Treatment Algorithm 2024 - Canine Chiari and Syringomyelia

University of Surrey Ref: Prof Clare Rusbridge, Professor in Veterinary Neurology

How to use this page
  • The Canine Chiari and syringomyelia treatment algorithm is now supported by many YouTube videos (some listed at the end of the document)
  • You can access the videos by clicking on underscored words → Click!
  • The Canine Chiari and syringomyelia treatment algorithm is also supported by Chiari-Check. A diagnostic tool which generates a Chiari-pain and SM-score to help determine if Canine Chiari or syringomyelia is likely before an MRI scan (or if MRI not possible) and ultimately to monitor clinical signs. → Chiari-Check
  • Chiari-Check is still under development developed and will improve in accuracy in time
  • The Canine Chiari and syringomyelia treatment algorithm is intended for veterinary surgeons and drugs should only be prescribed under the care of a veterinary surgeon
  • Please refer to your national guidelines - gabapentinoiddrugs and CBD oil are controlled in many countries and all the drugs indicated in the algorithm are being used off label and care givers should be advised accordingly
  • The video explaining the CMSM treatment algorithm can be accessed → Here
Medical Treatment algorithm 2024 - Chiari-Pain
Assumes poor / inadequate response to NSAID or other licenced medication
Assessment, diagnostic tests, refer if indicated
Clinical signs of CM-P
↓
Diagnosis
MRI not possible
High CM-P score
MRI confirmed
High CM-P score
↓
1st line therapy
4-week trial
Gabapentin
↓
2nd line therapy
4-week trial
Gabapentin
and NSAID
OR
Pregabalin
↓
3rd line therapy
4-week trial
Pregabalin
and NSAID
↓
4th line therapy
4-8 - week trial
usually with NSAID
Pregabalin and
Topiramate
OR
Pregabalin and
NMDA R antagonists
OR
Pregabalin and
Amitriptyline
OR
Pregabalin and
CBD oil?
Top up therapy / bad pain days
  • First line
    • Add a NSAID (if not already receiving)
  • Second line (not cats)
    • Add paracetamol (acetaminophen)
      • 10-20mg/kg up to every 8 hours
      • Long term not advised if giving more than 5 days reduce dose e.g. 10mg/kg every 12 hours
  • Third line
    • Ketamine (see supporting video)
      • Subcutaneous injection (one off or monthly)
      • Intravenous infusion (one off or monthly)
Treatment algorithm 2024 - Phantom Scratching (SM-S)
Assessment, diagnostic tests, refer if indicated
Clinical signs of SM-S
↓
Diagnosis
MRI not possible
High SM-S score
MRI confirmed
High SM-S score
↓
1st line therapy
4-week trial
Avoid triggers
AND
Gabapentin
↓
2nd line therapy
Avoid triggers
AND
Pregabalin
↓
3rd line therapy
Pregabalin and intermittent Maropitant (especially during triggering events e.g. grooming)
In addition, optimised management Chiari-Pain
Treatment algorithm 2024 - Syringomyelia weakness
Assessment, diagnostic tests, refer if indicated
Clinical signs of weakness related to syringomyelia
↓
Diagnosis
MRI not possible
High SM-S score and neuro exam
MRI confirmed
Neuro Exam
↓
1st line therapy
Hydrotherapy
Physical therapy
Physiotherapy
Surgery?
↓
2nd line therapy
4-8 - week trial
Trial of drugs that MIGHT
reduce CSF production?
↓
3rd line therapy
Re-evaluate all options above
↓
4th line therapy
4-week trial
Corticosteroids - "end stage disease"
Lowest dose to improve signs
When is surgery indicated?
  • CM Pain - unresolved with medical management
    • Add a NSAID (if not already receiving)
  • MRI suggests progressive disease likely
    • and where surgical management has fair to good prognosis to reverse that progression (i.e. collapse the syrinx).
  • Weakness (forelimb and spinal)
    • and where surgical solution that has a fair to good prognosis to improve or stabilise situation
Trial of drugs that MIGHT affect CSF production indicated?
  • Hydrocephalus
    • Surgery not option or failed
  • Poorly controlled CM pain
  • Weakness
    • Surgery not option or failed
Based on available evidence
  • First line - Topiramate
    • May be limited by sedation in neurologically compromised animal
  • Second line - Omeprazole
    • High Dose?
    • Preferred option if regurgitation also issue
Cervicothoracic torticollis / scoliosis
  • Syrinx in C1-C3 spinal cord segments.
  • Information from general proprioceptive afferents (neuromuscular spindles) disrupted.
  • Results in abnormal function of epaxial muscles maintaining normal orientation of the head and neck.
  • Often “improves” over years despite lack of improvement in SM due to central vestibular compensation.
Supporting videos (click to access)