Specialty Spotlight: Top 5 Neurology “Pitfalls” to Try to Avoid in General Practice

March 20th, 2026 | Posted in General, Medical Articles

Specialty Spotlight: Top 5 Neurology “Pitfalls” to Try to Avoid in General Practice

Todd Bishop, DVM, DACVIM (Neurology)

Neurologic cases can be intimidating. They often present suddenly and progress quickly. The good news is that many frustrating outcomes are preventable with a few consistent habits and early recognition of red flags.

Below are five of the most common neurology “pitfalls” we see in referral practice and how to avoid them.

1. Calling every neurologic episode a “seizure.”

Not every episodic neurologic event represents seizure activity. Common mimics include syncope, vestibular events, movement disorders (dyskinesia), narcolepsy or cataplexy, pain or muscle spasms, tremor syndromes, metabolic disturbances, and toxic encephalopathies.

When evaluating a first-time event:

• Ask the client to describe what they saw without using the word seizure. Have them act it out if possible.
• Ask the client to accurately identify seizure activity. Was there a true loss of consciousness? Tonic-clonic activity? Urination or defecation? Was the urine spurting or passively leaking? Drooling? Piloerection? A post-ictal phase? Did it occur during rest or activity?
• Request a video whenever possible.
• Run a minimum database: CBC, chemistry panel, endocrine testing as indicated, and blood pressure. Consider bile acids in young animals.

Consider referral for:

• First seizure under 6 months or over 6 years of age
• Cluster seizures (2 or more in 24 hours) or status epilepticus (continuous seizure active for 5-10 minutes or longer without recovery)
• Persistent neurologic deficits outside the post-ictal phase

 

2. Starting steroids before establishing a diagnosis.

Corticosteroids can significantly complicate neurologic diagnostics. They may alter MRI findings, invalidate CSF results, delay definitive diagnosis, skew treatment decisions, and, in some cases, worsen infectious disease.

Before initiating steroids:

• Perform and document a thorough neurologic exam.
• Run a minimum database: CBC, chemistry panel, urinalysis, T4, blood pressure.
• Consider discussing the case with neurology if immune-mediated disease is suspected.

If steroids are necessary:

• Start with anti-inflammatory doses, typically 0.5 to 1.0 mg/kg/day.
• Clearly document start date, dose, and frequency.

Thoughtful timing can make a meaningful difference in diagnostic accuracy.

 

3. Underestimating intervertebral disc disease progression. 

A painful dog that is still ambulatory can decline rapidly. Prognosis is closely tied to neurologic status at the time of surgical intervention.

Use a simple qualitative grading scheme:

• Pain only
• Ambulatory paresis
• Non-ambulatory paresis
• Paralysis
• Paralysis with loss of nociception

Progression between categories should prompt urgent reassessment.

If managing medically:

• Enforce strict rest and confinement, not simply “activity restriction.”
• Provide appropriate multimodal pain control such as NSAID or corticosteroid therapy, gabapentin, amantadine, and methocarbamol as indicated.
• Counsel clients clearly about signs of deterioration.
• Discuss the implications of surgical management before the situation becomes emergent.

Early referral often improves outcomes and reduces long-term morbidity.

 

4. Misclassifying vestibular disease. 

Not all vestibular cases are peripheral or “old dog vertigo.”

Peripheral indicators:

• Horizontal or rotary nystagmus with the fast phase away from the head tilt
• Normal mentation
• No postural reaction deficits
• Single cranial nerve deficits, such as facial paralysis or Horner syndrome

Red flags for central disease:

• Vertical nystagmus
• Changing direction nystagmus
• Altered mentation
• Postural reaction deficits
• Multiple cranial nerve abnormalities

Central vestibular disease warrants prompt referral, advanced diagnostics such as MRI or CT, CSF analysis, and potentially more aggressive medical or surgical treatment.

 

5. Skipping or incompletely documenting the neurologic exam.

Even a streamlined neurologic exam can provide invaluable triage guidance.

Focus on these core observations:

• Is the patient normally mentated?
• Are there obvious cranial nerve deficits? Screen for menace, PLR, palpebral reflexes, head tilt, and nystagmus.
• Can the patient stand and walk independently? Always place them on a carpeted surface and assess spontaneous ambulation before assuming paralysis.
• What is their posture? Look for kyphosis, low head carriage, stiff neck, head tilt, or flaccid tail.
• Is there evidence of paresis or ataxia, such as knuckling, dragging, scuffing, or limb crossing?
• Postural reactions and spinal reflexes are helpful, but careful observation of gait and posture is often more powerful.
• Assess nociception if the patient is non-ambulatory, as this is prognostic. Use hemostats applied to the nail base or digit and look for a conscious behavioral response.

From there, ask yourself:

• Is the exam normal or abnormal?
• Which limbs are affected?
• Is this neurologic or orthopedic?
• Is there focal spinal pain?

Be cautious of neurologic imitators such as:

• Bilateral cranial cruciate ligament ruptures
• Aortic thromboembolism, always palpate femoral pulses
• Immune-mediated polyarthritis

Clear documentation improves monitoring, strengthens referral communication, and supports more confident client prognostic discussions.

A Final Thought

Neurologic cases do not require perfection. They require pattern recognition, thoughtful documentation, and early collaboration when appropriate.

If you are ever unsure about localization, timing, or whether referral is indicated, we are always happy to talk through a case. A brief conversation can often prevent a much larger problem later.

We appreciate the work you do every day and are grateful to partner with you in the care of these patients.

– Todd Bishop, DVM, DACVIM (Neurology)