Sunday, 22 April 2018
Acupuncture for Small Animal Neurologic Disorders
Veterinary Clinics of North America: Small Animal Practice Volume 48, Issue 1, January 2018, Pages 201-219 Author links open overlay panelPatrickRoynardDVM, MRCVSabLaurenFrankDVM, MS, CVA, CVCH, CCRTcHuishengXieDVM, PhD, MSdMargaretFowlerDVM, MSef a Neurology/Neurosurgery Department, Long Island Veterinary Specialists, 163 South Service Road, Plainview, NY 11803, USA b Fipapharm, 26 rue du marais, Mont-Saint-Aignan 76130, France c Physical Rehabilitation and Acupuncture Service, Long Island Veterinary Specialists, 163 South Service Road, Plainview, NY 11803, USA d Department of Small Animal Clinical Sciences, University of Florida, 2089 Southwest 16th Avenue, Gainesville, FL 32608, USA e Acupuncture and Holistic Veterinary Services, 105 Lilith Lane, Summerville, SC 29485, USA f The Chi Institute of Traditional Chinese Veterinary Medicine, 9650 West Highway 318, Reddick, FL 32686, USA Available online 14 October 2017. crossmark-logo https://doi.org/10.1016/j.cvsm.2017.08.003 Get rights and content Previous article Next article Keywords Traditional Chinese veterinary medicine (TCVM) Acupuncture Electroacupuncture (EA) Herbal Dog Intervertebral disk disease (IVDD) Cervical spondylomyelopathy (CSM) Pain Key points • Research in neuroscience is progressively unveiling the different mechanisms of action of traditional Chinese veterinary medicine (TCVM) and allowing the modern clinician to understand it as a several millennia–old metaphor. • Scientific literature demonstrates the efficacy of TCVM for many small animal neurologic disorders, including intervertebral disk disease (IVDD), other myelopathies, and painful conditions. • TCVM, including acupuncture and herbals, is overall innocuous and easy to implement clinically. • TCVM can be used as an adjunct or occasionally as an alternative to conventional treatment, and can improve functional outcome and pain management. Video content accompanies this article at http://www.vetsmall.theclinics.com. Introduction Traditional Chinese medicine (TCM), such as acupuncture and administration of Chinese herbal formulas, has been used for thousands of years to effectively treat many conditions, including pain and neurologic issues.1,2 The first known text about TCM, Huangdi Neijing (Yellow Emperor’s Classic of Internal Medicine) is estimated from approximately the period 475 BC to 225 BC.3 Traditional Chinese veterinary medicine (TCVM) started in Chinese agricultural culture and is often associated with an equine practitioner known as Bo Le.4–6 Bo Le’s techniques were recorded in what many consider to be the first TCVM text, Bo Le Zhen Jing (Bo Le’s Canon of Veterinary Acupuncture).7 Western interest in TCM/TCVM started in the 1970s, and in the past 40 years has mushroomed in popularity, both clinically and in research (Fig. 1). Although TCVM has long been overlooked by some practitioners, modern neuroscience has shed some light on the mechanism of action of acupuncture.8–10 Despite the perception that TCVM presents the clinician with an entirely different way of approaching a patient, parallels with “Western” medicine are numerous, especially for those familiar with neurophysiology and neurologic disorders. Download high-res image (139KB)Download full-size image Fig. 1. PubMed search results for the word “acupuncture” by year. (Data fromwww.ncbi.nlm.nih.gov/pubmed. Accessed April 20, 2017.) Due to the paucity of clinical studies in veterinary acupuncture, much of the data available are human or laboratory based, and indicate evidence for its effectiveness. This is further supported by a few veterinary clinical trials and case reports. This review is meant to help guide the use of TCVM for neurologic disorders in small animals, based on available information and recommendations from experienced TCVM practitioners. Traditional Chinese veterinary medicine treatment modalities Acupuncture is defined as the stimulation of specific point(s) on the surface of the body by insertion of a needle, resulting in a therapeutic or homeostatic effect.11 From a TCVM standpoint, the aim is to allow Qi (energy) to flow harmoniously, which for a Western practitioner can be seen as a stimulation of the nervous system. TCVM defines 2 important concepts that are opposites, Yin and Yang, whose functioning relationship can be paralleled to anabolism and catabolism or to the parasympathetic and sympathetic components of the autonomic nervous system.12 Although TCVM presents the acupoints as areas where Qi is concentrated in the body, modern studies have revealed that acupuncture points are located in areas of sensitive neuroimmune modulation.13,14 Histologically, acupuncture points are found in areas with a high density of mast cells, lymphatics, and arteriovenous plexi, in addition to regions of concentrated innervation.13,14 This dense innervation consists of somatic afferent/efferent fibers, autonomic norepinephrine (NE) sympathetic fibers and cholinergic acetylcholine (Ach) parasympathetic fibers, with an increased ratio of myelinated to unmyelinated fibers compared with nonacupuncture points.14 Along this parallel, TCVM describes the acupoints as organized along several meridians portrayed as channels, similar to rivers where Qi flows, often following peripheral nerve pathways (eg, the pericardium [PC] meridian and the median nerve, the gallbladder [GB] meridian and the sciatic nerve). New research allows us to better understand TCM/TCVM theory as a several millennia–old metaphor, with the nervous system as a cornerstone of its mechanisms of action. Acupuncture has been used effectively for the treatment of neurologic disorders, such as intervertebral disk disease (IVDD)15 and spinal cord injury.16–18 Stimulation of acupuncture points with a needle produces analgesia, and other physiologic effects through neural, neurohumoral, neuromuscular, and musculoskeletal mechanisms.19 It has been demonstrated that certain acupoints can regulate proinflammatory factors, such as interleukin-6 (IL-6), cyclooxygenase-2 (COX-2), tumor necrosis factor-α (TNF-α), and many others.8,10,20–22 One of acupuncture’s most studied mechanisms is the stimulation of production of β-endorphins, promoting a profound and long-term analgesic effect.22,23 Moreover, certain acupoints can reduce the damage of free radicals and improve microcirculation.24,25 These events may contribute to the efficacy of acupuncture for the neurologic diseases discussed here. Stimulation of acupoints can be achieved by various techniques: dry needle (DN), electroacupuncture (EA), aqua-acupuncture (AA), and moxibustion (Fig. 2). DN is the most commonly used technique in veterinary acupuncture, and involves the insertion of fine, sterile needles into acupoints. EA, the modern practice of stimulating inserted needles with electricity, has been shown to have more profound effects compared with other techniques. It is used in many cases because of its rapid onset of pain relief and its ability to stimulate peripheral nerves. It is especially useful for neuralgia, nervous system injury, and persistent pain.8–10 AA is the injection of sterile liquids (eg, vitamin B-12) into acupuncture points, which may result in a prolonged stimulus. Moxibustion involves heating of an acupoint (directly or over a needle) with moxa, a type of bundled herb consisting primarily of Artemisia (mugwort). The mechanisms of moxibustion mainly relate to the thermal and nonthermal radiation, and pharmacologic effects of moxa and its combustion products acting on a specific acupoint.26 Download high-res image (613KB)Download full-size image Fig. 2. Different acupuncture techniques used in patients with multifocal IVDD: (A) DN technique on a 12-year-old Devon rex cat. (B) Electroacupuncture technique on a 7-year-old dachshund. (C) Moxibustion technique. The stick of moxa is held close to the needles to provide warming Qi. In general, herbal medicine is also used in TCVM as an adjunct to acupuncture. However, the review of this topic other than Yunnan Baiyao use is beyond the scope of this article. Epilepsy/seizure disorders From a TCVM standpoint, seizures are Internal Wind or “Wind in the Sea in Marrow”; the text Huangdi Neijing considered the brain, encased in a bony skull, as a reservoir of bone marrow, the “Sea of Marrow.” A recent review from the Cochrane Library concluded that there is not enough current evidence to support the use of acupuncture for human epilepsy, but it also noted that both DN and catgut implantation at acupoints may be effective in achieving at least 50% reduction in seizure frequency when compared with valproate and antiepileptic drugs in several trials.27 Better quality of life after treatment was also reported in the acupuncture groups.27 Although the use of EA has traditionally not been recommended in seizure disorders (due to a suspected but unverified pro-epileptic effect), recent research has shown beneficial effects of EA in several models of epilepsy, without however a consensus on acupoints and frequency to use. While using stimulation points outside the brain, the use of EA for seizures/epilepsy is somewhat similar in concept to the different intracranial or vagus nerve stimulation techniques in human refractory epilepsy (as EA may suppress seizures by parasympathetic activation and generation of similar neurotransmitters as intracranial electrical stimulation).28 As an example, it has been suggested that response to EA could predict therapeutic effect of hippocampal high-frequency electrical stimulation in patients with pharmacoresistant temporal lobe epilepsy29 and of anterior nucleus thalamus high-frequency electrical stimulation in medically refractory epilepsy.30 A study in rats found that both low-frequency (10 Hz/1 mA) and high-frequency (100 Hz/1 mA) EA at select acupoints significantly (P<.05 compared with control) reduced epileptic seizures, with greater control at the high frequency.31 Further research has shown that low-frequency (10 Hz) EA at bilateral gallbladder 20 (GB-20) suppressed pilocarpine-induced focal epilepsy by action on the μ, δ, and κ opioid receptors of the central nucleus of amygdala.28 Furthermore, EA at stomach-36 (ST-36) +/− stomach-37 (ST-37) reduced spontaneous seizures and can decrease epileptogenesis by elevating the expression of GAD(67) mRNA in the dentate gyrus granule cell layer,32 and by reducing mossy fiber sprouting and COX-2 levels in the hippocampus.33,34 Few clinical data are available regarding the antiepileptic effect of acupuncture in dogs, but 3 separate studies/case series reported success. One study using 2-mm to 3-mm gold wire pieces implanted at multiple acupoints reported a 50% or more reduction in the seizure frequency of 9 (60%) of 15 dogs with idiopathic epilepsy.35 Another case series describes the use of small subcutaneous gold implants placed over the calvaria on the Bladder (BL), Governing Vessel (GV), and GB meridians in 5 epileptic dogs nonresponsive to anticonvulsants, with 5 of 5 dogs experiencing decrease in seizure frequency after treatment.36 As gold implants can create significant signal loss and other susceptibility artifacts on MRI, Clemmons37 used 1.0 × 0.5-mm polylactic acid beads inserted at multiple acupoints using a modified 16-gauge needle in 10 dogs with refractory epilepsy (unsatisfactory seizure control despite 2 anticonvulsant medications within therapeutic range). He reported significant reduction in amplitude of electroencephalogram activity, reduction of seizures by more than 50% in 9 (90%) of 10 dogs, and change in seizure characteristics from cluster seizures to singular seizures.37 This may represent a promising new method to help control canine refractory epilepsy. Disorders of the spinal cord/myelopathies Spinal Cord Injury From a TCVM standpoint, spinal cord injuries (SCIs) are due to Qi and Blood stagnation, and acupuncture has long been used for various disorders of the spinal cord. Modern neuroscience has established the importance of secondary injury in SCI, with calcium entry in neurons and glial cells resulting in a cascade of cytokine and free radical release by activated microglia and damaged mitochondrial membranes.38,39 Of special interest are the roles of proinflammatory cytokines and mediators, such as TNF-α, interleukin-1β (IL-1β), matrix metalloprotease-9 (MMP-9), and nitric oxide (NO). Such factors promote the inflammatory cascade, and neuronal and oligodendrocyte damage, which leads to demyelination of axons and progressive disruption of nervous tissue. Long-term consequences of neuronal inflammation are associated with the development of astrocytosis, glial scar formation, and syringohydromyelia.39,40 Although there is currently no proven pharmacologic protocol protective from these secondary damages available to veterinary patients, recent research has shed some light on how acupuncture may fill this void. An experimental study of SCI in rats with sham/placebo control showed that DN treatment significantly (P<.01) improved functional recovery after SCI compared with control groups. Acupuncture treatment resulted in significantly attenuated microglial activation and significantly reduced expression of TNF-α, IL-1β, IL-6, MMP-9, NO synthase, and COX-2, providing neuroprotection and reducing apoptotic cell death of both neurons and oligodendrocytes. A significantly decreased size of lesion and axonal loss were also confirmed on histology and immune-histochemical staining.8 Interestingly, another study in a rat model of cerebral ischemic stroke showed that these benefits of acupuncture in SCI may extend to brain injury, as EA treatment reduced the motor impairment following middle cerebral artery occlusion, via inhibition of microglia-mediated neuro-inflammation and significantly decreased levels of TNF-α, IL-1β, and IL-6 in both sensorimotor cortex tissue and blood serum.41 Intervertebral Disk Disease Acupuncture has been shown to accelerate recovery of motor function and improve analgesia in dogs affected with IVDD,42–47 and TCVM for IVDD is documented in the veterinary literature.45 In a randomized controlled study in rats, EA inhibited Wnt-β-catenin, which may contribute to its effect in delaying the degenerative process of the cervical intervertebral disks.48 Acupuncture also can reduce the amount of type I collagen in the nucleus pulposus while promoting the production of type II collagen, changes necessary for the proper hydration of proteoglycans leading to compression resistance,49 thus improving the ability of degenerated disks to repair.50 EA also increased blood flow in the vertebrae and increased micro-vessel density compared with control rats.51 The number of normal neurons in the spinal cord and pelvic limb motor function were also increased.51 Some clinical research suggests that EA may have a success rate of 83% in treating canine thoracolumbar (TL) IVDD.44,47 In one study by Hayashi and colleagues,43 50 dogs with signs of TL IVDD were classified with a scale of neurologic deficits from grades 1 to 5 (Table 1). Dogs were separated into 2 groups, either receiving conventional medical treatment alone or conventional medical treatment with EA. In grades 3 or 4, the time to recover ambulation was significantly (P = .0341) less (10.10 ± 6.49 days) in the group receiving EA than without EA (20.83 ± 11.99 days). The success rate, defined as the ability to walk without assistance, for grades 3 or 4 was significantly (P = .047) higher with EA (10/10) than without EA (6/9). The overall success rate was significantly (P = .015) higher with EA (23/26; 88.5%) than without EA (14/24; 58.3%). Although this study presented methodological flaws and researcher bias (groups not matched, evaluator not blinded), EA combined with conventional medical treatment was more effective than conventional medication alone and resulted in a shorter time to recover ambulation (Fig. 3).43 Table 1. Neurologic grading scale in canine intervertebral disk disease and suggested recommendation for use of traditional Chinese veterinary medicine (TCVM) 0 Normal 1 Cervical or thoracolumbar pain, hyperesthesia: TCVM as an adjunct or alternative to standard management (cage rest and analgesics) 2 Ataxia, paresis, decreased proprioception, ambulatory: TCVM as an adjunct to standard management (cage rest and analgesics) including rehabilitation 3 Paresis with absent proprioception, nonambulatory: TCVM as an adjunct to standard management with recommendation for advanced imaging ± decompressive surgery and rehabilitation 4 Paralysis, nociception present: TCVM as an adjunct to standard management with recommendation for advanced imaging ± decompressive surgery and rehabilitation 5 Paralysis, absent nociception: TCVM as an adjunct to decompressive surgery and rehabilitation Download high-res image (189KB)Download full-size image Fig. 3. Effect of EA on IVDD in dogs. (Data from Hayashi A, Matera J, Fonseca Pinto A. Evaluation of electroacupuncture treatment for thoracolumbar intervertebral disk disease in dogs. J Am Vet Med Assoc 2007;231:913–8.) In a retrospective study, the outcome of 80 dogs with paraplegia and intact nociception from TL IVDD (grade 4) treated with EA and prednisone versus prednisone alone were compared. The combination of EA with prednisone was significantly (P = .01) more effective than prednisone alone to recover ambulation, allowed faster return to ambulatory status (P = .011), relieved back pain (P = .001), and decreased relapse rate (P = .031).52 Another study compared EA, hemilaminectomy, and hemilaminectomy + EA in 40 dogs with more than 48 hours of severe neurologic deficits due to IVDD (only grades 4 and 5) confirmed by diagnostic imaging (MRI, computed tomography [CT], myelography). “Clinical success,” defined as a patient initially classified grade 4 or 5 being classified as grade 1 or 2 within 6 months of treatment, was significantly (P<.05) higher for dogs that received EA alone (15/19 or 79%) or EA and surgery (8/11 or 73%) than for dogs that had surgery alone (4/10 or 40%) (Fig. 4). Thus, it was concluded that EA alone or a combination of EA + surgery, was more effective than surgery alone for recovery of ambulation and improvement in neurologic deficits.42 Download high-res image (144KB)Download full-size image Fig. 4. Effect of EA on IVDD in dogs. (Data from Joaquim J, Luna S, Brondani J, et al. Comparison of decompression surgery, electroacupuncture, and decompressive surgery followed by electroacupuncture for the treatment of dogs with intervertebral disk disease with long-standing severe neurologic deficits. J Am Vet Med Assoc 2010;236:1225–9.) TCVM can also be used for cervical IVDD and, in the authors’ experience, it may be one of the most rewarding conditions to treat with EA. A retrospective study described the use of 3 different acupuncture protocols using DN ± EA and Chinese herbs in 19 dogs with cervical myelopathy having previously failed conventional medical/surgical management (18 with IVDD, 1 with fibrocartilaginous embolic myelopathy). Conclusions regarding differences in efficacy between the protocols are difficult to surmise (operators not blinded; treatment based on severity and duration of clinical signs), but it is noticeable that all 19 dogs were improved from both a pain and neurologic function standpoint.53 A case report also describes the successful use of EA and herbals for IVDD at C3-C4 in a miniature pinscher.45 As noted in these publications, the investigators recommend using both local points (Jing-jia-ji, located dorsal and ventral to the transverse processes of the cervical vertebrae) and distal points when using acupuncture to treat cervical IVDD. Although the authors still recommend advanced imaging and decompressive surgery when indicated for cases of presumptive IVDD, these results justify offering EA as an adjunct to conventional treatment. A suggested recommendation for the use of TCVM based on grading of neurologic deficits is included in Table 1. Cervical Spondylomyelopathy A clinical trial of 40 dogs with presumptive or diagnosed cervical spondylomyelopathy (CSM) was conducted over 3 years to evaluate the efficacy of standard treatment (medical and surgical) versus standard treatment + EA. EA resulted in pain relief quickly, often after the first session, with proprioceptive deficits being slower to respond. The overall efficacy of EA was 85%, whereas surgery and conventional medications resulted in a low 20% efficacy in this trial.54 However, these results should be interpreted cautiously, as a number of dogs were only presumptively diagnosed with CSM, the method of randomization between the 2 groups was not clear, the assessors were not blinded, and the improvement rate reported with conventional management was markedly lower than reported elsewhere.55,56 In a retrospective study, medical records for 19 animals (13 dogs and 6 horses) with presumptive or diagnosed CSM treated with TCVM were reviewed.57 Treatment consisted of DN, EA, AA (1000 μg/mL vitamin B-12), Jing Tong Fang (Cervical Formula; Proprietary Chinese herbal formula manufactured by Jing Tang Herbal, Reddick, FL) for all patients, modified Da Huo Luo Dan (Double P II; Proprietary Chinese herbal formula manufactured by Jing Tang Herbal) in grades 2 or higher, and Shen Tong Fang (Body Sore; Proprietary Chinese herbal formula manufactured by Jing Tang Herbal) in patients with cervical pain. Additional Chinese herbal medicines were given and modified according to the Chinese pattern diagnosis at the time. Of the 19 cases, 10 (52.6%) had complete clinical recovery and 8 (42.1%) improved 1 or more grade(s). Only 1 (5.3%) of 19 had no improvement, a horse for which poor tolerance of acupuncture precluded the completion of treatment, resulting in 13 of 13 dogs improving. All 18 cases that responded were observed for at least 6 months and demonstrated good quality of life with no relapse. Despite shorter follow-up in these 2 EA studies than in other clinical studies of canine CSM,55,56 these results of overall improvement rate of 80% to 95%, compared with the previous reports of 70% to 90% of dogs improved after surgery (∼50% for conventional medical treatment) and warrant further clinical trials of management of CSM with TCVM. Furthermore, there were no cases of worsening with TCVM, making it a viable adjunct or alternative to conventional medicine and surgery, specifically early in the course of the disease. As for IVDD, the authors still recommend advanced imaging and surgery (if indicated) for presumptive cases of CSM, but also recommend integrating TCVM for ideal pain management and functional recovery (Fig. 5, Video 1). Download high-res image (690KB)Download full-size image Fig. 5. (A) Sagittal and (B) transverse MRI of a 9-year-old female spayed (FS) Doberman presented for tetraplegia, diagnosed with disk-associated CSM at C5-C6 (arrow). A ventral slot was performed at C5-C6. (C) Patient receiving electroacupuncture in local (Jing-jia-ji) and distal points postoperatively. Herbal treatment was also used with Cervical Formula (proprietary Chinese herbal formula manufactured by Jing Tang Herbal) and Buyang Huanwu. The patient recovered ambulatory status within 1 month (see Video 1). Traditional Chinese veterinary medicine for painful neurologic conditions/miscellaneous: acupuncture and pain Numerous human clinical trials, many with low to moderate evidence, have been evaluated in large systematic reviews and meta-analyses, and acupuncture has proven effective for different types of pain associated with neurologic conditions, including postoperative, headaches, sciatica, diabetic neuropathy,58,59 cervical, and lumbar.60–62 Acupuncture acts on all levels of the pain pathway, with many of the bioactive chemicals involved in inflammatory pain models decreasing with acupuncture,20,63 and also a modulatory effect on endogenous adenosine, cannabinoids, corticosterone, and opioids. Other mechanisms at the spinal cord level include serotoninergic, catecholaminergic, dopaminergic, substance P, and glutamate-receptor-driven pathways.10 In neuropathic pain (NP) models, acupuncture effects have been primarily studied at the spinal cord level. Low-frequency EA (2–10 Hz) has been associated with a more robust, longer-lasting endogenous opioid response than higher frequencies (100 Hz), which correlates with a vast quantity of research indicating that low-frequency EA inhibits NP more effectively, although both showed a positive response.10 It has been proposed that very low-frequency EA (2 Hz) triggers prolonged synaptic depression in the dorsal horn of rats, leading to an increased duration of analgesia.64 In tactile allodynia, non-nociceptive fibers Aβ (faster than C and Aδ fibers associated with pain) become involved in the pain signal.65–67 These changes, along with the gate theory68 and with the ability of EA to recruit Aα and Aβ before Aδ and C fibers,69 is another explanation for the ability of acupuncture to relieve NP. NP and inflammatory pain share some similarities, such as the stimulation of N-methyl-D-aspartate receptors, which gives EA the ability to target both based on its ability to activate α2-adrenoceptors and 5-HT1Ars and inhibit GluN1.10,70 EA’s analgesic effects are at least partially due to the inhibition of excitatory amino acids, such as glutamate, and stimulation of inhibitory amino acids, such as GABA.10,71–76 Other mechanisms of EA on NP include its ability to inhibit nerve-damage–induced upregulation of glial fibrillary acidic protein, OX-42, MMP-9, MMP-2, TNF-α, IL-6, IL-1β, and microglia activation in the spinal cord.77,78 Clinical veterinary studies evaluating acupuncture’s effectiveness for NP are lacking, but the authors have used acupuncture successfully in many cases, specifically early in the course of the disease. In cases of painful radiculopathy/“nerve root signature” (eg, foraminal IVDD, cervical or at L7-S1 with resulting sciatica), EA can be extremely rewarding and result in a fast improvement. It is unclear if the sharp, acute pain encountered in these cases is a true form of NP or nociceptive/inflammatory pain due to involvement of the local nervi nervorum,79,80 but clinicians should not underestimate the role of the nervi nervorum in subsequent development of long-term NP, and EA can help prevent this phenomenon.81 The authors also have used acupuncture successfully in the management of cases with paresthesia/dysesthesia of unclear etiology (eg, feline hyperesthesia syndrome). For more chronic cases with central nervous system NP (eg, Chiari-like malformation with syringohydromyelia), the lack of efficacy of acupuncture mentioned by some investigators82 may be related to central sensitization but also remodeling of the dorsal horn and higher centers of pain processing, emphasizing the need for early treatment. Traditional Chinese veterinary medicine and veterinary neurosurgery Several studies on postoperative pain after abdominal procedure in small animals have shown that acupuncture can decrease the dosage of anesthetic agent(s) required for surgery and can provide analgesia comparable to that achieved with injectable opioids or nonsteroidal anti-inflammatory drugs.83–85 In a controlled, blinded study on 15 dogs undergoing hemilaminectomy for TL IVDD, total dose of fentanyl administered during the first 12 hours after surgery was significantly (P = .04) lower in the group receiving EA than in the control group. Pain score (P = .018) was significantly lower in the EA group than in the control group 36 hours after surgery.86 Another study indicated that EA combined with low-dosage morphine suppressed postoperative pain better than either one did individually.87 One human clinical study on preoperative EA indicated significantly decreased amount of morphine required during the first 24 hours postoperatively and significantly reduced incidence of nausea and dizziness during the same period compared with sham EA.88 The authors routinely use EA as part of the postoperative pain management of every spinal surgery, ideally with bilateral stimulation because it is associated with better analgesic effect.89 Yunnan Baiyao (literally “the white medicine from the province of Yunnan”) is an herbal formulation of relative innocuity, and is easily implemented with many potential benefits in veterinary neurology/neurosurgery. Although its complete formula is owned and kept partially secret by the government of the People’s Republic of China, recent research has proven numerous benefits: as an antihemorrhagic agent, but also as an analgesic and antineoplastic supplement.90 In recent human clinical publications, Yunnan Baiyao has been associated with significantly decreased intraoperative blood loss,91 significantly decreased postoperative C-reactive protein and IL-6,92 and significantly decreased postoperative inflammation and swelling,93 with no allergic reactions, thromboembolic events, or other side effects reported. One of the authors (PR) is now routinely using Yunnan Baiyao preoperatively for every patient undergoing neurosurgery, specifically when the procedure can be planned several days ahead and if intraoperative hemorrhage is expected to be significant in volume (eg, craniectomy for multilobular tumor of bone, combined suboccipital and rostrotentorial craniectomy with occlusion of the transverse sinus, cervical dorsal laminectomy in large-breed dogs) or in terms of impact on visualization of the nervous tissue (eg, ventral slot) (see Fig. 5; Figs. 6 and 7, Video 2). Yunnan Baiyao is commercialized in capsules of 250 mg (16 regular capsules + 1 small “emergency red pill” in the middle of the blister) and other forms, such as paste, patches, powder, and aerosol. Suggested dosage is 1 capsule/10 kg by mouth once to twice daily for dogs (the “emergency red pill” can be given preoperatively), and 0.5 to 1 capsule by mouth twice daily for cats. Download high-res image (692KB)Download full-size image Fig. 6. (A) Sagittal CT image of a 9-year-old male neutered (MN) Pitbull presented for a large mass in the occipital area (arrow). The osteolytic mass invades the occipital, parietal, and temporal bones of the calvaria bilaterally. Biopsy was consistent with an osteosarcoma of high grade and surgical removal was elected. As perioperative hemorrhage was expected to be significant, the patient was treated with Yunnan Baiyao for a week before surgery. (B) Surgical removal was uneventful, with minimal blood loss and no transfusion required. Patient 3 days postoperative, with normal neurologic examination (see Video 2A and B). Download high-res image (473KB)Download full-size image Fig. 7. (A) Dorsal and (B) transverse postcontrast brain MRI of a 5-year-old FS mixed breed dog. A large contrast-enhancing mass is seen at the level of the right cerebello-ponto-medullary angle (arrow), consistent with a choroid plexus tumor. Before surgery, the patient was treated with Yunnan Baiyao to help hemostasis. Gross total resection was achieved through a combined suboccipital and right rostro-tentorial craniectomy, with occlusion of the right transverse sinus. (C) The patient suffered neurologic worsening postoperatively, with nonambulatory tetraparesis, right facial paralysis, and severe right head tilt, and received extensive rehabilitation/EA with marked improvement of all deficits and recovery of ambulatory status (D). Discussion/controversies about the use of traditional Chinese veterinary medicine Although advances in neuroscience are slowly explaining the TCM/TCVM theory and the metaphor it constitutes, much remains to be discovered (eg, specificity of action of certain acupoints, role of the different frequencies used in EA). Before this is achieved, it is the authors’ opinion that TCVM is most successful when an experienced practitioner makes an accurate Chinese pattern diagnosis, then chooses the appropriate acupuncture and herbal prescriptions. Although often effective in straightforward simpler cases, “cook-booking” or using a predetermined routine set of acupoints may not be as effective in more complicated cases. Similar to conventional operator-dependent disciplines, such as neurosurgery, acupuncture treatments can be heavily dependent on practitioner expertise and a higher level might reflect on a better outcome for the patient, but also for the overall cohort in controlled studies. This may explain the discrepancy in the perceived benefits of acupuncture among clinicians and when comparing studies, as one’s assessment of his or her own performance is influenced by skill/capabilities level,94 the perceived difficulty of the task performed,95 and the self-relevance of the task.96 These could be some of the contributing factors to why there are few scientifically valid clinical studies on veterinary acupuncture, resulting in skepticism in some of the scientific community, but also raises the question of the role of formal education in the veterinary curriculum. Although nearly 25% of recent graduates face questions regarding the potential benefits of TCVM on a frequent basis, a lack in formal scholar training exists, with only 1 (3%) of 34 American Veterinary Medical Association–accredited colleges offering a required course in complementary and alternative veterinary medicine and 15 (44%) of 34 offering an elective course.97,98 There remains a need for an evidence-based, unbiased scholar training of acupuncture and TCVM modalities in the veterinary curriculum.98 Summary As research unveils the different mechanisms of action of acupuncture and Chinese herbals, TCVM can be better understood by Western practitioners. The laboratory models and limited clinical research available are supportive for the use of TCVM in the management of neurologic conditions in small animals, specifically in cases of IVDD, other myelopathies, and painful conditions. The relative innocuity of TCVM modalities (specifically acupuncture) make them easy to implement in a clinical setting, and provide a useful adjunct or occasionally alternative to conventional management. TCVM is best used in conjunction with a proper conventional diagnosis and can result in faster recovery and better pain control in neurologic conditions, whether the patient is managed medically or surgically (eg, IVDD). There remains a need for larger randomized controlled trials before further indications can be fully validated, along with an evidence-based approach to TCVM to reach unbiased conclusions in veterinary education and medical recommendations. Supplementary data Download video (15MB) Help with mp4 files Video 1. Nine-year-old FS Doberman 1 month postoperative C5-C6 ventral slot for disc-associated CSM (patient presented tetraplegic). Download video (7MB) Help with mp4 files Download video (11MB) Help with mp4 files Video 2. 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