Seven years ago on this day Bailey had a very involved surgery. People told us to put him down- a 16 month old dog; we opted to save him. Today he is having the time of his life.

One Pomeranian’s Journey With Atlantoaxil Instability Luxation.

Pomeranians are called the heart break breed, but Pomeranians have hearts that won’t break.

You know when you have this feeling that there is something wrong, you call the vet, make an appointment and off you go. In a 16 month old pom you don’t expect the worst, but when the worst is what you get, you now have to deal with what that is.

It started in March 2010 as a disinterest in going for a walk. We would get to the corner and Bailey would want to turn around and go home. It wasn’t lethargy and he was not limping or eating differently so we thought it would pass. The only thing we noticed was a small sway in the head, like he had a kink in his neck from sleeping funny. A few more days passed and we were at advanced dog training. The trainer noticed the sway in the head and said, “Judy, I think Bailey needs to see a Neurologist”. “What?!” I was shocked. Here was a healthy vibrant young pom. I just couldn’t believe what I was hearing. Knowing that my trainer had tons of experience over the years with her own dogs health issues, clients dogs and me having 3 other pom’s at home, 2 with many of the terrible issues that face the breed, BSD, Thyroid, Collapsing Trachea, Cushing’s disease etc. (Yes my dogs have it all) I made the vet appointment the very next day. Once at the vet office I requested all the blood tests for various conditions and requested an X-ray.  The vet felt that some of the blood tests were overkill, but agreed. When it came to the X-ray, she felt it was not necessary. I took her advice, although not willingly, and home I went with pain killers prescribed by the vet and an appointment with her canine Chiropractor. All the results of the blood work came back normal, so they suggested crate rest until the next appointment. He seemed better, but painkillers can mask an underlying problem. 2 weeks passed and we were in front of a certified canine Chiropractor. They are first certified for human Chiropractic, then for canine. She was very concerned as she looked at Bailey. His head would sway to one side and then the other. She did a mild adjustment and sent him home. Back to crate rest. The next day, he was crying when he stood up and was not interested in eating. Then all of a sudden he fell over screaming, the worst noise I have ever heard in my life. He was out of his crate to eat and stretch his legs when this happened. I got him calm but as the day progressed his pain increased. When I took him out of the crate to go outside, I would carry him and put him gently in the grass; he could not stand and would scream and his legs were curled under him. This had been going on now for a few hours and was getting worse, so we rushed him to the emergency hospital. The first Dr. that saw him felt it was a disc in the neck that needed surgery. They got him comfortable, but didn’t stabilize the neck. They didn’t know what his condition really was. He stayed there overnight and in the morning the Dr. on staff saw Bailey. Thank God he had the foresight to have an MRI done. After the MRI and his reading the report we got a call. Bailey had Atlantoaxil Instability Luxation. What is that? I asked, he explained it me over the phone and asked for my husband and me to come meet with him. Once at the emergency hospital they seated us in the mourning room, never a good sign. Dr Galingo came in and he had a book with him. He showed us the problem with Bailey’s neck based on a diagram in a medical book. He explained to us that he was born with a rare birth defect called Atlantoaxial Instability Luxation. It is a condition in which the first two cervical (neck) vertebrae are not firmly attached. Normally, the atlas (the first cervical vertebra) and the axis (the second cervical vertebra) are attached by a group of ligaments. They are further stabilized by a prominence on the axis called the dens that protrudes into a hole in the atlas. Atlantoaxial instability can lead to cervical spinal cord injury, the symptoms of which include: neck pain; a drunken, staggering gait; paralysis of all four legs; or sudden death. In Bailey’s case, he fell over and became paralyzed when the ligaments ripped. Basically, the ligaments were doing all the work that the dens bone wasn’t. He also explained to us that this happens at a young age, usually between the ages of 6 months and 18 months. Dr. Galingo then showed us the options for a type of surgery, very specialized that required a Neurologist. He wanted us to transfer Bailey to the VRC, Veterinary Referral Center and Emergency Services in Malvern, PA. About 1 hour trip from our house and a hospital that my 2 older pom’s went to all the time to see specialists in dermatology & internal medicine. The emergency center wrapped him up in multiple blankets and off we went. It was a Friday night and as we drove him down to the VRC, I couldn’t believe what was happening. Once there, they got Bailey comfortable and went over his condition again. They urged me to sign a DNR form, but I said no. He was not going to die from a DNR, I wanted them to try to save him if they could. We left the hospital that night very sad, confused and depressed. We stopped for a quick bite to eat and sat there just staring at our food. How could a young, healthy pomeranian from a well known breeder be in such a state of distress. Why was this condition never mentioned to Vets’s in medical school? So far, every Veterinarian we talked to had never heard of this condition. The following morning we had a phone conference with Dr. Avril Arendse, a Neurologist at the VRC. She said the plain x-rays of the cervical spine showed no luxation between the vertebrae, but noted that there was a larger than normal space between the dorsal spinous process of C2 and the dorsal laminae of C1. On ventrodorsal projection the cervical spine, the dense, appears to be hypoplastic. She said that this is consistent with injury to the dorsal ligment. Dr. Arendse had stabilized his neck with a custom fit heat molded plastic brace that was very secure and layered with padding and tape. She informed us that Bailey was currently paralyzed from the swelling on the spinal cord as a result of the injury. First, we had to try to get him feeling his paws again so that he could regain any or all movement to his limbs. Then he needed involved surgery and long term care to get him back to as normal as possible. He had a 70% chance of a 100% recovery. It was in his best interest to have the surgery at the U of Tenn, Vet Teaching Hospital in Knoxville, TN. Another shocking realization, this was not a surgery that your average surgeon can do. I was so confused by everything and I kept going back to the X-ray that I was denied at the beginning of all this. It would have shown the birth defect in the dens bone, Bailey still would have needed the surgery, but he wouldn’t have had the ligament damage. He would simply have needed the procedure to repair the neck. I was also stunned to learn that many dogs die from this condition and are found dead on the floor when the owner comes home. Only about 10% survive the catastrophic injury of the ligaments ripping away from the neck and of that small percent, very few are saved by their owners. 

After an initial 4 day stay at the VRC, Bailey came home to rest up for his surgery. The options were either rush down to Tenn. that week as the Neurologist who Dr. Arendse wanted to perform the procedure was leaving for a teaching rotation, or wait 5 weeks until he returned to the hospital. Everyone decided that the 5 week rest would decrease the swelling and give him a chance to heal first, so that was what we did. The first thing they wanted me to do was provide round the clock PT, a minimum of 4 times a day but more was even better, moving each joint, knee, hip and ankle of each paw. I laid him on a Pilates mat on the counter which is where he was fed and cleaned each day. He was fed off of a spoon and barely ate. I rubbed water along his teeth every hour, trying to keep him hydrated. He was on several medications being given 3 times a day. My two older pom’s were on several medications that also were being given twice a day. It equalled 29 doses of medicine to 3 dogs in each 24 hour time frame. I made a chart and filled it out for each dog, medicine and dose. I stayed up around the clock with Bailey for the first 3 weeks, only cat napping for 45 minutes to an hour at a time.  A dear friend, who is a trained vet and now works solely as a house call vet performing private in home euthanasia, came over every night to check Bailey’s lungs and help him pee until he was moving a little bit. Bailey made weekly trips to the VRC to have his brace changed and be evaluated by Dr. Arendse. 

Due to the fact that Bailey suffers from car sickness, and could not throw up in the neck brace, he was also given a motion sickness medicine. With all the meds he was on the newest problem was appetite. At the beginning of all this, he weighed 9 pounds, a pound overweight for his size. By the time he came home from surgery he weighed 6 pounds. About 3 weeks into the rehab on his mobility, 2 weeks before surgery, he regained some movement and started to stand unsupported. Then he started to walk again. Now that the mobility was back, we had to keep him calm. His neck was only being held onto his body by the little bit of ligament left and the neck brace. I got a stroller that I could take him outside in to get some fresh air. He was isolated from the other dogs and could not play or even be with them other than to lay on my lap and let them come over to smell him. Dr. Arendse kept saying he was a very special dog, that not all dogs could handle this type of crate rest and isolation. He was so patient and calm. His crate had to be small enough that he could not jump around in it. 

On May 16th we headed down to the U of Tenn. in Knoxville from our home in PA. It was a beautiful day and the drive down was equally enjoyable. Holiday Inn has a special rate that was amazing for families traveling to U of Tenn. for surgery; they let us stay there with all 4 dogs and were so kind and gracious. The morning of May 17th, we met with the Neurologist. Dr. William Thomas. This was a very routine surgery for him, but as with any surgery there were risks. This type of surgery has been around about 30 years. The good news was because of his size, he would have an easier surgery. Smaller pom’s and other toy dogs that are born with this condition, usually have to have thin wires put into the neck through the bones. In the larger dogs, 7 plus pounds, screws can be used without the need for a plate to stabilize them. The risk of the structure failing, is far less. In small dogs wires are used and in some cases, small pins that are cemented onto a plate that is attached. According to Dr. Thomas, The University performs 6-10 atlantoaxial sugeries a year. They see a pomeranian every couple of years or so. They see more yorkies, chihuahuas and toy poodles with the condition but they may be more popular breeds in our region.Dr. Thomas says “Very few general practitioners do this surgery because it is not a common surgery, it requires certain equipment they may not have and they generally have not been trained in the specific procedure. Most neurologists that do a lot of neurosurgery do the procedure because they were trained in it, but there are some that don't. Regarding the specifics of the surgery, the use of pins and bone cement is just a variation in the procedure that Bailey had. They used small screws in Bailey because they have good holding power and can provide some compression across the joint. But in dogs that are really small (smaller than Bailey) Dr. Thomas usuallywill use the threaded pins and bone cement because you don't need as much bone. The bone cement helps hold the pins in place.”

(Surgical treatment of atlantoaxial subluxation and instability is challenging due to a variety of anatomical deformities of the C1 and C2 vertebral bodies and the often immature bone structure of these patients. A successful outcome, defined as an improvement in clinical signs with no reported recurrence or necessity for further surgery, was reported in 75-85% dogs in two recent reports *1,2.

1. Sanders SG et al.: Outcomes and Complications Associated With Ventral Screws, Pins, and Polymethyl Methacrylate for Atlantoaxial Instability in 12 Dogs. J Am Anim Hosp Assoc 2004;40:204-210.

1. Platt SR et al.: A Modified Ventral Fixation for Surgical Management of Atlantoaxial Subluxation in 19 Dogs. Veterinary Surgery 33:349–354, 2004)

According to Dr. Peter Sebestyen, DVM, Diplomate ACVS at Veterinary Surgical Specialists of Orange County;  In September 2010 A 15 week old, 1.8 pound female Pomeranian presented to VSS with a history of ataxia and screaming when moved. Survey radiographs showed subluxation of C1- C2 and a diagnosis of atlantoaxial instability (AAI) was made. Initially, conservative management with neck brace was recommended due to concerns related to the very young soft boney structures and the size of the patient. However, adequate reduction and stabilization of the atlantoaxial joint could not be achieved with neck brace alone and the patient’s clinical signs continued to be severe and progressive. Four weeks after the initial presentation the neurological condition deteriorated to non-ambulatory tetraparesis. Surgical treatment with ventral stabilization with K-wires and polymethyl methacrylate (PMMA) was recommended despite continued concerns for immature bone structure (18 weeks old at the time of surgery). Recently a second pomeranian puppy in CA had a similar surgery to the one listed above in Dr. Sebestyn’s report. Whether this is becoming more common or not, is yet to be determined.

After a full exam Dr. Thomas then had to determine if Bailey was well enough for the surgery. Another side effect of the neck brace is skin infection. At Bailey’s last brace change a rash had been found so now he was on antibiotic’s too. I had decided that if we had to wait a few more days for the rash to be gone, we were waiting right down in Tenn. I was not leaving Tenn. until Bailey had his surgery. Luckily he was well enough for the procedure. 

Tuesday morning, May 18th, my little Bailey had his big scary surgery. He came through it with flying colors and stayed a few more days in the hospital to rest and be stable enough for the long car ride home. The new clock started ticking down. We were over the hump and now it was rest, rest, rest.  The scariest part was that 10 days after his surgery and only 1 week after returning home from Tenn., the entire Neurology world of Vets was flying to LA for the yearly convention. There was no one on the east coast for me to call if something went wrong. We made it through those 5 days and as the weeks went by I stayed home around the clock with my Boo Bear. With each follow up he was getting better in his walking and eating. The secret in getting him to eat was and still is boiled organic chicken breast. I mixed in an organic kibble, organic pumpkin and organic brown rice. He gained back the right amount of weight and in July was finally able to go for a 2 block walk. By the end of July, Bailey returned to advanced dog training for the social part of it, nothing more. He will never be allowed to jump or run up and down steps. A fall is too risky, since he has screws in his neck. In August the neck brace came off and was replaced with a removable one. Dr. Arendse gave me the directions on how to construct the brace as I sew for a living. The base of the brace was pipe insulation (the grey thick stuff) cut to size, padded and then covered with fabric. Now Bailey had protection when he needed it. While at this appointment, I found out a chihuahua had just come to see Dr. Arendse for a similar procedure. The family was going to head down to U of Tenn. for the surgery. I felt for them, what they were going through.

We moved our yearly vacation from August to September, knowing that he would be out of the permanent brace for over a month by then and in the removable brace. We also thought that with the potential vacationing kids back in school, less little hands to pat him on the head. While on vacation in Martha’s Vineyard, I got a photo of Bailey running on the beach. After everything that had happened, that sunny morning on State Beach in MA seemed like a fairy tale ending to a horror movie. The damage to the ligaments is permanent, but with time he has learned how to move around fairly normal. It is only noticeable, when he is standing still and his paws start to wiggle, For me, it is a painful reminder every day how a very minor symptom, the small head sway he had, was an indication of something very serious. We are all very busy, over extended, rushing to get everything done. AAL is a condition that can come up out of no where and take the life of your young pom or injure him or her like what happened to us with very little warning.  My goal with this story is to make pom owners aware of this rare condition. It is also present in other small breed dogs. Many vets, when you ask them if they have heard of this will say they have not.  Since so many dogs die from it, there is not a lot of knowledge at the general veterinarian level. Only a Neurologist would have a working knowledge of this condition. If you have a fear that this is something that you see in a puppy or young adult, carefully have them X-rayed and have them seen by a neurologist. That is all it takes.  

I would like to thank Dr. Arendse for taking Bailey’s case as she was leaving for board preparations a few days after he was admitted and she took his case anyway, meeting with him and caring for him while studying for her tests. Without her my little Bailey Boo might not be here.