Thursday, October 7, 2010

How To Know if Your Dog has an Ear Infection

Ear infections are difficult and painful for your dog. But how can you figure out if your dog has an ear infection, or something more serious? If you suspect your dog has an ear infection, contact VCA-VRA today.

Signs of an Ear Infection

About twice per week we are presented with a dog that has rather profound and acute signs of vestibular disease. These patients usually present a head tilt, often falling towards the side of the tilt, and occasionally vomiting. Early on, the dog will have a peculiar "typewriter-like" movement of the eyes which is called nystagmus. The eyes will move quickly in one direction then drift more slowly in the other direction and this eye movement will continue over and over again. Often, we get concerned pet owners that think these signs might be related to a brain tumor.
About 95% of the time these dogs have a triad of subtle signs which in combination are pathognomonic or absolutely diagnostic for ear disease extending beyond the ear drum. The reason that these cases are presented to us on a referral basis is because this group of clinical signs is rare in the most common form of ear infection. The many thousands of dogs that get an ear infection every year have an infection of their external ear which is technically designated as Otitis Externa. These dogs will typically shake their heads and paw at their ears and rub their ears on the ground. Often evidence of an infection is readily appreciated when one looks into the dog's ear canal unaided.

Issues Associated with Dog Ear Infections

The vestibular signs described above don't occur until the infection has spread past the ear drum which is the farthest medial (towards the midline) extent of the external ear canal.
Virtually all dogs whose infection has spread further and now have a more striking set of presenting signs has some if not all of the abnormalities caused by changes in all three of the nerves noted below: 

  1. 1)      Cranial Nerve VIII: Vestibular Disease - Head Tilt, Circling, Nystagmus  Vomiting, Falling towards the side of the tilt
  2. 2)      Cranial Nerve VII: Facial Palsy - Decreased movement of the face on the same side as the affected ear. The dog cannot blink his eye on that side and frequently his lip hangs down and won't move. Most of the time the whole ear moves much less on the affected side compared to the unaffected side.
  3. 3)      Cervical Sympathetic Palsy also called Horner's Syndrome (named after Johann Friedrich Horner, the Swiss ophthalmologist who first described the syndrome in 1869) - the pupil is smaller on the affected eye, the eye is sunken back slightly making the opening or orbital fissure smaller, this sign is enhanced because the eyelid droops somewhat.
This triad of signs is not only pathognomonic or diagnostic for ear disease but in virtually every case where middle or inner ear disease is suspected, all three of these nerves are affected. If one doesn't have all three nerves affected, then one should put disease processes, other than an ear infection, higher on the list of potential diagnoses.
What is important to note here is that although many conditions affecting the brain are life threatening, most ear infections are not. For many years we explained how the bony sac that is the middle ear or Tympanic Bulla in dogs is a good place for infection to sit and cause the clinical signs described. Certainly the middle and inner ear is virtually the only place in the skull where all three nerves are in proximity to one another. Repeated advanced studies have shown the middle ears to look perfectly normal in the face of rather severe clinical signs. Some dogs definitely have severe middle ear infections that are well documented with advanced studies, but this is usually the exception rather than the rule. This leaves us to wonder if the adjoining bone, the petrous temporal bone, might be the source of the infection and the area in which these three nerves are affected. At the current time the exact pathology has been elusive and we really can't say more than these dogs have ear disease. Fortunately, response to therapy is excellent.

Treatments for Canine Ear Infections

Topical medications alone are adequate to cure these cases about 95% of the time. We particularly like medications with Dimethyl Sulfoxide (DMSO) in them and have found most of them safe even when the tympanum (ear drum) is torn. Oral medications seem to be unnecessary.
If topical medication does not work, we recommend a thorough inspection of the ear canal and tympanum and bulla with endoscopy. This is often quite successful at removing much of the offensive material and increases the chance of a complete recovery. Unfortunately once the defenses have been breached and an ear infection has occurred, it is easier for the next infection to occur.
A very successful preventative approach that we use on dogs who's infection is under control consists of keeping the ears acidified so that infection is much less likely to take hold. White vinegar mixed with an equal portion of room-temperature water placed in both ears without pressure and then massaged 100 times keeps most infections away. This 50 percent vinegar solution should be used twice per week for good long-term infection prevention.

If you believe your dog has an ear infection and is in need of treatment, contact VCA-VRA today!

Saturday, September 25, 2010

Video Blog: Passive Range of Motion Exercise for Dogs

The Passive Range of Motion exercise or the PROM is a mainstay of the home exercise program. The idea behind this exercise is quite simple: one is to move a joint through a normal or limited range of motion to keep the joint itself and its associated structures healthy. This exercise can be used to keep tissue healthy while one is waiting for healing. These exercises can also be used to increase the joint's mobility towards normal. It is also useful to use these exercises to maintain joint health, including circulation and mobility in the face of degenerative conditions. Although it would be impossible to review range of motion exercises for every joint in the canine body or for every condition where this would be useful. The value of the embedded videos demonstrate the slow methodical motion that seems to work best. We will frequently include these types of exercises in our home animal rehabilitation programs.

Monday, September 20, 2010

About US

Veterinary Specialty Services, LLC

VSS, LLC is an extension of one of the oldest and most respected specialty animal hospitals in the world. Dr. Steve Steinberg started a referral only hospital in 1977. He has been involved in specialty veterinary medicine since that time and has consulted with some of the largest veterinary corporations and most progressive veterinary universities in the world.

VSS, LLC practices veterinary neurology and animal rehabilitation medicine at VCA/VRA one of the largest referral-only hospitals in the country. We merge our extensive experience, with our state-of the-art equipment, never losing sight of the fact that the patient that you are bringing is one of your best friends. Our tens of thousands of neurology cases over the years never cause us to lose sight of this commitment.

Dr. Steve Steinberg has lectured extensively all over the world including having produced numerous publications. He is considered a pioneer in neurosurgery especially those cases involving brain tumors. Our interest in conservative management of the geriatric neurologic and orthopedic patient is gaining national interest.

Dr. Steinberg lectures on various topics for the Canine Rehabilitation Institute out of Wellington, Florida.

You can find us at 500 Perry Parkway, Gaithersburg, MD 20877

Our phone number is 301-926-3300 and our fax number is 301-977-1308

Please make appointments for neurologic evaluations with our director of Neurologic Services Ms. Yona Severe

Please make appointments for rehabilitation services with our director of Rehabilitation Services Ms. Renee Mills

We see emergencies 24/7 if Dr. Steinberg is in town.

Cage Confinement Tips for Dogs With Spinal Diseases

The vast majority of dogs with mild to moderate spinal disease--especially when intervertebral disc prolapses are suspected--do amazingly well with STRICT cage confinement. This is in most cases this is more important than any medications we can put a dog on. Actually, in many cases, medication actually increases movement and increases the recovery time.

So how do you cope with cage confinement? Typically, it’s harder on the owner than it is the dog. But remember—it’s for the best!

How To Cope With Cage Confinement

Below are some tips to get you and your dog through cage confinement:

  • The best cages are the fiberglass airline carriers. The floor space should be just large enough for your dog to turn around, but no larger. Extra space can be taken up with a cardboard box or pillow if the cage is too large. Here are two different examples of cages to use. We don't endorse any specific kennel brand. The wire cages are not perfect--animals with paresis in particular can get their feet caught in them—so be cautious.
  • Food and water in the cage is best but some animals are too messy and may require these activities occurring outside of the cage.
  • The first 48 hours usually set the tone for this confinement. If every time your dog whines you go to them, they will want you sitting there all of the time. Putting them somewhere where there isn’t a lot of activity and foot traffic is usually best.
  • Your pet should be restricted to going out-of-doors--no more than three times per day. and that is just to use the bathroom--no exercise!
  • A re-examination after the two weeks is strongly suggested. We are very active in canine rehabilitation training and we believe that rehabilitation activities can prevent recurrences.
  • Evaluations at each out-of-doors trip to be sure your pet is continuing to improve are very important.
  • If your pet isn’t making steady progress and improvement, we should be contacted immediately. Continued improvement should be expected and any loss of progress may be very important. Large changes from walking to paralysis should be considered emergencies. Call us immediately.

For more information, contact VCA-VRA today.

Does Your Dog Have Degenerative Myelopathy?

Does Your Dog Have Degenerative Myelopathy?

Degenerative Myelopathy is a diagnosis that no pet owner wants to hear. But with a simple at-home test, you can point to an answer. Of course, it is important to always consult a professional at VCA-VRA if you have any questions.

Signs of Degenerative Myelopathy in Dogs

Being on the lookout is important with this disease—it does not cause pain in your dog, so they won’t actively whimper or cry. Also some of the serious signs—loss of bowl control and the loss of functionality in limbs—do not come until late in the disease. If you notice that your dog is moving slowly, or suspect a spinal problem, here are some things to look out for:

  • The condition is slowly progressive and unrelenting
  • Your dog begins to drag one a hind limb, followed by a spreading of this asymmetry through a side of their body
  • It is unresponsive to the medications that are commonly used for spinal conditions, such as corticosteroids and non-steroidal anti-inflammatory medications

Keeping your dog active is a great method of prevention.

About Degenerative Myelopathy

In 1973 the disease was first described by Dr. Skip Averill, who thought it was a degenerative condition of the mid-thoracic spinal cord. He thought it primarily affected German Shepherds, Collies, and mixes of those two breeds. While clinical signs had been noted years before, it was thought previously to be the result of compression of the spinal cord from ossifications within the dura—described as ossifying pachymengitis. However, in the mid-70’s, it was learned that several other breeds of dogs having similar symptoms.

Although a great deal of anecdotal information was presented on the internet, very little hard data was available to add to the science of this disease. Within the last few years, it became a serious problem in Corgis. Dr. Joan Coates and Dr. Gary Johnson and their co-workers have found a genetic association in this disease that has been found to be statistically relevant.

Unfortunately, the test will only determine if a dog can get the disease. But fortunately, false negatives are virtually unheard of. This means that if one's dog is negative for this disease with this test, our science today tells us they don't have DM.

In addition, a genetic link has been found between the dog disease and Amyotrophic Lateral Sclerosis (ALS)—commonly called Lou Gehrig's disease.

VCA-VRA supports this test. Not because it is perfect--but because this diagnosis is frequently used when a dog has an undiagnosed spinal cord condition. There are other diseases that are progressive and some of them are not fatal. Degenerative Myelopathy, to the best of our knowledge, is always fatal. We encourage owners to perform this simple, at-home test and see if their dog is negative. If so, they should consider further testing to find out whether their dog has a similar-looking neurologic condition.


For some more information bout degenerative myelopathy, check out these links:

Friday, September 10, 2010

Tumors in Dogs


Kayla, a 6-year-old spayed female German Shepherd owned by a local veterinarian, presents with a history of recent onset seizures. Although Kayla shows no other signs and her neurologic examination is otherwise normal, a prefrontal meningioma is certainly a consideration. MRI confirms this diagnosis within a few days, and Kayla heads to the surgery table. The tumor is approached through her frontal sinus and a large portion of her right olfactory tract is removed so that there are clean margins. Kayla’s recovery is uneventful and she goes on to run, play and be the wonderful family member she was before this ordeal first started. She never has another seizure and she lived for three years eventually succumbing to suspected tumor regrowth at the age of nine.

Of course, we best remember our successes, but the decision making process surrounding this most common of brain tumors is not so straightforward.

At least 85% of the older dogs that we see with recent onset seizures have a brain tumor. The vast majority of those are meningiomas and those patients that present without other neurologic signs, are most likely to have a prefrontal neoplasm that must be irritative but not affecting critical neural pathways. Most of these dogs present with seizures. These seizures can most often be terminated in the short-run with corticosteroids.

We know that the Golden Retriever is over represented with this particular neoplasm and more often than not, their meningiomas are in this prefrontal location. Although brachycephalic breeds have a higher incidence of brain tumors, they do not often have meningiomas. Boxers often present with brain tumors at a younger age (five to eight years) and typically present with additional signs of intracranial dysfunction such as “head-pressing”, circling, compulsive pacing and behavioral changes as well as seizures.

Although all meningiomas arise from arachnoid cells, there are several types of meningiomas. It is difficult to distinguish between them based upon MRI findings. In cats, meningiomas tend to compress the brain as they grow and their growth is assumed to be quite slow because the severely compressed cortex looks rather healthy once the neoplasm is removed. In dogs, it is far more likely that the meningioma will actually invade the brain tissue itself and for that reason, the tumor is often much more difficult to remove. Although we often state that canine meningiomas are slow growing, the evidence that this is true is anecdotal at best.

As in all things oncologic, there are several treatment options available. Radiation, as the sole therapy, has limited use with this particular tumor type in my opinion. In the few that I have followed, radiation shrinks the tumor somewhat (about 10%) and then it begins to grow again within a very short period of time.

We have placed dozens of dogs on CCNU using a modification of the protocol first described by Dr. Lisa Fulton and me in 1982. Whether this is a good primary protocol is unknown. We do not have any cases where there is a biopsy diagnosis and a follow-up autopsy that shows there is complete tumor remission. Nor, do we have any cases where the follow-up MRI shows complete regression of the tumor. We do, however, have numerous cases that have survived for the entire treatment course of twelve months and beyond. We have a handful of cases where the owner reports modest to complete recovery but, when the MRI’s were repeated, the tumor is unchanged or mildly smaller in size.

Surgical excision of this neoplasm is quite popular among those neurologists that perform surgery. Wide excision, with tumor-free margins, should theoretically be curative. This has not turned out to be the case and in several patients tumor re-growth has been discovered at some distance from the original surgical site. Whether this represents seeding from the original surgical removal, or is the result of the meningeal tissue being specifically prone to forming tumors at this time in the animal’s life, is totally unknown. An even more bothersome aspect of these meningeal re-growths is that the tumor can re-grow at a truly impressive rate. We have removed neoplasms that are only 1 cm3 in volume and tumor re-growth twelve weeks later reveals a neoplasm at the surgical site that is ten times larger. Does this reflect an enhanced growth rate related to some factor involved in the original surgery or was this a fast-growing neoplasm from the onset? These questions remain unanswered.

Over the years and after hundreds of meningioma surgeries, I, in conjunction with the neuropathology department at The University of Pennsylvania, have gone back over dozens of meningiomas to see if there is some association between the behavior of the neoplasm and the histopathologic type of meningioma removed. To date, no hint of an association has been discovered. It is quite remarkable that a meningioma in the same location, presenting with the same clinical signs and the exact same MRI findings, is likely to be one of several different types of meningiomas recognized by the WHO (World Health Organization). The WHO recognizes nine different types of meningioma.
1) Meningotheliomatous
2) Fibrous
3) Transitional
4) Psammomatous
5) Angiomatous
6) Papillary
7) Granular Cell
8) Myxoid
9) Anaplastic

We have also seen no correlation between tumor size and the success rate of any of the treatments. This surprisingly includes cases involving the surgical removal of very large tumors sometimes yielding the best patient response and longest survival times.

We currently are following an 11 year old, German Shepherd that presented with a single generalized seizure. An MRI revealed a pea-sized prefrontal meningioma-like lesion. We discussed surgical removal, but the owner elected to wait and see what happens without treatment of any kind. We repeated the MRI on this dog six months later and the tumor was unchanged in every way. We hope to follow this dog with additional MRI studies and are hopeful that, ultimately, the diagnosis will be confirmed on autopsy.

We have a handful of dogs whose tumor was removed a second time, after confirming they have regrown. We have had a small number of owners ask that radiation or chemotherapy be performed on animals that have had a surgical excision. It is hard to know the impact of these follow-up treatments, when we include a substantial population whose tumor never returns once it is removed. A corollary to this includes the fact that on presentation, the average age of these dogs is ten and they therefore may succumb to other age-related diseases before we actually know how the tumor or the surgical site might behave.

With all of this experience and with so few really dependable facts, the discussion with the pet owner about their best choices is both challenging and extensive. As with any treatment plan, the veterinarian wants to know the percentages when discussing complications and successful outcomes with the client. Although our experience in treating prefrontal meningiomas at VRA extends over three decades and includes hundreds of cases, dependable facts that apply to this very common brain neoplasm have neither surfaced in our collective literature nor our collective experience.

Friday, September 3, 2010

Video Blog: Dog Rehab with Bear Bells Exercise

This exercise has this strange name because of the device we used to use to reinforce this exercise. Bear bells are Velcro straps with a free hanging bell attached that one can obtain from any camping store. They are to be placed on one's backpack when one is in the Bear Country so the Bear can hear you coming. This encourages the Bear to leave before you reach them or if the Bear is hungry get out the condiments before you reach them. In the same way, we can use this contraption as a therapy device!  

A strap-like device that is placed above the hock or "ankle" in the dog will generally get their attention and they will start lifting the limb higher in the leg with the strap. In dogs that drag their toes this encourages them to lift their limbs higher and we often can retrain them to have a better less traumatic gait. In our experience, the bell sound which was supposed to reinforce the change in gait doesn't seem to have much effect on most dogs and the bell itself seems unnecessary.

We commonly use Velcro straps that are readily available and also find that pony-tail scrunchies are excellent for this exercise. There are a large number of variations on how to use these straps and scrunchies, and we recommend that our rehab specialists try variations on your dog till we find the most effective method. Bear Bells is an extremely common home exercise that we recommend.

Video Blog: Tail Pull Rehab Exercise for Dogs

As some dogs age they have a tendency to have entrapment of their nerve roots at the caudal spinal canal above their tails. Dogs who are afflicted with this problem may be predisposed to this condition because their spinal canals are particularly narrow at that level. Although this condition represents quite a number of various degenerative changes, these dogs are commonly lumped into the category of Cauda Equina Syndrome. Cauda Equina literally means horses' tail and the end of the spinal canal with its many nerve roots looks very much like a horse's tail. The presentation for this condition is quite variable. Hindlimb lameness or gait abnormalities as well as a weak tail and sometimes a loss of control over urine and stool are most common.

The surgical treatment for this condition has been well described and has a high rate of success, but since many of these dogs are older, a more conservative approach is desirable. Several years ago it was noted in cadavers that when the hind limbs of dogs were pulled forward that the entire lower spinal cord and roots moves as much as three-quarters of an inch. This should come as no surprise to any one who has tried sitting in a chair with their head tucked down against their chest knows that with a straight leg lift one can feel the tug on the spinal cord from one end to the other.

Several years ago in response to this information we initiated conservative treatment for Cauda Equina Syndrome with aggressive tail manipulation. To our surprise we determined that we were experiencing about a 75% improvement rate in cases.

Although the success of this therapy seems to require aggressive manipulation that really should be performed by our rehab therapists on a regular basis, our home program includes straight tail pulls performed by the owner (see the attached movie).

Sit behind the dog and place a hand on the caudal "points" of your dog's pelvis (the ischia) on each side of the anus and pull for five to 10 seconds straight back with quite a bit of force. This should not be painful and should be repeated 4-5 times per session and 3-4 sessions per day is recommended.

Thursday, September 2, 2010

Video Blog: Exercises for Dogs with Spinal Problems

Cookie Stretches are one of the best exercises for dogs with spinal problems who are not experiencing acute pain or clinical signs. It has been well documented in man that these kinds of stretching exercises decrease the incidence of back and neck problems and the hope is that those results will carry over to our canine friends.

To start Cookie Stretches one stands behind the patient and stabilizes their pelvis. The idea is to prevent the dog from actually turning and rather stretch the back and neck tissues themselves. Once the pelvis is stable then the dog is encouraged to take a treat from one side then the other in a slow alternating manner. Dogs with back and neck problems will have very little mobility and will not be able to reach all the way back to their hips or tail but with time most dog's flexibility increases quite dramatically.

This is an excellent exercise to perform first thing in the morning before your dog goes out into the yard or for his first walk. As with most rehab exercises, it is best to perform this activity for a short period of time, i.e. a couple of minutes, rather than setting aside a long period of time considering the nature of the dog's attention span. Likewise these exercises are best performed multiple times per day rather than attempting a long single session per day.

Once a significant amount of flexibility is attained, more advanced stretching can be attempted including activities like "sit-ups" and stretching by moving the head through various planes not just side to side.

Wednesday, September 1, 2010

Video Blog: Sit to Stand Exercise for Dogs

The "Sit To Stand" exercise is one of the most common exercises that we give to our dog owning clients. In so many cases we are working with dogs that have hindlimb weakness. This exercise can be compared to weight-lifting exercises to buiold strength.

The dog is positioned head away from the owners body with the owner kneeling or crouching over the dog. The hind limbs are squared up so that the paw's position on the ground is directly under the dog's hip joints. In small dogs the thumbs are placed over the tops of the pelvis and the pinkie fingers are placed behind the knees. Pressure is placed downward over the pelvis at the same time that the pinkies are pressing on the backs of the knees. This forces the dog to squat and the resistance the dog places against this movement tires the muscles used in standing. Three or four sqats is the correct number to start with and one quickly gets a feel for the number that is takes to tire these muscles. Like most rehab exercises, this one should be performed 3-4 times per day and shouldn't take more than a few minutes each time. Working on this exercise for a longer period of time is counterproductive.

In smaller dogs it often helps to put your "Pinkie" behind the knee to get the stifle (knee) to flex while pushing on the pelvis (hip bones).

In larger dogs it is not possible to position ones Pinkie properly and some pressure can be exerted behind the hamstring muscles. In very large dogs it is often necessary to place one's shoulder over the pelvis to produce enough downward force to cause a squat.

Monday, July 26, 2010

VCA VRA History

Steinberg and Cowell


A convergence is most commonly used in astronomical circles, when a series of unrelated events coincide in a unique manner. The seventies were host to a convergence of sorts that was to become Veterinary Referral Associates, Inc., one of the first referral-only veterinary hospitals in the world.

In 1971 Dr. Jacques Jenny died of cancer. Although many well-known veterinarians are associated with the term “pioneer”, the term truly applies to Dr. Jenny. He defined the biology of bone healing using intramedullary pins, Kuentscher nails, in fracture treatment and was the first to bring the compressive ASIF plating system to America and improved upon this system, teaching it to others for many years. He worked alongside human orthopedic surgeons and in the fifties and sixties carved out a place that was equal to his counter-parts in human medicine. He created many unique surgical treatments that he applied with equal skill to horses, dogs and cats. Dr. Jenny chaired the organizing committee for the college of veterinary surgeons and served as its first president.

1971 was also the year that Dr. Peter Ihrke graduated from veterinary school. Peter was destined to become a world famous veterinary dermatologist who has spent most of his career at the University of California in Davis. Upon graduation from Penn, Peter stayed on at Penn as an Associate in Dermatology under the tutelage of Dr. Bob Scwartzman. There were no formal training programs and although there were a few dozen internships, one could become an academic specialist, virtually the only kind of specialist at the time, without one.

1974 was the year that four young energetic veterinarians decided to try something completely new. Dr. Ken Cowell, an Auburn graduate, completed a veterinary internship at South Shore Animal Hospital. This hospital would later become VCA/South Shore in South Whalen, Massachusetts. Dr. Steve Steinberg, a University of Pennsylvania graduate, completed an internship at Henry Bergh Memorial Animal Hospital in New York City. Dr Anne Chiappella, a California native and Davis grad, completed an internship at The University of Pennsylvania. Dr. Clark Dickinson, a seasoned practitioner, was just looking for something new.

1974 was the year Peter Ihrke tried something new. At the request of local practitioners, he started coming to the Washington, DC area once per month to see dermatology cases. The local practitioners loved him and he was an immediate success.

Because of the tremendous legacy of Dr. Jenny, the University of Pennsylvania had established various avenues that would carry his name forward and hold it as a beacon for future generations. In 1974 the Veterinary School through the foresight of Dean Bob Marshak decided to try something new and adventurous, training programs for the teaching of young veterinarians heading into veterinary specialties. They called these programs “residencies” to mimic similar programs that had been the mainstay of training in human medicine. Clark Dickinson became the first Jacque Jenny Honorary Orthopedic Resident. At the same time Ken Cowell became the second orthopedic resident, Steve Steinberg the first neurology resident and Anne Chiapella the first internal medicine resident. Since there wasn’t an established program, these residents were in a kind of free-form adventure where they became best of friends and were supportive of each other. Because there weren’t established programs, these residents also worked alongside contemporaries in training programs who were called instructors, associates, fellows etc. The lines for education in specialties were poorly drawn.

All of the residencies were of two years duration and in 1976 Steinberg stayed on at Penn as an Associate Instructor, Cowell went on to a surgical practice, Chiapella stayed at Penn as an instructor in medicine and Dickinson went on to a private practice in New Jersey.

In 1976 some innovative and congenial veterinary practitioners formed a partnership and opened one of the first emergency hospitals in the country in Rockville, Maryland. Peter Ihrke worked at several of the partner’s practices on a once a month basis. Metropolitan Emergency Animal Clinic (MEAC) still thrives today.

Three of the MEAC vets determined that specialization could be the wave of the future. The emergency hospital was unused during the day and therefore would be a great place to have specialists. It should be understood; the emergency hospital and the idea of private practice specialization were virtually unheard of at that time in 1976.

In February of 1977, Dr. Dick Weitzman, Dr. Sandy Karn, and Dr. Suzanne Jenkins set up a meeting through Peter Ihrke with Steve Steinberg and Ken Cowell. Peter Ihrke had emphatically stated over and over that if Steinberg and Cowell, who had become best of friends, were serious about private specialty practice, the Washington, DC area was the best place for “instant success”.

What Steve Steinberg and Ken Cowell didn’t realize at the time was that they were so poor they would have a hard time recognizing failure. In 1976 each had made an annual salary of $7000. Steve Steinberg and Ken Cowell went to the First American Bank of Maryland with a business plan in March of 1977. It was the seventies and both were wearing suits and both were not wearing a single piece of clothing that they had not borrowed (see picture). Steve Steinberg shaved off his “afro” sized hair and removed his earring. They were soon to be businessmen. A loan officer at the bank, Jack Issacson, loved the idea and without collateral allowed the pair to borrow $13,000. They eventually had to borrow a total of $33,000 to get stated.

On October 1, 1977, H. Steven Steve Steinberg, V.M.D. and Kenneth R. Cowell, D.V.M., A Professional Corporation, was formed. The name was a dull mouthful and they were instantly known everywhere as “Steinberg & Cowell”.

On November 1, 1977 they opened their doors at MEAC and were an instant success. The first year they grossed $125,000 and they each received $ 17,000 in compensation. They were wealthy but only by their previous standards. They fortunately had made a pivotal decision, that they would keep all of their equipment separate from that of MEAC’s. Everything they owned went into cardboard boxes at night and was locked up in a closet including unhooking and wheeling the film processor into the closet so the emergency hospital could tank develop their films at night. A film processor in private practice was unheard of in those days. All of these supplies had to be wheeled out each morning. This allowed them to understand and control their own inventory, hard for neophytes, but a very valuable lesson.

Steinberg & Cowell were growing by leaps and bounds and it was hard to get the MEAC partners to realize that unless they could expand they would have to move on. Each of the partners had their own practices to run and didn’t really have the time to understand the specialist’s predicament.

In 1980, Steinberg was driving up what was a small two-lane road, Route 28( today a multi-lane highway). He passed one of the most unique structures in the county, the old Garrett Farmhouse and Barn. Mr. Garrett gave up farming when his wife died and sold a small 6-acre plot with the farmhouse and barn to Dr. Denham, a veterinarian. Dr. Danny Denham had come to the Washington area through the Army eight years previously. He had been stationed at Walter Reed Army Hospital and had turned the Garrett Barn into a veterinary hospital. Denham was leaning on the fence talking to a local large animal practitioner. Steinberg knew Denham through referrals and stopped to talk. When Steve Steinberg complained that Steinberg & Cowell was bursting at the seams Denham said, “Well, I’m moving to Oklahoma, so why don’t you buy my place.”

The move occurred in 1981 to what people refer to throughout the country as “The Barn”. Dr. Anne Chiapella was added as an internal medicine specialist and Dr. David Saylor was added soon after as the soft-tissue surgeon. Dr. Saylor is the current Medical Director and Dr. Chiapella has her own practice nearby in Virginia.

In 1984, Ken Cowell, after eight years, left veterinary medicine, truly at the top of his game, to try his hand at one of his many other interests. He has never returned to veterinary medicine. With the transition in ownership to Steve Steinberg, the hospital changed names to Veterinary Referral Associates, Inc. (VRA).

With the new name came a surge of new specialties many yet to have their own certifying college many yet to have been seen elsewhere. The practice had frequent national notoriety, with articles and stories appearing throughout the country. Many specialists in the US and Europe have spent time studying the hospital and in some cases training there. Dozens of famous figures have come through VRA’s doors and a change in administrations always marks a wave of new and old politicals changing addresses.

In 1995, being one of the largest and most progressive referral hospitals in the country, Steinberg was approached by five separate and unrelated groups to purchase VRA. For the first time Steve Steinberg stood back and wondered if this thing he built was really something that someone would want to buy.

In May of 1995 Dr. Bruce Ilgen and Mr. Bob Antin came to Gaithersburg and met with Steinberg for lunch. Because Steve Steinberg had heard the other pitches first and they were all the same he was unimpressed. One group flew Steinberg to Maine and made their offer in conjunction with laying out his future with their company. When Bob Antin heard of this, he called and said Steinberg had to come to Santa Monica (VCA’s home in those days) and see their operation. VCA owned 64 hospitals at the time, less than a half dozen east of the Mississippi. Steinberg flew to Santa Monica the day after his Maine trip.

Steve Steinberg and Bob Antin immediately connected and spent most of two days together, comparing notes, sharing stories, talking family.

February 1, 1996, VRA became VCA/VRA.

Tuesday, July 6, 2010

Veterinary Medicine: It's All in the Journey

I was blessed by a great beginning to my veterinary neurology career. I became hooked on the nuances of a vast, complex system that was an enigma to most, but a rather straight journey through every neuron and pathway that controlled an animal's body, envisioned and shared through the eyes of a great teacher, Dr. Skip Averill.

This journey, though, didn't solidify until I was exposed to a mentor who was truly in awe of what he didn't know and what at the time was unknowable. A mind that was able to avoid the pitfalls of oversimplification but with an efficiency of language on the edge of the sacred, he produced short concise sentences that avoided faithfully an unknown or unproven thought. This, my greatest teacher, mixed language skills and knowledge in a way that made those in his presence self-conscious of their own communications. This ability was lost on most and incomprehensible for many. In a setting, where too many were in awe of what they knew, this was a fresh way of projecting knowledge that was too unique for many to grasp. This was my second teacher Dr. Sheldon Steinberg (no relation to me).

The slide from studying and grasping the intricacies of what was known to the arena of appreciation of what wasn't known, ignited a passion in me to try to recognize the truth when available and feel the power of what wasn't understood on a continual basis. I have yet to put my arms around these topics with clear and efficient language but the groundwork for the thought processes is strongly in place. Every known becomes shrouded in the uncertain. Every diagnoses is challenged. Every truth is held up to the light, looking for that crack that shows its insides to be different than expected.

Many think that we in veterinary medicine are hamstrung by patients that can't convey by language the simplest of facts but this is a total misconception. Our history taking skills are well honed, our powers of observation must be strong, our hands must be determined, our senses on edge but ask any veterinary clinician if they miss verbal communication with their patients and they will invariably state that they hadn't even noticed it was missing.

The "toys of medical science" have brought a new dimension to our quest to discover but have not hardly replaced our most basic of tools. In this state of transition we have made some serious missteps. We often confuse the paperwork with the patient. We often convince ourselves that we have a diagnosis when we may be simply close to one. We often believe the patient recovered because of us, when in fact it was in spite of us.

Mastery of a skill, it has been said, takes about ten years. Those of us who are in the hands-on professions know what dues have to be paid to become skilled, but there are few joys that can compare with holding a beloved pet in ones hands and through skilled manipulation determine the most productive next direction and from that step determine the most productive treatment options and from that step see the most beautiful gaze of thanks from an owner and their animal friend, who now have a diagnosis and hopefully a successful treatment ahead of them.

Monday, June 14, 2010

The Veterinary Rehab Business

You wake up. Your not sure of where you are. The nurse asks if you would like some juice. Expecting the worst, your just-operated-upon knee doesn't feel bad at all. Of course, once the local anesthetic wears off things will be different. What's in the immediate future, one word, Physical Therapy! Woops; that's two words but in veterinary medicine we have to use just one word. The word Rehabilitation or Rehab for short.

Some wonderful Physical Therapists and forward-thinking Veterinarians, have been exploring these reparative techniques for treating our companion animals for quite a few years. While this form of treatment has become routine in human medicine, this aspect of veterinary medicine has really only come into its own over the last decade or so.

I have been fortunate enough to take numerous classes at The Canine Rehabilitation Institute(CRI) of Wellington, Florida.

While rubbing elbows with extremely knowledgeable and dedicated Physical Therapists who have decided to treat companion animals, my eyes were opened to an entirely new way of examining and healing. The basis of any approach to an animal patient is having the correct diagnosis. The diagnostic skills of the veterinary rehab specialist extend the scope of tentative diagnoses well beyond what was available to me in veterinary school. Likewise, the approach to treating even the most common companion animal diseases evolves from a completely different direction and incorporates many techniques, unheard of in the world of traditional veterinary medicine.

Many times the disease states we are trying to improve with rehab are the result of neurologic dysfunction. Therefore, a merger of skill sets led me to the faculty of CRI. I teach veterinary neurology, incorporating my new found knowledge of animal rehabilitation. After more than 35 years practicing veterinary neurology and lecturing on various topics in veterinary neurology all over the world, this wonderful collaboration was new, exciting and more than anything, rewarding.

We started applying our new found knowledge to my neurology patients that were recovering from surgery. This naturally extended to encompass a much larger group of patients....Those that are older, who have lost neurologic function that aren't good surgical candidates no matter what the diagnosis. We have also focused on those young patients where surgery for one reason or another isn't an option. All of these animals are beloved family members and just need a little help to get through the day in the most pain-free and efficient manner. The goals may be small, getting up stairs unaided, getting in or out of the family car, going for hours without urinary or fecal accidents. Of course, the approach to the athlete or working dog are quite different and require different standards. Once everyone agrees on the goals and they are there in front of us, our dedicated team of Rehabilitation Specialists, under my guidance, directs our efforts to get these patients to these desired endpoints. Weeks of slow progress, so often ends in the most rewarding of success stories.

After building a brand-new veterinary facility with an outdoor work area, a dry rehab area, and a wet rehab space, it was only natural to explore similar areas of recovery in the orthopedic realm. The idea is that by increasing strength, improving range of motion, controlling pain and inflammation with individualized plans for each patient, we can improve their response to traditional treatment by decreasing the recovery time and by improving the recovery outcome. As with the neurologic patients, we are exploring the many options for those patients where surgery might be the best choice but is not a consideration. Our approach is all about balance and quality of life issues.

Can there be a more rewarding sentence, " For the first time in years, my best friend wagged his tail and effortlessly climbed up on the sofa next to me to help me read a book"?

Thursday, June 10, 2010

CCNU and Treating Canine Brain Tumors

On December 23, 1971, President Richard Nixon signed the National Cancer Act. This was soon designated as our national "War on Cancer". This act opened the door and financed a massive review of drugs synthetic and natural that might produce a positive result in the treatment of cancer. In response to this effort a massive amount of review material was generated that was available to the public at the NIH library in Bethesda, Maryland.

As we solidified our meager knowledge about brain tumors in dogs, Dr. Lisa Fulton, our gifted oncologist, and I realized that if we were going to attack these tumors, we would have to better establish the same multi-modal techniques available in human medicine. We had been performing CT scans since 1977 and MRI's since 1984. Being very selective with our cases, we were able to define intracranial masses with a new degree of certainty. We approached tumor removal and biopsy with trepidation but early post-operative surgical results were quite encouraging. Realizing that man and dog were quite different when surgical planning was on the table was quite a fascinating lesson. Radiation therapy was not readily available but was developing in the private veterinary sector quickly. It was available enough for us to call upon it if we thought this was the best choice. What we were missing was that chemotherapeutic agent that penetrated the blood brain barrier with manageable toxic side effects. All of the currently available agents did not penetrate this biological impasse that so carefully guarded the brain's home.

Fortunately President Reagan's act to remove cancer from the face of the earth put a huge amount of readily available knowledge in one place. Whenever I could get away from my growing Specialty Hospital (Veterinary Referral Associates, Inc., in Gaithersburg, Maryland), I went down to the hallowed halls of the NIH library in Bethesda and read article upon article about medicinals of all types, many of which would be explored and abandoned and never be heard of again. During one of these sojourns, I came across a drug called BCNU or Carmustine. Bis-chloronitrosurea is a nitrosurea that is actually related to "Mustard Gas" an agent used by the Germans against the British and French during World War One. Mustard Gas' nephews and nieces would in a peculiar turn of events become key players in the "War on Cancer"? There in Bethesda, I found that some of the original research on BCNU was performed on the dog and there was substantial information that it crossed the blood brain barrier. Not only were these effects exactly what we were looking for but it also had an oral analog, CCNU or Lomustine that could be administered in pill form. To develop treatment protocols from the available research was kind of like trying to guess how much weight a bridge can hold by jumping up and down upon it. The fact is that most of the dogs we wanted to treat were going to die in a few months without treatment and the owners were always made aware of our ignorance. Starting in about 1983, Dr.Fulton and I determined a dosage protocol that was well tolerated and at least by anecdote seemed to extend our patient's lives. The real breakthroughs were to come when we had biopsy material and long-term followup, with autopsies, once our patients died. In the world of veterinary medicine these numbers are always small. Our ability to pull multiple centers together to get real statistically relevant numbers has been stymied by our culture.

In 1990, Lisa and I published the first paper on the use of CCNU in the dog. It continues to be one of numerous primary chemotherapuetics used in dog cancer treatment today. It has a significant place in the treatment of canine brain tumors.

We have yet to erase the frustration of treating canine brain tumors but we certainly have one more bullet in our arsenal.

Tuesday, June 8, 2010

Securos Veterinary Tools

In 1976 I was trained to perform spinal surgery in dogs and cats by the flamboyant and very skilled Dr. Eric Trotter of the veterinary teaching hospital at Cornell University in Ithaca, NY. I was ending my neurology residency at the University of Pennsylvania and Cornell was one of the premier institutions for veterinary neurosurgery. Little did I realize that in just another year I would be opening one of the first private practice veterinary specialty hospitals in the country and the lessons I learned in Ithaca would be indispensable.

One of the procedures I learned was how to perform a cervical ventral decompression. In this procedure, once the trachea and esophagus are moved out of the way, one is looking right at the bottom or ventral aspect of the cervical spine. Once the muscles are removed a high speed drill is used to carve a slot through the intervertebral disc and adjoining vertebrae and then comes the fun part. An opening is made into the spinal canal and through this tiny opening the protruded disc material is removed. The surgical approach can be quite deep, as much as seven inches sometimes. The hole carved into the bone gives one a 1/2 inch to a 3/4 inch slot to maneuver this offensive, abnormal disc material, out of the hole so it will cease to irritate the spinal cord and the associated nerve roots. This abnormally positioned material which originally was part of a once healthy intervertebral disc, produces one of the most painful conditions in the world of the dog.

I can't remember what instrument Dr. Trotter used for this procedure, but after I performed several hundred of these surgeries I found a dental instrument that was just perfect for teasing the abnormal disc material safely out of these tight, deep quarters. Having hundreds of these procedures in my future (by now I have performed several thousand cervical decompressions) I purchased about a half dozen of these perfect dental pics.

The pics had two ends and over the years the instruments were either misplaced or an end broke off because they weren't of the finest steel. Twenty some years later, I found myself with just one single pic with only one working end and the manufacturers of this instrument out of business. In earnest, I bought instruments that looked similar from catalogs and off the exhibit tables of our national shows. Only trying these supposed replacement instruments, did I realize that the predicament I was in was more serious than originally thought.

Along comes a gregarious and passionate tool maker/artist Harry Wooton. Harry and I met at a surgery conference and ended up at dinner together arranged by a mutual friend. Harry was the President of a veterinary company, Securos,, that designs instruments for the veterinary orthopedic market. Harry shared his passion for design at dinner and when I described the instrument that I could not find, he assured me he could make it to my exact standards. With giddiness, I started imagining slight changes I might make to the "perfect instrument" that just moments before was irreplaceable.

When I expressed my concern about allowing this one-of-a-kind instrument out of my sight, Harry assured me if I overnighted it to him he would copy it and I'd have it back in just two days. This became the only hitch in our relationship. The instrument wasn't back in three days and now I was worried. When I called Harry with trepidation, he told me he didn't think he could do the instrument justice copying it in the office so he had sent it to Germany for a better reproduction, my heart sank. I envisioned every nightmare that ended with the irreplaceable becoming the irretrievable.

Not all nightmares come true. Harry's team of engineers went into high gear and reproduced this instrument with my exact recommendations, making this beloved instrument even more perfect. A few prototypes later, I now have six of the most perfect instruments for this delicate procedure. They fit my hand and my need perfectly. Harry's the best.

Monday, June 7, 2010

Brain Tumors in Dogs

After holding my breath and removing my first brain tumor from a dog in 1982, it is worth taking pause and reflecting on what we have learned during these 28 years and several hundred brain tumors later. One really big issue is that dogs aren't people. They probably don't have right brains and left brains as is common to man. This difference is critical as information in the dog is most likely stored in both hemispheres. The ability, well recognized in young children, for one area of the brain to take over for another may stay with dogs their entire lives as both brain hemispheres aren't restricted as they are in adults. In man, the need to fit language skills somewhere has often been incriminated for this hemispheric commitment. This and the fact that dogs are called upon to perform in a more limited way, for example no opposable thumbs, can't read a book; make our surgical decisions in dealing with the dog brain much more flexible. Because dogs can perform adequately, often with just minimal deficits, with large portions of their brains missing, the approach to a more radical surgery in the dog is often acceptable where this wouldn't be the case in man. The vast majority of dog brain tumors are primary and have not arisen elsewhere. The large majority of dog brain tumors do not metastasize elsewhere. Therefore with all of these attributes that distinguish our considerations in dealing with the dog brain, a wide surgical excision even in the most extensive hemispheric lesions has yielded in many cases very acceptable results. The MRI's attached and the short videos are all from the same 10 year old, castrated male boxer. The tumor seen on the attached MRI's was removed with wide margins. The tumor was an Oligodendroglioma, a highly malignant tumor in the dog but if removed totally, can yield some excellent results in selected cases.

Here is this dog 8 weeks after surgery.

Immediately post operatively these dogs are quite incapacitated but with time other areas of the brain take over and within weeks they frequently make a very acceptable recovery.

Eight months after surgery this same 10 year old Boxer is doing great. We will continue on his chemotherapy protocol for approximately 12 months. The video below is at his eight month checkup.