Hind leg neuropathy/knuckling in cat-need advice (complicated case)

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Sienna's mom
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Hind leg neuropathy/knuckling in cat-need advice (complicated case)

Post by Sienna's mom »

Hi there,

I have a almost 17 year old cat who is dealing with left hind leg neuropathy/knuckling and I'm at a loss for what to do. Her case is a complicated one, so please bear with me as I try to provide you with as much information as possible.

She was diagnosed with both large cell and small cell lymphoma in October of 2021. After speaking with an oncologist, we opted to proceed with chemotherapy (CHOP protocol) as I was told the side effects from tx are minimal in cats and her quality of life would not suffer. She tolerated the first two rounds of treatment very well; you wouldn't even know that she had cancer or that she was being treated for it. After the last drug was administered during the third round of treatment, we noticed that she started limping and her left hind leg seemed quite painful. We rushed her to the emergency clinic where she underwent numerous diagnostic tests (CT scan, myelogram etc.) and the neurologist suspected a slipped disc. We were reassured that he could fix this problem and it would be fair to proceed with the surgery as she was considered to be in remission, and he performs this procedure on older cats all of the time. After the surgery was completed, he explained that he didn't find a slipped disc but still opted to do a laminectomy procedure to relieve the pressure/compression in her spine. When we brought her home, she was on heavy pain medication for a few days and was walking on her hocks.

We resumed her final round of chemotherapy one week after her surgery and she continued to do well. Every week we saw improvement; she was no longer walking on her hocks, the limp had almost disappeared completely and she had no pain.
And then it was time for the final drug in her last round of her chemotherapy treatment. As soon as we brought her home, we noticed her left leg was sliding from under her and over the next few days things continued to worsen. The pronounced limp returned along with the pain and this time it was a little worse. We also noticed that she started knuckling.

We had her seen by both the neurologist and oncologist again and the neurologist believes she has peripheral neuropathy secondary to an idiosyncratic drug reaction to one of the chemo drugs as this happened twice after the same drug was given. The oncologist doesn't seem to believe this is the case because neuropathy in cats secondary to chemotherapy is quite rare and on the few occasions that it does happen, it's not usually due to this particular drug. We have recently done blood work and it all came back within normal limits so this is not secondary to diabetes etc. She is also hyperthyroid, but we have that well controlled with medication.

It has been just over four weeks since her last chemo treatment and unfortunately we don't see much improvement with her leg. We have been able to keep her discomfort under control with pain medication. I am frustrated and upset and don't know where to go from here and no one seems to be able to give me any concrete answers as to why this has happened.

Does anyone have experience with neuropathy secondary to chemotherapy treatment? I don't know what else could have caused this.
I know that nerve regeneration can take time but is there anything I can do at home to help with this? I have looked into Methyl B12 which is said to help with neuropathy (at least neuropathy caused by diabetes) but there have also been some studies that imply this could be a contraindication when your cat has cancer. I am waiting to hear back from my regular vet on this matter.

TLDR: My cat has left hind leg neuropathy suspected to be secondary to chemotherapy tx. Does anyone have any experience with this? Anything I can do at home to help with nerve regeneration? I'm worried that because I have seen virtually no improvement in 4 weeks, this won't get any better. Her quality of life is of utmost importance to me.

Thank you in advance.
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CarolC
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Re: Hind leg neuropathy/knuckling in cat-need advice (complicated case)

Post by CarolC »

Hi Sienna's mom,

Please do not apologize for writing a long and complete post. Details are a good thing!! The more, the better.

I have to say immediately I have no experience with this, which is what you are really looking for. However I checked and it appears I do have some information on drugs in my veterinary drug reference handbook.

Do you know which drugs were in her CHOP protocol, or more specifically, which one she reacted to the last 2 times? By chance was it vincristine? That one is listed in the CHOP protocol when I google it, and I see neuro side effects associated with it.

BIg welcome!

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Sienna's mom
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Re: Hind leg neuropathy/knuckling in cat-need advice (complicated case)

Post by Sienna's mom »

Hi CarolC,

Thank you for your reply and warm welcome. :) I'm glad you don't mind the really long posts. I'm desperate for help at this point and don't want to leave anything out in case someone might have some advice.

The CHOP protocol consists of four rounds of treatment and includes the drugs vincristine, cyclophosphamide, doxorubicin and prednisolone.

The drug she seems to have reacted to is doxorubicin which has everyone baffled as it's not known for causing neuropathy. I read chemotherapy induced neuropathy can happen, but like you said, it's usually with vincristine. Maybe it's a delayed response to the vincristine? The oncologist insists that she's only had this happen once in her entire career with vincristine and it was with a dog. My cat is atypical though...it was incredibly hard to diagnose her cancer even though she ended up having two forms of it. And I also don't understand why she improved drastically after the laminectomy surgery either then? Maybe it was just coincidental in terms of the time her nerves needed to regenerate. Or maybe it's something else all together.

I also want to mention that she was diagnosed with very mild HCM back when we received her cancer diagnosis. I only discovered this because I read it on a report. No one discussed treatment with me and my regular vet didn't seem too concerned when I brought it up with her.

Her medications are as follows: Methimazole 2x daily (1.25 mg in the am and 2.5 mg in the pm), Prednisolone (5mg) 1x daily, and most recently Gabapentin (25 mg) 2x daily for pain. Occasionally we give Mirtazapine when her appetite is low but it's not often at all.

I am worried that I saw improvement within two weeks the first time this happened and now I'm not seeing much at all after four weeks. But I guess that may be due to the fact that her nerves hadn't fully healed/regenerated and then we gave her the drug again.

Is there anything we can do (regardless of the cause) at home to help with neuropathy?
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Re: Hind leg neuropathy/knuckling in cat-need advice (complicated case)

Post by critters »

:whale: We've never done neuropathy from chemo, but I had 1 with contracture (from knuckling) and foot drop from spinal cord injury (shot in the spine) and another with a paralyzed arm from being hit by a car. I suggest splinting it; an over the counter splint or a custom one should help a lot. We've used both; the contracture needed custom splints and shoes. Splints (called AFOs or ankle-foot orthoses in humans) can help them stay functional and reduce disability from complications (like Koi's contracture) whether or not the nerve recovers (Koi's did not, but Tristalyn's did).
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Re: Hind leg neuropathy/knuckling in cat-need advice (complicated case)

Post by Sienna's mom »

Hi Critters,

Thank you for the suggestion. I will definitely look into getting a splint for her.

Right now I have her confined to a room where she can't use stairs or jump on anything. I am torn between balancing muscle loss/weakness vs her injuring herself or hindering any possible nerve regeneration. Should I continue to keep her confined and minimize her activity level? I don't know if continued rest or exercise is more beneficial at this point.

Does anyone know if massage or heat therapy helps with neuropathy? I seem to find varying opinions on the subject and was wondering if anyone had any personal experience with it.
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Re: Hind leg neuropathy/knuckling in cat-need advice (complicated case)

Post by CarolC »

I'm afraid this isn't going to be a lot of help. I wish it was. I did quite a bit of searching and didn't really find anything definitive. So I'm not sure anything in this will be of much help at all, except maybe the link about Fripple.

These are brand names for doxorubicin in the veterinary field. Using a brand name did help to find additional info, instead of only searching doxorubicin.
https://www.marvistavet.com/doxorubicin.pml wrote: ADRIAMYCIN, ADRIBLASTIN®, ADRIBLASTINA®, ADRIBLASTINE®, ADRIM®, ADRIMEDAC®, BIORRUB®,
CAELYX®, DOXO-CELL®, DOXOLEM®, DOXORBIN®, DOXORUBIN®, DOXOTEC®, DOXTIE®,
FARMIBLASTINA®, FAULDOXO®, FLAVICINA®, IFADOX®, MYOCET®, NEOXAN®, RANXAS®,
RIBODOXO-L®, RUBEX
Cats are not furry little humans, and the following info is about humans, so it may not apply. Two major drugs websites for humans show peripheral neuropathy as a possible side effect from doxorubicin. However the veterinary websites giving info on doxorubicin pretty much say what your oncologist said, no observations of peripheral neuropathy worth mentioning. All cats are individuals, so I don't think there's any guarantee she had no reaction to it, though. Highlighting added.
https://www.drugs.com/medical-answers/long-term-side-effects-adriamycin-3537947/ wrote: Adriamycin has been associated with several long-term neurological side effects, such as:
Peripheral neuropathy: This is damage to the nerves that carry messages from the brain and spinal cord to the rest of the body. Symptoms may include cold hands and feet, poor limb circulation, pins and needles, numbness, an increased risk of infections and injury
• Muscle weakness
• Cognitive changes: Often described as “chemo fog”. These may cause difficulties with multitasking, concentrating, or headaches. In most people these are temporary; however, they may persist in some people.
https://www.webmd.com/drugs/2/drug-6666/adriamycin-pfs-intravenous/details/list-sideeffects wrote: a disorder of the peripheral nerves that enable movement called peripheral motor neuropathy
Then I wondered, if it turns out that this is peripheral neuropathy from chemo, how long does it last? I couldn't find anything for doxorubicin, but did for vincristine. Again this is for humans and may not apply, but it's encouraging to see it usually improves in humans.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3480245/ wrote: Vincristine neuropathy is usually reversible when therapy is discontinued. The median duration of paresthesias and motor weakness after treatment discontinuation is 3 months.
This article is veterinary. It talks about peripheral neuropathy in cats from other causes (not from chemo) and it says full recovery can take up to 6 months. But at least it is talking about recovery, so that's a little encouraging, too.
https://www.msdvetmanual.com/cat-owners ... es-in-cats

For what it's worth, I've had 3 very senior cats who walked down on their hocks. I'm sure they had very senior kidneys, but none of them were diabetic. I don't remember knuckling, though. These are links about my cats hock walking, you can skip them if you like. They don't tell you much except that it's not uncommon at a certain age.
viewtopic.php?f=22&t=13016&p=67826&hilit=hocks#p67826
viewtopic.php?f=4&t=11280&p=57555&hilit=hocks#p57555
viewtopic.php?f=4&t=20082&p=102938&hilit=hocks#p102938

Here is a link to a webpage about a cat named Fripple who walked on his hocks and his mom made him a baby shoe, which you can see in the pictures.
https://web.archive.org/web/20060327074 ... /index.htm

The next two ideas are way out of the fringe, but I'm including them anyway.

When I read your original post about the limping/knuckling of unknown cause, it reminded me of a post from years ago about a cat that was dragging both hind legs. Improbable as it sounds, it was related to constipation. That idea became more interesting when I read that a side effect of vincristine can be constipation. But it doesn't fit the pattern that each time your cat began limping following doxorubicin treatment. So this is probably unrelated, but here was the post.

viewtopic.php?f=4&t=7198

This says vincristine can cause constipation as a neuro side effect. Highlighting added.
https://www.marvistavet.com/vincristine.pml wrote: Vincristine has some potential for neurologic side effects, especially in cats.
A neurologically based constipation may result,
particularly in cats. Difficulty coordinating the feet may be seen.
The following article says to be on the lookout for neurolymphomatosis in cats with lymphosarcoma (lymphoma) and don't just assume limping is chemo-related. The kitty in this case turned out to be limping from lymphosarcoma in the sciatic nerve. I am including only the first line and the conclusion, but you can read the whole report by clicking the following link. Red highlighting added
https://journals.sagepub.com/doi/10.1177/2055116919833534 wrote:
Abstract
Case summary A 16-year-old domestic shorthair cat was evaluated for acute-onset right pelvic limb monoparesis localized to the sciatic nerve.

[skip]

Conclusions
NL should be considered as a differential diagnosis for
any cat presenting with a mono- or polyneuropathy. It is
important to recognize this disease not only as a differential
for neuropathies in cats and dogs, but also as a
differential for animals with known lymphosarcoma and
neuropathies, which might otherwise be overlooked as a
paraneoplastic neuropathy or neuropathy secondary to
chemotherapy administration
.33,34
After reading that, I had more questions.
1) Your kitty had a CT. Wouldn't that have shown lymphosarcoma of the sciatic nerve? Don't know. It looks like maybe you need an MRI or PET scan for that level of detail, but this is so far over my head I can't even guess.
2) Your kitty had surgery. Wouldn't the surgeon have seen it? Again, I have no idea.
The best thing to do, if you think it's worth it, might be to send the article to someone qualified to understand it and ask if this possibility can be ruled out.

For what it's worth, here is another article talking about lymphoma in the spinal cord. It is not clear to me whether it presents as lameness in these cases. I had a bunny with a spinal tumor and he became unable to walk.
https://www.sciencedirect.com/science/article/abs/pii/S1090023316301101 wrote: Abstract
In cats, lymphoma (lymphosarcoma) is the most common neoplasm affecting the spinal cord and the second most common intracranial tumour. Although lymphoma commonly develops in the spinal cord as a part of a multicentric process, a primary form may occur. Lymphoma can exhibit a wide range of morphological patterns, including intraparenchymal brain mass, lymphomatosis cerebri, intravascular lymphoma, lymphomatous choroiditis and meningitis, extradural, intradural-extramedullary or intramedullary lymphoma in the spinal cord, or neurolymphomatosis in the peripheral nerves. Lymphoma may occur as a paraneoplastic disorder associated with peripheral neuropathies.
The only other thing I wanted to mention, which again does not address your real questions, is about the HCM. I don't know if that is a side effect of her hyperthyroidism. If it is, it can resolve in some cases. My Teddy had HCM with his hyperthyroidism and it resolved on its own after radioactive iodine treatment. Here are 2 links about that. (You can skip them, just more posts about my cat).
viewtopic.php?f=10&t=3128&p=14342&hilit ... thy#p14342
viewtopic.php?f=10&t=5120&p=27824&hilit=resolved#p27824 (resolved)

Anyway, I thought about cardiomyopathy, and how it can cause clots, and how clots can break free and cause saddle thrombus, which causes paralysis. But that would be intensely painful and I think pretty much any vet would catch that if that was what happened, and it affects both hind legs. There is a milder form where a smaller clot can partially occlude just one femoral artery and affect only one leg. I think/hope a vet would catch that, too, I don't know. But that does not fit with the pattern of seeing her limping each time after receiving her doxorubicin chemo. So I think that was all a detour.
https://www.dvm360.com/view/how-handle-feline-aortic-thromboembolism wrote: The embolus usually follows the path of least resistance and lodges at the aortic trifurcation, occluding blood flow to both pelvic limbs. The thromboembolus may be small enough to only partially occlude one femoral artery, resulting in unilateral signs.
I really hope you get your answer, and if you do, maybe you could post it here. It might help someone else someday.
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Re: Hind leg neuropathy/knuckling in cat-need advice (complicated case)

Post by critters »

I don't know that it's likely to hinder healing, but it's terribly important to prevent complications, like contractures or skin breakdown. These are difficult, and sometimes impossible, to fix once they happen. Koi came with both, and the custom products at least helped to protect his skin. Not even surgery could release the contractures; in other words, he was a permanent knuckler with that foot. He hock walked on the other, but that never broke down.
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Re: Hind leg neuropathy/knuckling in cat-need advice (complicated case)

Post by Sienna's mom »

Wow! Thank you so much for all of the information and links to the various articles.

I also have concerns that this may be lymphosarcoma of the sciatic nerve. However, I also don't understand how that could have been missed during her original workup AND surgery. Or why it got better after the surgery only to happen again.

This entire situation has been very heartbreaking and extremely difficult to navigate. An emotional rollercoaster actually. It also seems to constantly be changing. Her left leg is now sliding out laterally when she walks. The knuckling seems to only occur when she's on softer terrain like carpet or a mattress.

She's eating, drinking, and still able to use the litter box. Her BMs are normal.

I have sent another email in to the neurology department with the latest update and hope to hear back from them soon.

I will be sure to keep you updated.
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Re: Hind leg neuropathy/knuckling in cat-need advice (complicated case)

Post by CarolC »

Replies in blue...
Sienna's mom wrote: Thu May 19, 2022 10:49 am Wow! Thank you so much for all of the information and links to the various articles.

I also have concerns that this may be lymphosarcoma of the sciatic nerve. However, I also don't understand how that could have been missed during her original workup AND surgery. Or why it got better after the surgery only to happen again.

It's completely baffling why it improved after surgery, and then returned. Did the surgeon give her a steroid injection or send her home with anti-inflammatory medication after surgery (beyond the heavy pain medication that was only for a few days)?

Has her dose of prednisolone changed between the first time she had the apparent idiopathic reaction to doxorubicin (which went away after 2 weeks) and now?

It seems like if it was a tumor you might expect to see progression, and it doesn't sound like that's the case. From your description, it really sounds more like an insult to the nerves (such as by a reaction to the medication) that happened and is not ongoing, but awaiting recovery.

Is it possible she was a little arthritic in her left hip before she ever had chemo, and it just wasn't obvious? I'm remembering Betsy, and she could walk but had stopped jumping up on chairs. I'm not sure I immediately noticed when she quit jumping on chairs. Even arthritis in the hip joint can make them not pick up their foot like they used to. Perhaps she's been a little tired from the chemo, as your would expect, or possibly the effects of various meds on her system inflamed her joints a little and kind of unmasked what was already there.

Teddy was the same age as your kitty (16) and he wasn't diabetic and his kidneys were fine, but he had age-related mobility issues, more noticeable in one leg, very much like your cat. The vet mentioned calcification of the spine. I'll insert the post about Teddy below.

https://handicappedpet.net/helppets/viewtopic.php?p=57555#p57555 wrote:
I have a Maine Coon cat who is also about 16. He was walking almost down on his hocks and I was afraid he had become diabetic and took him in to be checked. His glucose came back fine and kidney values were fine. The vet put him on the floor and let him stand on 3 legs while he lifted one hind foot off the ground. Then he let him stand on 3 legs while he lifted the other hind foot off the ground. My cat could remain standing on three legs when one foot was lifted, but he sunk down when the other foot was lifted, showing his weakness is more on one side. He pointed out that he walks with his hind feet wide apart, which he said indicated he was having a problem with proprioception. The vet asked if he sometimes drops a "poop" outside the box (yes). He said it is neurological. I think he mentioned calcification in the spine which is kind of unusual in cats, and said there is really no treatment. (Sorry, my memory is spotty here.) I think he said they used to give pain meds but they found they didn't help. Anyway, my cat is 16, he can walk but with a degree of difficulty, and we are just accepting it. We'll make any adaptations that might be needed. He's basically happy. :)

You were asking about whether heat would help neuropathy, and I haven't had a pet with neuropathy. But my very senior Betsy had a lot of arthritis and loved :wub: to sleep on a heating pad. I felt like it helped her do her grooming. She was one of my cats who walked on her hocks. (I know they say to wrap the heating pad in a thick towel.)

It is getting harder to find a heating pad that doesn't turn itself off nowadays. Here are links to one I think stays on.
https://www.sunbeam.com/pain-relief/gen ... 12979.html
https://www.walmart.com/ip/Sunbeam-Heat ... /491144515


Betsy_2006-04-27.jpg
Betsy_heating_pad2.JPG

This entire situation has been very heartbreaking and extremely difficult to navigate. An emotional rollercoaster actually. It also seems to constantly be changing. Her left leg is now sliding out laterally when she walks. The knuckling seems to only occur when she's on softer terrain like carpet or a mattress.

I think knuckling on soft surfaces is just the laws of physics. If a pet does not pick up the foot very high, and the foot sinks into 1/4" of carpet or mattress, that will give enough friction to catch the toe and cause the paw to flip under when it's brought forward. There's nothing to catch the toe on linoleum or a smooth surface. If she's like my dog, she barely notices.

There is a fix for sliding out laterally, at least in dogs. I'm not sure about cats.


She's eating, drinking, and still able to use the litter box. Her BMs are normal.

I have sent another email in to the neurology department with the latest update and hope to hear back from them soon.

I will be sure to keep you updated.
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Re: Hind leg neuropathy/knuckling in cat-need advice (complicated case)

Post by Sienna's mom »

After surgery, she received Fentanyl 50mcg/ml until she was discharged from the emergency clinic. She was sent home with Gabapentin (50 mg) 3x daily, and Buprenorphine 0.3mg/ml 3 x daily. Her pain meds were only given for a few days as she was quite comfortable after that. She also was (and still is) on Prednisolone (5mg) 1 x daily. This dose has not changed since her cancer diagnosis in October of 2021.

I reached out to the neurologist and he said the recent sliding of her leg is "normal" for a cat with ataxia and to give it more time.

The more I think about it and the more I reassess her every day, I'm wondering if the oncologist is right and this is infact unrelated to the chemotherapy. And the timing is just coincidental. When I palpate her lower back (just above the base of her tail) it's obviously uncomfortable and this discomfort seems to worsen with activity. Maybe it's possible that whatever was causing the initial compression (he could not determine what that was) in her spine has since returned.
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Re: Hind leg neuropathy/knuckling in cat-need advice (complicated case)

Post by CarolC »

Sienna's mom wrote: Fri May 20, 2022 10:29 am After surgery, she received Fentanyl 50mcg/ml until she was discharged from the emergency clinic. She was sent home with Gabapentin (50 mg) 3x daily, and Buprenorphine 0.3mg/ml 3 x daily. Her pain meds were only given for a few days as she was quite comfortable after that. She also was (and still is) on Prednisolone (5mg) 1 x daily. This dose has not changed since her cancer diagnosis in October of 2021.
Sienna's mom wrote: Tue May 17, 2022 7:44 pm Her medications are as follows: Methimazole 2x daily (1.25 mg in the am and 2.5 mg in the pm), Prednisolone (5mg) 1x daily, and most recently Gabapentin (25 mg) 2x daily for pain. Occasionally we give Mirtazapine when her appetite is low but it's not often at all.
It looks like after the surgery she was on 150mg gabapentin per day, and now she's on 50mg per day.
Sienna's mom wrote: Fri May 20, 2022 10:29 am The more I think about it and the more I reassess her every day, I'm wondering if the oncologist is right and this is infact unrelated to the chemotherapy. And the timing is just coincidental. When I palpate her lower back (just above the base of her tail) it's obviously uncomfortable and this discomfort seems to worsen with activity. Maybe it's possible that whatever was causing the initial compression (he could not determine what that was) in her spine has since returned.
That's interesting about the spot on her lower back. Could it be arthritis?

Is it closer to her tail than the location where he did surgery? If the spot you are noticing is really close to the base of her tail, it may be too far back to affect the function of the legs.

This diagram shows how the nerves that affect the hind legs connect with the spine a bit forward from the tail. If you are finding a sore spot right near the base of her tail, it's possible that is too far rearward to affect hind legs, you'll have to see what you think?
:arrow: :arrow: http://familyvet.com/storage/app/media/anatomy_c6.jpg

I can't speak for a cat, but personally, if I just had spinal surgery 5 weeks ago, I think I'd still be feeling it...

I don't know if this is possible, but I wonder if there could be a spot in her lower back where they injected dye for the myelogram you said she got at the emergency vet. From what I read, sometimes they inject dye up closer to the neck, and sometimes in the lower back. The vet would have to tell you if they did it in the lower back, and whether it could theoretically still be sore weeks later. According to this, the place for a lumbar injection is L6-7 in cats. Here is a nice diagram to refer to, showing where lumbar 6 and 7 are located, almost to the sacrum, so you can see if it matches the place she is sore.
:arrow: :arrow: http://curiosityclub.weebly.com/spine.html

My Sammy was acting painful one time and I didn't know why. The vet found a sore spot on his spine. He actually flinched when the vet touched it. I couldn't figure out how he got hurt. My best guess was another cat was involved. He did mutual grooming with a younger cat who was sometimes frisky. They would lie on an elevated area about 6' off the ground beside the stairs. I wondered if he fell off or got knocked off the edge accidentally by the other cat. He was maybe 17 when it happened. He was limping for a while, but it got better.

My Moki got hurt when he and I assume some other cats were playing in the living room. I had a potted plant on a stand and came home to find the pot on the floor and Moki's tail hanging down like a horse's tail. The stand must have been knocked over and the pot fell on him. Fortunately it got better. But there are so many things that can happen. A broom falling over. Falling off the TV and landing wrong. We get older and we don't bounce like we used to.
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Re: Hind leg neuropathy/knuckling in cat-need advice (complicated case)

Post by Sienna's mom »

CarolC wrote: Fri May 20, 2022 5:36 pm It looks like after the surgery she was on 150mg gabapentin per day, and now she's on 50mg per day.
That is correct. However, she was only on the higher dose for a few days post surgery. She wasn't on any kind of pain medication for weeks before this happened again and was doing well.
CarolC wrote: Fri May 20, 2022 5:36 pm That's interesting about the spot on her lower back. Could it be arthritis?

Is it closer to her tail than the location where he did surgery? If the spot you are noticing is really close to the base of her tail, it may be too far back to affect the function of the legs.
It's possible there is some kind of arthritis going on. She was very active for her age, still jumping from heights that quite frankly, had me worried at times. The sore spot is close to the base of her tail but it also extends right up into her surgery site which ends about an 1 1/2-2 inches above her tail.
CarolC wrote: Fri May 20, 2022 5:36 pm I can't speak for a cat, but personally, if I just had spinal surgery 5 weeks ago, I think I'd still be feeling it...
The surgery was actually done just over 11 weeks ago. She was walking on her hocks (The specialist said this was normal) for roughly two weeks post procedure but she was also very fast and had no pain after we discontinued the pain medication. She was pretty much back to normal right up until we went in for her last chemotherapy appointment which was just over five weeks ago. The same painful leg symptoms (including the pronounced limp) returned; only this time it was worse. That's why the neurologist suspects the Doxo because the back/leg issues occurred twice after the same drug...but like I said, the oncologist doesn't seem convinced.
CarolC wrote: Fri May 20, 2022 5:36 pm The vet would have to tell you if they did it in the lower back, and whether it could theoretically still be sore weeks later. According to this, the place for a lumbar injection is L6-7 in cats. Here is a nice diagram to refer to, showing where lumbar 6 and 7 are located, almost to the sacrum, so you can see if it matches the place she is sore
The report says Intervertebral disk extrusion L7- S1-dorsal laminectomy performed. I'm not entirely sure where they injected the dye but I do believe it was in the lower back. According to the diagram, I would definitely say her sacrum is sore and the pain extends upwards into the lumbar area including the last vertebrae. I can ask the specialist about lingering pain secondary to the injection but that doesn't explain why she had no pain for weeks in between.

I just want to thank you for sharing your personal experiences as well as providing all of the useful information. It's really helping me work through and possibly get to the bottom of this.

After reading about your cats, I think it's worth mentioning that Sienna actually had a fall from a speaker in our basement a few months ago. Now this speaker is only about two feet off of the ground but she landed awkwardly and actually cried out in pain and held her leg up for a minute or two. It reminded me of what it looks like when an animal tears their cruciate. We mentioned the fall to the oncologist and she didn't seem concerned. Sienna seemed fine after that and things appeared normal for another two weeks until her chemo appointment. Shortly after that, the painful limp occured for the first time.

The Neurologist performed the laminectomy surgery and things improved greatly and as I mentioned above, she was almost back to normal and had no pain until her last chemotherapy appointment. During this time, she was confined to a small area in our basement for six weeks (as per the specialist's instructions) where she could not jump or use the stairs. When she was in for that last chemotherapy appointment (five weeks ago) she also saw the neurologist who said she could start using the stairs etc. So we let her and then this happened again. Maybe it's possible that the original leg/back issue was not fully addressed so when we allowed her to resume some normal cat activities, things flared up again? Maybe the timing of the doxorubicin is just coincidental?
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Re: Hind leg neuropathy/knuckling in cat-need advice (complicated case)

Post by CarolC »

Sienna's mom wrote: Sat May 21, 2022 11:54 am
CarolC wrote: Fri May 20, 2022 5:36 pm It looks like after the surgery she was on 150mg gabapentin per day, and now she's on 50mg per day.
Sienna's mom wrote: Sat May 21, 2022 11:54 am That is correct. However, she was only on the higher dose for a few days post surgery. She wasn't on any kind of pain medication for weeks before this happened again and was doing well.
OK, got it.
Sienna's mom wrote: Sat May 21, 2022 11:54 am It's possible there is some kind of arthritis going on. She was very active for her age, still jumping from heights that quite frankly, had me worried at times. The sore spot is close to the base of her tail but it also extends right up into her surgery site which ends about an 1 1/2-2 inches above her tail.
OK.
Sienna's mom wrote: Sat May 21, 2022 11:54 am The surgery was actually done just over 11 weeks ago. She was walking on her hocks (The specialist said this was normal) for roughly two weeks post procedure but she was also very fast and had no pain after we discontinued the pain medication. She was pretty much back to normal right up until we went in for her last chemotherapy appointment which was just over five weeks ago. The same painful leg symptoms (including the pronounced limp) returned; only this time it was worse. That's why the neurologist suspects the Doxo because the back/leg issues occurred twice after the same drug...but like I said, the oncologist doesn't seem convinced.
Eleven weeks is quite a while. Sorry, I had the timeline wrong.
Sienna's mom wrote: Sat May 21, 2022 11:54 am The report says Intervertebral disk extrusion L7- S1-dorsal laminectomy performed. I'm not entirely sure where they injected the dye but I do believe it was in the lower back. According to the diagram, I would definitely say her sacrum is sore and the pain extends upwards into the lumbar area including the last vertebrae. I can ask the specialist about lingering pain secondary to the injection but that doesn't explain why she had no pain for weeks in between.
True. Having no pain during the weeks in between makes the myelogram dye idea less likely.
Sienna's mom wrote: Sat May 21, 2022 11:54 amAfter reading about your cats, I think it's worth mentioning that Sienna actually had a fall from a speaker in our basement a few months ago. Now this speaker is only about two feet off of the ground but she landed awkwardly and actually cried out in pain and held her leg up for a minute or two. It reminded me of what it looks like when an animal tears their cruciate. We mentioned the fall to the oncologist and she didn't seem concerned. Sienna seemed fine after that and things appeared normal for another two weeks until her chemo appointment. Shortly after that, the painful limp occured for the first time.
That is extremely interesting, especially if it was her left leg she was favoring.
Sienna's mom wrote: Sat May 21, 2022 11:54 am The Neurologist performed the laminectomy surgery and things improved greatly and as I mentioned above, she was almost back to normal and had no pain until her last chemotherapy appointment. During this time, she was confined to a small area in our basement for six weeks (as per the specialist's instructions) where she could not jump or use the stairs. When she was in for that last chemotherapy appointment (five weeks ago) she also saw the neurologist who said she could start using the stairs etc. So we let her and then this happened again. Maybe it's possible that the original leg/back issue was not fully addressed so when we allowed her to resume some normal cat activities, things flared up again? Maybe the timing of the doxorubicin is just coincidental?
It does make you wonder, doesn't it. Sounds plausible.

Here's another thing I don't know. I read that doxorubicin is a blistering agent and they have to be extra careful it stays in the vein and does not leak out into surrounding tissue while the chemo is administered. I read that in order to get the needle inserted exactly right, and keep it in place so it doesn't move, vets will sometimes sedate the pet, especially cats.

If that's the case, I don't know if they lay the kitty on his/her side on a towel, or place the kitty in one of those foam immobilizers like they use for spay/neuter. Is there any chance she's been laid in an immobilizer in a way that might be uncomfortable if she had a recent lower back injury from a fall? I wonder if the oncologist sedates and immobilizes for the doxorubicin, and not for the other types of chemo she got. That could make it look like the doxorubicin was to blame, when it might have been something about the sedation and immobilization. Possibly she might have showed the same soreness if they had sedated her for some other type of chemo, but they didn't because it's only necessary with doxorubicin, which causes bad burns if it leaks out of the vein. Don't know.

EDIT TO CORRECT: From the way the following paragraph is worded, it sounds like their doxorubicin cats get full sedation. The first time I read it, I was thinking it was anaesthesia, but maybe not. I'm not sure why they would use positioners to lay the cat on her back. Chemo isn't spay surgery, the drug goes in the foreleg. No idea at all.

Highlighting added.

https://www.vetspecialty.com/specialties/medical-and-radiation-oncology/treatment-options-for-pets-with-cancer/chemotherapy/chemotherapy-for-dogs-and-cats-frequently-asked-questions/ wrote: Some drugs must be delivered directly into the vein only because they can damage other types of tissues. These drugs are called vesicants. Some vesicants will cause minor irritation (Vincristine, Vinblastine, and Mitoxantrone). Adriamycin (Doxorubicin) and Doxil can cause very severe damage which may require surgery to repair. We take great precautions when giving these drugs, including placing an indwelling intravenous catheter and diluting the drug. We sedate all cats for Adriamycin to prevent movement, and a few dogs also require a mild sedative to discourage movement as well.
Highlighting added.
https://journals.sagepub.com/doi/full/10.1177/1098612X18781391 wrote: Degenerative joint disease
Degenerative joint disease (DJD) may be present in cats of all ages, but the majority are 12 years or older. in addition, clinical signs are typically subtle. Therefore,
exercise caution with patient positioning during anesthesia
https://www.dvm360.com/view/anesthesia-for-the-geriatric-patient" wrote: Between the decreased muscle mass and higher incidence of osteoarthritis, geriatric patients should be transported and positioned with care. Adequate padding of dependent areas and reducing stress on joints and ligaments are essential. When considering analgesic drugs, the pain associated with positioning should be considered in addition to the procedure itself.
It's not the same thing, but I have a dog with cervical IVDD, and I have to tell the vet or groomer not to lay her on her side or the neck problem acts up and she ends up miserable and on medication. This is the same dog that bounces up and down on her bottom like crazy when we do treats, so she's normally OK, but if she moves wrong and strains her neck, that's what happens. It is something individual with her. I remind them again at every appointment, and also have a sign taped to her carrier.

I'm just thinking, if there is some position your cat should not be put in, it would be helpful to know what it is. Also, you might want to avoid having pre-anaesthetic or any vaccinations given in the area.

There have been several dogs posted on this board who developed spinal problems following a vet procedure. Here is an early one, and the vets did say they thought it was likely due to his position during the procedure. You put a creaky old dog on his back on a foam positioner (trough) on a stainless steel table for 2 hours, especially a heavy dog, and they aren't used to being in that postion and it's a strain on their creaky old back. I usually wouldn't worry about a cat as much. It's easier to put a small dogs or cat on the table in a controlled manner compared to a 90-lb dog. But if your cat had a recent injury, that might make it uncomfortable. Don't know, just wondering. Highlighting added.
https://handicappedpet.net/helppets/viewtopic.php?p=9496#p9496 wrote:
Hunter is fifteen-year-old, 90 pound shepherd, dobie, Aussie, wolf mix in good health. We just had surgery to remove a large, fast growing fatty tumor from his abdomen, and to get a prostate test. Recovery went fine for two days, then he stopped walking, lay down, and had terrible pain if moved. Brought him to the hospital. Terrible pain at the base of his spine. Steroids dropped all the swelling, and the pain seems to have dissipated.
[skip]
All the doctors have opined, as you did, that he was splayed out in some fashion that strained something, and a minor movement triggered something.

To me the main thing is, she may be currently limping, but she's got bowel and bladder control, which is great. I think I'd want to be sure she doesn't try anything athletic before the soreness has a really good chance to heal.
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Systemic Toxicity Associated With Doxorubicin Administration in Cats

Post by FYI »

https://onlinelibrary.wiley.com/doi/pdf ... .tb01024.x
Cats 3 and 6 developed muscular weakness, particularly in the rear legs during treatment cycles 9 and 10. Examination of the sciatic nerve in four cats (cats 1, 2, 4, and 6) showed moderate myelin degeneration (Fig. 5).
The myelin degeneration of the sciatic nerve found in four cats was unexpected. Therefore, sciatic nerves had not been sampled at necropsy in all cats, and additional nerves were not sampled in any cats. Two cats did develop muscular weakness that may have been related to peripheral nerve dysfunction. We could find no reference to myelin degeneration associated with doxorubicin administration in any other species. The incidence, distribution, and pathophysiology of this myelin degeneration in cats treated with doxorubicin deserves further study.
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Re: Hind leg neuropathy/knuckling in cat-need advice (complicated case)

Post by Sienna's mom »

They didn't use sedation for her chemotherapy appointments, including the times she received doxorubicin.

BUT, and this is the interesting part, they did have to give her a mild sedative (for the first time) at her last appointment because she was being "difficult". We noticed her leg was a little wonky the second we got her home and it continued to get worse from there.
I'm not blaming anyone as I appreciate restraint is necessary and would have more than fine in any other situation. But I do wonder if the restraint/positioning caused something to flare up or be re-injured in the process due to her existing condition?

I guess I just don't know what to do about it now and it's a helpless position to be in. The neurologist says to give things more time but it's already been weeks with no improvement. And how do we know how much time to give if they can't seem to figure out why this is happening? I worry about pain and her quality of life. I seem to have things well controlled and she is constantly looking for love and attention but she must be experiencing some degree of pain if she's limping. I can take her in for another CT scan (which will require more sedation) but I don't know much more that will tell us at this point. And the thought of putting her through another surgery is something I would definitely struggle to get behind after everything she has has already been through. :cry:
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