a full survey be launched which in itself is also not an onerous task.

The demo showed that even when a full survey is launched, it takes only 1025 seconds from start to finish. This is of course very important for busy vets in practice the SAVSNET philosophy has always been to make participation in the scheme as easy as possible and to combine it with feedback to practices in the form of benchmarking data. Being involved in the scheme will not be difficult, but it will be valuable to your practice, and to the profession.

Team talkA new team of staff has been employed to provide a strong infrastructure to SAVSNET, and it was the first time some of them had attended BSAVA Congress. Tarek Menacere is the new Database Developer; he was struck by the number of people there and the range of exhibitors. Fernando Snchez-Vizcano Buendia is SAVSNETs new epidemiologist, just back from his part in organizing the Society for Veterinary Epidemiology and Preventive Medicine (SVEPM) conference in Madrid. He was impressed by the organization and thegood mix of business and academia.

Project Co-ordinator Suzanna Reynolds is a qualified vet and so has attended BSAVA Congress many times as a delegate when working in small animal practice. However she found the experience very different as an exhibitor: The atmosphere amongst the exhibitors was fantastic. When we arrived everything we needed had been delivered and once we collected our lead retrieval device, we set up the stand and were ready to go. I thought that there might be quiet times outside of the breaks, but the reality is that there is a constant swirl of delegates its a brilliant networking occasion.

At Congress, delegates got to meet the team from the Small Animal Veterinary Surveillance Network and found out just how important this project could be to the profession. The event also saw the launch of the new website which will help you find out how to get involved and keep informed

From left: Susan Dawson, Fernando Snchez-Vizcano Buendia, Andrew Ash, Philip Jones, Suzanna Reynolds, Alan Radford, Sally Everitt

All go for SAVSNET

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Working towards welfare

Fernando Snchez-Vizcano Buendia Epidemiologist

Born in Murcia, Spain, Fernando graduated in Veterinary Science from the University of Murcia in 2005. The following year he spent seven months training in Epidemiology and Preventi ve Veterinary Medicine at the Complutense University of Madrid (UCM). Fernando spent the next four years in the Animal Research and Technology Center of Valencia (CITA-IVIA) working on his PhD developing epidemiological models to analyse the risk of entry of highly pathogenic avian in uenza virus and Newcastle disease virus into Spain. During his PhD, Fernando spent three months in the Veterinary Clinical Sciences Department of the Royal Veterinary College (RVC). Since obtaining his PhD he has worked as a post-doctorate researcher in the VISAVET group at UCM. Looking for new challenges brought him to his new role. SAVSNET will allow the monitoring of spati al and temporal trends of animal and zoonoti c diseases and syndromes in UK, which provide valuable informati on in terms of early detecti on and more cost-e ecti ve control of expected and unexpected health-related events.

Susan Bolan Administrator

Susan has joined SAVSNET aft er spending a signi cant period working for the NHS. She was initi ally involved with processing and reporti ng of waiti ng list stati sti cs for the Regional Health Authority. Following a career break she returned to Wirral Hospital Trust, taking on secretarial and administrati ve roles to support managers and consultants in a variety of disciplines. She looks forward to using her experience to drive the SAVSNET project forward and to engaging with the veterinary profession. Susan hopes that joining the SAVSNET team will allow her to diversify somewhat; having dealt solely with the human populati on previously, it will be interesti ng and challenging to build up knowledge about domesti c small animals. Shes de nitely a cat person, being owned by two at present.

Tarek Menacere Database developer

Tarek graduated from the University of Liverpool in 2006 with a rst-class degree in Computer Science. He worked at Lancaster University within the Security Lancaster research group, and for the last ve years he has been developing soft ware for the use of security groups in the areas of decepti on, insider threat and linguisti c analysis. He has been in charge of successfully delivering soft ware for projects totalling over 700,000 worth of investment and is now keen to take up the challenges