Re: Re: diagnostic questions re neurologic GSD

[Guest guest]

Pam those neuro notes sound very familiar. I think is correct. There is a lot of controversy over when to use CT vs MRI and this is particularly true for LS disease. I suspect that isn't what you have here. I think if you get a positive DM test and the owners want to turn every stone do the MRI and if it's clean you probably have a presumptive DX of DM. We put these dogs in a pretty rigorous rehab program as it has been shown to increase their life expectancy from some work Bern, Switzerland. Nice job!SteveSent from my iPad

Hi!

1. rDVM has the dog on pred for the past 6 months. The owners do not report

> that this has helped, in fact the dog has continued to worsen and they would

> like to stop the pred because of the side effects (PU/PD/PP). However, their

> vet has told them pred is the treatment for his (undiagnosed?) condition and

> if they stop he will get worse faster. Pred is not a treatment I would have

> recommended for anything on my differential list other than brain tumor,

> especially if there is no improvement after 6 months. Am I mistaken?

I think it is fine to wean off the pred...just make sure he is not getting worse. I typically don't use pred, unless I know what I am treating.

>

> 2. They were told a myelogram would be preferential to an MRI because the

> surgeon could be standing by to go straight to surgery without waking the

> dog up. Surely the same could be true of an MRI if one went to a facility

> that had both MRI and surgeons? I thought myelograms were pretty much things

> of the past on account of seizure risk and the low amount of information

> obtained compared to MRI, although I know some people like to do CT plus

> myelogram. Are there any surgeons or neurologists out there who would care

> to comment? My inclination is to encourage an MRI if the DM test is negative

> to try and rule in or out IVDD, LS stenosis, neoplasia.

I guess it depends on the practice. An MRI is much safer and you get a better view of the spinal cord itself. I prefer it over myelograms. I am always willing to take a dog to surgery right after the MRI if it needs to be done.

>

> 3. Lumbosacaral stenosis/disease -- it is my understanding this is not

> uncommon in shepherds and with surgery there is potential for return to full

> function. Is this the understanding of anyone else (who might know more than

> I do), and does this presentation sound like LS disease? In my notes from

> CRI neuro course I see that LS dogs tend to have absent cranial tibial

> reflexes, severe atrophy of cranial tibialis, and don't flex their stifles

> when walking -- that does not describe this dog. However, the radiographic

> picture of the LS junction certainly seems abnormal. For LS disease is MRI

> the best diagnostic tool? and is surgery mandated or can they be rehabbed

> (or does it depend on the underlying etiology?)

LS disease is common in Shepherds - but more common, is radiographic "suggestions" of the disease and no compression seen with imaging. You can see a varying degree of signs - from unilateral pelvic limb lameness , to decreased reflexes, to decreased/absent anal tone and tail tone. From you description of this dog - I would be inclined to think that there is atleast a T3-L3 myelopathy - although the LS region could be affected.

I hope that helps.

Kube, DVM

DACVIM (Neurology)

>

> Hi All,

>

> Today I evaluated a 7 yr old 120 pound MN GSD with an 8 mo history of

> progressive hind limb ataxia and weakness. It began mildly but currently he

> is very weak and ataxic with profound proprioceptive deficits in both hind

> legs, difficulty rising or negotiating stairs, and frequently falling when

> walking (although he does walk and even run). He has normal spinal reflexes

> (sciatic, patellar, gastroc, cranial tibial) on both sides -- well they seem

> normal to me although it's possible the right was stronger than the left but

> I don' t know if that means the right is hyper or the left is hypo. Mild

> pain to palpation at the T-L junction, where he has spondylosis on rads, and

> in the low lumbar/sacral region, where he seems to have collapsed disk space

> and sclerotic end plates of L7 and S1 (rads are from the rDVM, who actually

> interpreted them as lytic S1 but to me they just look bright). Reduced hip

> extension on the right, where rads show evidence of mild to moderate CHD.

> Otherwise good joint ROM. Atrophy of hind limb musculature especially

> biceps, symetrical.

>

> It's hard to say whether the dog is painful. He didn't mind any

> manipulations other then hip extension, was fine with tail pulls, did sink

> away from LS pressure but that might have been due to weakness. He really

> struggles to rise but again that might all be weakness. He does have a

> tendancy to sit with his hind limbs straight out in front of him like an

> acutely paralyzed IVDD dog -- I don' t know if this means anything.

>

> To my mind the differentials for this dog include DM, lVDD, intra or

> extradural neoplasm, cauda equina syndrome (lumbo sacral disease), diffuse

> neuropathy (seems unlikely since only hind limbs are affected), cranial

> neoplasm. Have I missed anything?

>

> In addition to his regular vet, the dog is seeing another vet for

> chiropractic and acupuncture and a number of alternative treatments

> including some herbs (not sure what), Heel and Traumeel. Their differentials

> were: DM, myelopathy, neuropathy

>

> I sent out DM DNA test today.

>

> My questions are as follows:

>

> 1. rDVM has the dog on pred for the past 6 months. The owners do not report

> that this has helped, in fact the dog has continued to worsen and they would

> like to stop the pred because of the side effects (PU/PD/PP). However, their

> vet has told them pred is the treatment for his (undiagnosed?) condition and

> if they stop he will get worse faster. Pred is not a treatment I would have

> recommended for anything on my differential list other than brain tumor,

> especially if there is no improvement after 6 months. Am I mistaken?

>

> 2. They were told a myelogram would be preferential to an MRI because the

> surgeon could be standing by to go straight to surgery without waking the

> dog up. Surely the same could be true of an MRI if one went to a facility

> that had both MRI and surgeons? I thought myelograms were pretty much things

> of the past on account of seizure risk and the low amount of information

> obtained compared to MRI, although I know some people like to do CT plus

> myelogram. Are there any surgeons or neurologists out there who would care

> to comment? My inclination is to encourage an MRI if the DM test is negative

> to try and rule in or out IVDD, LS stenosis, neoplasia.

>

> 3. Lumbosacaral stenosis/disease -- it is my understanding this is not

> uncommon in shepherds and with surgery there is potential for return to full

> function. Is this the understanding of anyone else (who might know more than

> I do), and does this presentation sound like LS disease? In my notes from

> CRI neuro course I see that LS dogs tend to have absent cranial tibial

> reflexes, severe atrophy of cranial tibialis, and don't flex their stifles

> when walking -- that does not describe this dog. However, the radiographic

> picture of the LS junction certainly seems abnormal. For LS disease is MRI

> the best diagnostic tool? and is surgery mandated or can they be rehabbed

> (or does it depend on the underlying etiology?)

>

> sorry for all the questions but any thoughts appreciated

> thanks

> Pamela Mueller PhD DVM

> www.animaltherapycenter.com

>

[Guest guest]

 

Pam those neuro notes sound very familiar.

 

yes they do don't they? reminds me of warmer times in Florida....

 

I think is correct. There is a lot of controversy over when to use CT vs MRI and this is particularly true for LS disease.

When you say CT do you mean CT plus myelogram or just CT? I remember that you are more of an advocate for CT in some cases (although I am never sure WHICH cases and since we have a local MR that is what we tend to push). But I assume you would not advocate myelogram alone (that is what was recommended to these owners) -- just not enough information compared to advanced imaging, right?

 

I suspect that isn't what you have here.

That is good to know; I was thinking too it did not really fit with all the signs but I thought " German Shepherd, trouble walking, odd looking LS junction on rads, LS disease, fixable with surgery " and don't want to miss a fixable problem and condemn the dog to a non-fixable one like DM or neoplasia. He does kind of collapse when I press on the LS region, do you think that is pain (DM should not be painful) or could it be just weakness?

 

I think if you get a positive DM test and the owners want to turn every stone do the  MRI and if it's clean you probably have a presumptive DX of DM.

 Hmm I thought the DM DNA test was so good that we had presumptive dx of DM if we get a homozygous dog with clinical signs we don't need any more tests such as MRI (although our local neurologist, Jerry Northington, does not believe this) . This is what I have told owners. Is this too much  certitude?

 

We put these dogs in a pretty rigorous rehab program

Yes we seem to specialize in this at our place we have had several dogs (presumptive DM based on DNA, all Boxers) treated with aggressive rehab lots of water work and of course we can't say if it increased these particular dogs' life expectancy as they all ended up euthanized anyway, but they seemed to do well and owners were happy. They were older than this dog (who is only 7) however.

 

thanks,

Pam Mueller

 

[Guest guest]

Steve, and all: I ended up needing to review the evidence for rehab for degenerative myelopathy last year, and wanted to share this with you. Training intensity appears to be important. There is evidence that the rehab exercises in ALS patients should be low impact. (Fortunately, in this case, there is a human model for an animal disease). A study using a transgenic mouse model for ALS (Muscle & Nerve, DJ Mahoney et al, 2004) reported that when a protocol based on high intensity endurance exercise was used (motorized treadmill with progressively longer times and increasing speeds x 5 times/wk ), the male mice actually had a more rapid deterioration of hind limb motor function and died sooner. We need to evaluate carefully the publication that was reported in J Vet Internal Med from the authors in Berne, concluding that physiotherapy results in longer survival times. That conclusion may be correct, but there are 2 serious flaws in that study -- dogs were not randomly assigned (owners were able to decide if they wanted to be in the treatment group) and the end-point was when the owner decided to have the dog euthanized, not a biological marker to indicate the stage of the disease. It is not hard to imagine that people who have spent a lot of time working with their dog also decided to keep their dog going a few weeks or months longer. Hence the need for a Degen Myelopathy Severity Scale and DM Functional Rating Scale to assess the dogs, as they have established for ALS patients. I plead guilty for being in academia and not undertaking more randomized controlled clinical trials, but I think that the conclusions of this publication on positive effects of rehab in DM need to be considered carefully until we have some form of biological marker or rating scale to get more objective assessments.

JanJanet Steiss, DVM, PhD, PT, Dipl. ACVSMRProfessor, Dept of Anatomy, Physiology & Pharmacology College of Veterinary Medicine Auburn University AL 36849 ______________________________ work ph: FAX (departmental): alternate email: steisje@...

To: VetRehab From: vrasteve@...Date: Wed, 20 Apr 2011 00:08:49 -0400Subject: Re: Re: diagnostic questions re neurologic GSD

Pam those neuro notes sound very familiar. I think is correct. There is a lot of controversy over when to use CT vs MRI and this is particularly true for LS disease. I suspect that isn't what you have here. I think if you get a positive DM test and the owners want to turn every stone do the MRI and if it's clean you probably have a presumptive DX of DM. We put these dogs in a pretty rigorous rehab program as it has been shown to increase their life expectancy from some work Bern, Switzerland. Nice job!

Steve

Sent from my iPad

Hi!1. rDVM has the dog on pred for the past 6 months. The owners do not report> that this has helped, in fact the dog has continued to worsen and they would> like to stop the pred because of the side effects (PU/PD/PP). However, their> vet has told them pred is the treatment for his (undiagnosed?) condition and> if they stop he will get worse faster. Pred is not a treatment I would have> recommended for anything on my differential list other than brain tumor,> especially if there is no improvement after 6 months. Am I mistaken?I think it is fine to wean off the pred...just make sure he is not getting worse. I typically don't use pred, unless I know what I am treating.> > 2. They were told a myelogram would be preferential to an MRI because the> surgeon could be standing by to go straight to surgery without waking the> dog up. Surely the same could be true of an MRI if one went to a facility> that had both MRI and surgeons? I thought myelograms were pretty much things> of the past on account of seizure risk and the low amount of information> obtained compared to MRI, although I know some people like to do CT plus> myelogram. Are there any surgeons or neurologists out there who would care> to comment? My inclination is to encourage an MRI if the DM test is negative> to try and rule in or out IVDD, LS stenosis, neoplasia.I guess it depends on the practice. An MRI is much safer and you get a better view of the spinal cord itself. I prefer it over myelograms. I am always willing to take a dog to surgery right after the MRI if it needs to be done.> > 3. Lumbosacaral stenosis/disease -- it is my understanding this is not> uncommon in shepherds and with surgery there is potential for return to full> function. Is this the understanding of anyone else (who might know more than> I do), and does this presentation sound like LS disease? In my notes from> CRI neuro course I see that LS dogs tend to have absent cranial tibial> reflexes, severe atrophy of cranial tibialis, and don't flex their stifles> when walking -- that does not describe this dog. However, the radiographic> picture of the LS junction certainly seems abnormal. For LS disease is MRI> the best diagnostic tool? and is surgery mandated or can they be rehabbed> (or does it depend on the underlying etiology?)LS disease is common in Shepherds - but more common, is radiographic "suggestions" of the disease and no compression seen with imaging. You can see a varying degree of signs - from unilateral pelvic limb lameness , to decreased reflexes, to decreased/absent anal tone and tail tone. From you description of this dog - I would be inclined to think that there is atleast a T3-L3 myelopathy - although the LS region could be affected.I hope that helps. Kube, DVMDACVIM (Neurology)>> Hi All,> > Today I evaluated a 7 yr old 120 pound MN GSD with an 8 mo history of> progressive hind limb ataxia and weakness. It began mildly but currently he> is very weak and ataxic with profound proprioceptive deficits in both hind> legs, difficulty rising or negotiating stairs, and frequently falling when> walking (although he does walk and even run). He has normal spinal reflexes> (sciatic, patellar, gastroc, cranial tibial) on both sides -- well they seem> normal to me although it's possible the right was stronger than the left but> I don' t know if that means the right is hyper or the left is hypo. Mild> pain to palpation at the T-L junction, where he has spondylosis on rads, and> in the low lumbar/sacral region, where he seems to have collapsed disk space> and sclerotic end plates of L7 and S1 (rads are from the rDVM, who actually> interpreted them as lytic S1 but to me they just look bright). Reduced hip> extension on the right, where rads show evidence of mild to moderate CHD.> Otherwise good joint ROM. Atrophy of hind limb musculature especially> biceps, symetrical.> > It's hard to say whether the dog is painful. He didn't mind any> manipulations other then hip extension, was fine with tail pulls, did sink> away from LS pressure but that might have been due to weakness. He really> struggles to rise but again that might all be weakness. He does have a> tendancy to sit with his hind limbs straight out in front of him like an> acutely paralyzed IVDD dog -- I don' t know if this means anything.> > To my mind the differentials for this dog include DM, lVDD, intra or> extradural neoplasm, cauda equina syndrome (lumbo sacral disease), diffuse> neuropathy (seems unlikely since only hind limbs are affected), cranial> neoplasm. Have I missed anything?> > In addition to his regular vet, the dog is seeing another vet for> chiropractic and acupuncture and a number of alternative treatments> including some herbs (not sure what), Heel and Traumeel. Their differentials> were: DM, myelopathy, neuropathy> > I sent out DM DNA test today.> > My questions are as follows:> > 1. rDVM has the dog on pred for the past 6 months. The owners do not report> that this has helped, in fact the dog has continued to worsen and they would> like to stop the pred because of the side effects (PU/PD/PP). However, their> vet has told them pred is the treatment for his (undiagnosed?) condition and> if they stop he will get worse faster. Pred is not a treatment I would have> recommended for anything on my differential list other than brain tumor,> especially if there is no improvement after 6 months. Am I mistaken?> > 2. They were told a myelogram would be preferential to an MRI because the> surgeon could be standing by to go straight to surgery without waking the> dog up. Surely the same could be true of an MRI if one went to a facility> that had both MRI and surgeons? I thought myelograms were pretty much things> of the past on account of seizure risk and the low amount of information> obtained compared to MRI, although I know some people like to do CT plus> myelogram. Are there any surgeons or neurologists out there who would care> to comment? My inclination is to encourage an MRI if the DM test is negative> to try and rule in or out IVDD, LS stenosis, neoplasia.> > 3. Lumbosacaral stenosis/disease -- it is my understanding this is not> uncommon in shepherds and with surgery there is potential for return to full> function. Is this the understanding of anyone else (who might know more than> I do), and does this presentation sound like LS disease? In my notes from> CRI neuro course I see that LS dogs tend to have absent cranial tibial> reflexes, severe atrophy of cranial tibialis, and don't flex their stifles> when walking -- that does not describe this dog. However, the radiographic> picture of the LS junction certainly seems abnormal. For LS disease is MRI> the best diagnostic tool? and is surgery mandated or can they be rehabbed> (or does it depend on the underlying etiology?)> > sorry for all the questions but any thoughts appreciated> thanks> Pamela Mueller PhD DVM> www.animaltherapycenter.com>

[Guest guest]

Jan, and all,I totally agree with what you have said and did actually know about the mouse study. I have a comment and an experience.I think the Bern study was presented in Barcelona at the ESVN and if not I was at least there when the Bern group presented their findings and I think they had more cases in the proceedings report than in the cases presented in the ACVIM article and it seemed to me to be more convincing than the published report.Second, we have worked with a few dogs in rehab intensively that went on to autopsy confirmation and my anecdotal experience has been that they have gone longer before being euthanized than if one doesn't work with them. Maybe that is simply a reflection of more dedicated owners.Unfortunately these kinds of studies stay in our shared literature for years without ever being challenged or repeated.Thanks for your input.steveTo: vetrehab From: steisje@...Date: Wed, 20 Apr 2011 17:03:00 +0000Subject: RE: Re: diagnostic questions re neurologic GSD

Steve, and all: I ended up needing to review the evidence for rehab for degenerative myelopathy last year, and wanted to share this with you. Training intensity appears to be important. There is evidence that the rehab exercises in ALS patients should be low impact. (Fortunately, in this case, there is a human model for an animal disease). A study using a transgenic mouse model for ALS (Muscle & Nerve, DJ Mahoney et al, 2004) reported that when a protocol based on high intensity endurance exercise was used (motorized treadmill with progressively longer times and increasing speeds x 5 times/wk ), the male mice actually had a more rapid deterioration of hind limb motor function and died sooner. We need to evaluate carefully the publication that was reported in J Vet Internal Med from the authors in Berne, concluding that physiotherapy results in longer survival times. That conclusion may be correct, but there are 2 serious flaws in that study -- dogs were not randomly assigned (owners were able to decide if they wanted to be in the treatment group) and the end-point was when the owner decided to have the dog euthanized, not a biological marker to indicate the stage of the disease. It is not hard to imagine that people who have spent a lot of time working with their dog also decided to keep their dog going a few weeks or months longer. Hence the need for a Degen Myelopathy Severity Scale and DM Functional Rating Scale to assess the dogs, as they have established for ALS patients. I plead guilty for being in academia and not undertaking more randomized controlled clinical trials, but I think that the conclusions of this publication on positive effects of rehab in DM need to be considered carefully until we have some form of biological marker or rating scale to get more objective assessments.

JanJanet Steiss, DVM, PhD, PT, Dipl. ACVSMRProfessor, Dept of Anatomy, Physiology & Pharmacology College of Veterinary Medicine Auburn University AL 36849 ______________________________ work ph: FAX (departmental): alternate email: steisje@...

To: VetRehab From: vrasteve@...Date: Wed, 20 Apr 2011 00:08:49 -0400Subject: Re: Re: diagnostic questions re neurologic GSD

Pam those neuro notes sound very familiar. I think is correct. There is a lot of controversy over when to use CT vs MRI and this is particularly true for LS disease. I suspect that isn't what you have here. I think if you get a positive DM test and the owners want to turn every stone do the MRI and if it's clean you probably have a presumptive DX of DM. We put these dogs in a pretty rigorous rehab program as it has been shown to increase their life expectancy from some work Bern, Switzerland. Nice job!

Steve

Sent from my iPad

Hi!1. rDVM has the dog on pred for the past 6 months. The owners do not report> that this has helped, in fact the dog has continued to worsen and they would> like to stop the pred because of the side effects (PU/PD/PP). However, their> vet has told them pred is the treatment for his (undiagnosed?) condition and> if they stop he will get worse faster. Pred is not a treatment I would have> recommended for anything on my differential list other than brain tumor,> especially if there is no improvement after 6 months. Am I mistaken?I think it is fine to wean off the pred...just make sure he is not getting worse. I typically don't use pred, unless I know what I am treating.> > 2. They were told a myelogram would be preferential to an MRI because the> surgeon could be standing by to go straight to surgery without waking the> dog up. Surely the same could be true of an MRI if one went to a facility> that had both MRI and surgeons? I thought myelograms were pretty much things> of the past on account of seizure risk and the low amount of information> obtained compared to MRI, although I know some people like to do CT plus> myelogram. Are there any surgeons or neurologists out there who would care> to comment? My inclination is to encourage an MRI if the DM test is negative> to try and rule in or out IVDD, LS stenosis, neoplasia.I guess it depends on the practice. An MRI is much safer and you get a better view of the spinal cord itself. I prefer it over myelograms. I am always willing to take a dog to surgery right after the MRI if it needs to be done.> > 3. Lumbosacaral stenosis/disease -- it is my understanding this is not> uncommon in shepherds and with surgery there is potential for return to full> function. Is this the understanding of anyone else (who might know more than> I do), and does this presentation sound like LS disease? In my notes from> CRI neuro course I see that LS dogs tend to have absent cranial tibial> reflexes, severe atrophy of cranial tibialis, and don't flex their stifles> when walking -- that does not describe this dog. However, the radiographic> picture of the LS junction certainly seems abnormal. For LS disease is MRI> the best diagnostic tool? and is surgery mandated or can they be rehabbed> (or does it depend on the underlying etiology?)LS disease is common in Shepherds - but more common, is radiographic "suggestions" of the disease and no compression seen with imaging. You can see a varying degree of signs - from unilateral pelvic limb lameness , to decreased reflexes, to decreased/absent anal tone and tail tone. From you description of this dog - I would be inclined to think that there is atleast a T3-L3 myelopathy - although the LS region could be affected.I hope that helps. Kube, DVMDACVIM (Neurology)>> Hi All,> > Today I evaluated a 7 yr old 120 pound MN GSD with an 8 mo history of> progressive hind limb ataxia and weakness. It began mildly but currently he> is very weak and ataxic with profound proprioceptive deficits in both hind> legs, difficulty rising or negotiating stairs, and frequently falling when> walking (although he does walk and even run). He has normal spinal reflexes> (sciatic, patellar, gastroc, cranial tibial) on both sides -- well they seem> normal to me although it's possible the right was stronger than the left but> I don' t know if that means the right is hyper or the left is hypo. Mild> pain to palpation at the T-L junction, where he has spondylosis on rads, and> in the low lumbar/sacral region, where he seems to have collapsed disk space> and sclerotic end plates of L7 and S1 (rads are from the rDVM, who actually> interpreted them as lytic S1 but to me they just look bright). Reduced hip> extension on the right, where rads show evidence of mild to moderate CHD.> Otherwise good joint ROM. Atrophy of hind limb musculature especially> biceps, symetrical.> > It's hard to say whether the dog is painful. He didn't mind any> manipulations other then hip extension, was fine with tail pulls, did sink> away from LS pressure but that might have been due to weakness. He really> struggles to rise but again that might all be weakness. He does have a> tendancy to sit with his hind limbs straight out in front of him like an> acutely paralyzed IVDD dog -- I don' t know if this means anything.> > To my mind the differentials for this dog include DM, lVDD, intra or> extradural neoplasm, cauda equina syndrome (lumbo sacral disease), diffuse> neuropathy (seems unlikely since only hind limbs are affected), cranial> neoplasm. Have I missed anything?> > In addition to his regular vet, the dog is seeing another vet for> chiropractic and acupuncture and a number of alternative treatments> including some herbs (not sure what), Heel and Traumeel. Their differentials> were: DM, myelopathy, neuropathy> > I sent out DM DNA test today.> > My questions are as follows:> > 1. rDVM has the dog on pred for the past 6 months. The owners do not report> that this has helped, in fact the dog has continued to worsen and they would> like to stop the pred because of the side effects (PU/PD/PP). However, their> vet has told them pred is the treatment for his (undiagnosed?) condition and> if they stop he will get worse faster. Pred is not a treatment I would have> recommended for anything on my differential list other than brain tumor,> especially if there is no improvement after 6 months. Am I mistaken?> > 2. They were told a myelogram would be preferential to an MRI because the> surgeon could be standing by to go straight to surgery without waking the> dog up. Surely the same could be true of an MRI if one went to a facility> that had both MRI and surgeons? I thought myelograms were pretty much things> of the past on account of seizure risk and the low amount of information> obtained compared to MRI, although I know some people like to do CT plus> myelogram. Are there any surgeons or neurologists out there who would care> to comment? My inclination is to encourage an MRI if the DM test is negative> to try and rule in or out IVDD, LS stenosis, neoplasia.> > 3. Lumbosacaral stenosis/disease -- it is my understanding this is not> uncommon in shepherds and with surgery there is potential for return to full> function. Is this the understanding of anyone else (who might know more than> I do), and does this presentation sound like LS disease? In my notes from> CRI neuro course I see that LS dogs tend to have absent cranial tibial> reflexes, severe atrophy of cranial tibialis, and don't flex their stifles> when walking -- that does not describe this dog. However, the radiographic> picture of the LS junction certainly seems abnormal. For LS disease is MRI> the best diagnostic tool? and is surgery mandated or can they be rehabbed> (or does it depend on the underlying etiology?)> > sorry for all the questions but any thoughts appreciated> thanks> Pamela Mueller PhD DVM> www.animaltherapycenter.com>