practitioner issue 2, 2014

PROMOTING EXCELLENCE SYMPOSIUMA N N U A LTH10

HILTON HEAD ISLAND, SC | OCTOBER 9 - 12, 2014

Published by the Florida Association of Equine Practitioners,an Equine-Exclusive Division of the Florida Veterinary Medical Association

Issue 2 • 2014

Celebrating 10 Years of Excellence In Equine-Exclusive Continuing Education

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• EXECUTIVE COUNCIL •

Summer in Florida brings heat, humidity and recovery from the hectic winter pace of breeding and the winter training season. At the FAEP, we are hard at work on our educational programs. Our mission is to support the professional development of our members and to educate our members on conditions affecting the equine industry as well as methods for improving the welfare of horses in the state of Florida. Our educational programs achieve this by providing the most relevant and up-to-date information possible so that we can provide the best care for our patients. We do this by focusing on smaller meetings in great locations that encourage personal interaction between attendees and speakers.

Mark your calendars, the Ocala Equine Conference will be held January 23rd-26th, 2015, in Ocala, Florida. We will be offering a comprehensive ultrasound wet lab covering musculoskeletal, abdominal and thoracic imaging. Our Keynote speaker will be Dr. Sue McDonnell, who will discuss the many facets of equine behavior. Dr. Ted Stashak will present an outstanding case-based seminar on wound management that will deliver practical, “take home and use tomorrow” information. Other distinguished speakers include Drs. Steeve Giguere, Eric Mueller, Rich Redding and Karen Wolfsdorf discussing foal respiratory disease, GI issues, lameness, imaging, and reproduction.

We are very excited to celebrate the 10th anniversary of the FAEP! We invite you to join us in beautiful Hilton Head, South Carolina from October 9th-12th, 2014, for the FAEP’s 10th Annual Promoting Excellence Symposium. Our outstanding educational program features a 4-hour Master Class on laminitis with Dr. Chris Pollit, the "FAEP News Hour" with Drs. Chris Kawcak, Rob MacKay and Margo Macpherson and more of the world’s best speakers on the topics of lameness, surgery, imaging, medicine and reproduction in the equine athlete. Our innovative Equine Sports Rehabilitation track will focus on practical take home information and the similarities and differences between equine and human rehabilitation techniques. Drs. Duncan Peters and Rob van Wessum will address the rehabilitation of the equine tendon, ligament and spinal/pelvic injuries. Dr. Jen Skeesick PT, DPT, SCS will discuss rehabilitation from a human physical therapy perspective and Dr. Shelia Schils will discuss the development of equine rehabilitation protocols. Please see complete details in this issue. Enjoy world-class continuing education in a world-renowned location. Experience our brand of Southern Hospitality by joining us for our “Low Country Boil and Barbecue” with entertainment provided by the always hilarious Dr. Bo Brock. It will be a great opportunity to catch up with colleagues and enjoy an interactive social evening. We look forward to seeing you in Hilton Head!

Please come see us at one of our meetings and consider joining our team. We currently have openings on our educational, Practitioner and legislative committees. We are always accepting articles for publication in The Practitioner and would love to have your input. We strive to be an inclusive, diverse organization, and we need your continued input to achieve that goal. I am looking forward to seeing you all at a meeting soon!

The 2014 Equine Foot Symposium in Orlando, Florida was a great start to our year. A dynamic mix of farriers and veterinarians interacted in case study discussions led by our noted speakers. Our lecture topics included the veterinarian-farrier relationship, shoeing for different surfaces, shoeing modifications for hind limb problems, and hoof wall defects. The focus of the meeting was on the hind limb and Mitch Taylor CJF, AWCF presented his ever popular anatomy dissection wet lab detailing hind limb structure. The interactions between veterinarians and farriers left us with renewed respect for each other and fresh ideas to help our patients as a team.

Suzan C. Oakley, DVM, Diplomate ABVP (Equine) - FAEP President

Corey Miller, DVM, MS,

Diplomate ACT President-Elect

[email protected]

Anne L Moretta, VMD, MS

FAEP Council Past [email protected]

Mr. Philip J. HinkleExecutive [email protected]

Gregory D. BonenClark,

DVM, Diplomate [email protected]

Amanda M. House, DVM, Diplomate ACVIMRepresentative to FVMA

Executive [email protected]

Liane D. Puccia, DVM

[email protected]

Ruth-Anne Richter, BSc (Hon), DVM, MS

[email protected]

Jacqueline S. Shellow, DVM, MS

[email protected]

Adam Cayot,DVM

[email protected]

Armon Blair,DVM

[email protected]

•

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• EXECUTIVE COUNCIL •

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CONTROVERSIES OF CERVICAL VERTEBRAL STENOTIC MYELOPATHY

Cervical vertebral stenotic myelopathy (CVSM) occurs in two forms. The first is a developmental disease observed in young growing horses where it appears to be a multifactorial disease. The second form is in older horses where stenosis is due to osteoarthritis of the articular process joints leading to impingement of the spinal cord. The developmental form occurs in young, often rapidly growing horses and appears most frequently in Thoroughbreds. Attempts to confirm an inherited basis have been unsuccessful to this point, although there appears to be some genetic predisposition combined with diet, rate of growth, trauma and gender. The most common sites for dynamic lesions are in the mid-cervical region, while static stenosis is more often observed at C5-6 and C6-7. Clinical signs are characterized by ataxia and weakness, caused by narrowing of the cervical vertebral canal in combination with malformation of the cervical vertebrae. This results in intermittent or continuous compression of the spinal cord and subsequent neurologic disease. Generally the age of onset of clinical signs is between 3 months and 1 year of age, however, variation in time of onset can be seen.

Physical examination may reveal abrasions around the heels and medial aspect of the thoracic limbs due to interference, and short, squared hooves due to excessive toe dragging. Some cases, especially in young horses affected with CVM, have signs of developmental orthopedic disease such as physitis, joint effusion secondary to osteochondrosis, and flexural limb deformities.

Neurologic examination reveals upper motor neuron signs and general proprioceptive deficits. Symmetric ataxia, paresis, dysmetria, and spasticity will be present in all four limbs, usually more noticeable in the pelvic limbs than in the thoracic limbs. Horses with significant degenerative joint disease of the articular processes may have lateral compression of the spinal cord causing asymmetry of the clinical signs. Ataxia and paresis can be noted at a walk during which the horse may demonstrate truncal sway, circumduction of the pelvic limbs, toe-dragging, and stumbling. Signs will be exacerbated when the horse is circled, led up and down a hill or over obstacles, or when the horse’s head is elevated during the neurologic examination. Signs can wax and wane in severity or have periods of stabilization. Confirmation of the diagnosis requires radiography and myelography.

Standing lateral radiographs of the cervical vertebrae often reveal bony malformations and probable narrowing of the vertebral canal. The sagittal ratio method is accurate for identification of stenosis of the cervical vertebral canal, however, the use of this method to identify specific sites of

spinal cord compression will result in false positive diagnoses. Therefore, myelography remains the diagnostic tool of choice for antemortem diagnosis of CVSM and location of specific sites of compression.

Myelography is an important antemortem diagnostic tool and is essential prior to surgical intervention. Interpretation of myelographic results represents the second area of controversy regarding CVSM. Myelography is required to confirm diagnosis of focal spinal cord compression and to identify the location and number of lesions, particularly if surgical treatment is pursued. Radiographs are performed with the neck in neutral, flexed, and extended positions. Criteria for evaluating equine myelographic radiographs include a reduction of thickness of the contrast columns to less than 2 millimeters and attenuation of both the dorsal and ventral contrast columns by greater than 50% at diametrically opposed sites. Currently, we use combinations of all published information regarding interpretation of myelographic studies combined with two independent reader opinions along with our clinical experience.

Medical and surgical therapeutic options exist. Medical therapy is aimed at reducing cord swelling and edema formation with subsequent reduction of the compression on the spinal cord. Treatments with non-steroidal anti-inflammatory drugs combined with dimethyl sulfoxide, mannitol or hypertonic saline are most commonly used. Corticosteroids are indicated in horses with acute spinal cord trauma.

For horses less than one year of age, changes in management, including restricted exercise and diet, are recommended. The “paced growth” program, of which the efficacy has been demonstrated in young horses with early clinical or radiographic signs of CVSM, includes stall rest and a diet that is aimed at reducing protein and carbohydrate intake, and thus reducing growth and allowing the vertebral canal to “catch up.” This study however, did not have control groups or any histopathologic evidence of compression of the spinal cord. It is important that these diets meet minimum requirements of other essential nutrients, and it is recommended that this type of growth retardation be confined to selected individuals and is professionally supervised. A recent publication by Hoffman and Clark showed 30% of horses with a presumptive diagnosis of CVM that were managed conservatively were able to race. Most of the horses that were able to race had signs that were less than or equal to grade 1 in the thoracic limbs and less than or equal to grade 2 in the pelvic limbs (JVIM March/April 2013). Although this was a retrospective study, the outcome indicates that conservative management may be successful in some horses.

Stephen M. Reed, DVM, DACVIM

6 The Practitioner Issue 2 • 2014

CONTROVERSIES OF CERVICAL VERTEBRAL STENOTIC MYELOPATHY

In adult horses with compressive lesions of the spinal cord, the options for medical therapy are restricted to stabilizing a horse with acute neurologic deterioration and injecting the articular joints with a combination of corticosteroids, antimicrobials, and chemical mucopolysaccharides, such as hyaluronate sodium, in an attempt to reduce soft tissue swelling and stabilize or prevent further bony proliferation. Injecting articular joints may be beneficial in horses that demonstrate mild to moderate neurologic deficits.

Surgical treatment of CVSM is the third area of controversy with CVSM, mainly due to concerns regarding the safety of the horse after surgery, and the potential heritability of the disease. Concerns regarding safety of the horse following surgery are based on the assumption that neurons do not regenerate sufficiently after vertebral body stabilization, and thus, even if the compression is alleviated, the irreversible neuronal damage that is present would make a horse unsuitable for performance activities. In humans, 80% of patients with cervical spondylotic myelopathy that had cervical laminectomy with posterior lateral mass fusion/fixation showed improvement, and 80-90% of humans with discogenic radiculopathy of the cervical spine showed improvement following anterior interbody fusion. In dogs with caudal cervical spondylomyelopathy, 89% showed improvement after surgical intervention and 77% of horses with CVSM showed improvement of neurologic deficits, and 61% returned to performance activity. This suggests that surgical intervention appears beneficial in humans, dogs, and horses, and that safety for performance should be evaluated on a case-by-case basis by thorough neurologic examinations. Before surgery is performed, the owners and trainers of the horse should be informed of the risks, liabilities, and responsibilities that are involved.

Surgical techniques for treatment of CVSM were first introduced in 1979, and have been refined since then. The two types of surgery that are advocated are subtotal dorsal decompression laminectomy and ventral interbody fusion. Ventral interbody fusion is currently the most commonly used surgery for CVSM. This surgery is a modification of the one that was developed by Cloward (1958) for use in humans. A stainless steel basket (Bagby basket) packed with an autogenous bone graft is used for interbody fusion. To encourage through-the-implant growth of bone, the surgical procedure for ventral interbody fusion has been recently modified so that it is no longer required to make a drill-hole in order to place the basket. In the new technique, a core of bone (the isthmus) is left and a kerf is created in order to thread the basket over the isthmus. A bone graft is used to fill the remaining space. Leaving the isthmus and its blood supply helps bony fusion to occur more rapidly. This surgery is recommended for all compressive lesions because it results in osseous remodeling of the articular processes and regression of associated soft-tissue swelling at the treated site.


Beginning in 2007, we have performed 342 myelograms with 237 horses diagnosed with cervical vertebral stenotic myelopathy. Eighty four of these horses had surgery at Rood and Riddle and all had Seattle Slew Implants at one or two sites.

Following surgery, an improvement of 1-2 out of 5 grades is expected. Since the likelihood of a horse improving more than 3 grades is minimal, we believe that horses with grade 1 to 3 degree of severity are the best candidates for surgical correction, although we have operated on horses that were grade 4 and two that were grade 5 just prior to the time of surgery. When possible, we recommend surgery for horses that have only 1 or 2 sites of compression, but we have performed surgery on at least one horse affected at 3 sites.


Dr. Stephen M. Reed received his Doctor of Veterinary Medicine Degree at The Ohio State University in 1976. He completed his internship and then did his residency from 1976-1979 at Michigan State University.

Dr. Reed was on the faculty of Michigan State University from 1979-1983, and The Ohio State University from 1983-2007.

He currently practices internal medicine at Rood & Riddle Equine Hospital in Lexington, Kentucky.

Dr. Reed’s career has predominantly been dedicated to teaching, with an emphasis in Equine Neurologic Diseases.

www.faep.net The Practitioner 7

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ENOSTOSIS-LIKE LESIONS: WHERE DO WE STAND?

Michael W. Ross, DVM, DACVS

Enostosis-like Lesions (ELL)1

For many years small radiodensities in the medullary cavities of long bones, in particular the third metacarpal/metatarsal bones (Mc/MtIII), were thought to be incidental radiological findings.

In some horses they were likely incidental, but by using bone scintigraphy combined with lameness examinations we described a new clinical syndrome causing lameness in some horses. We coined the name enostosis-like lesions (ELLs) to describe these medullary opacities (this was actually capitulation given the fact the reviewers/editors were not convinced we had proven the lesions to be “enostosis” since neither biopsies nor necropsy examinations had been performed). Enostosis-like lesions are focal or multifocal areas of increased radiopharmaceutical uptake (IRU) within the medullary cavity of long bones often corresponding radiologically to numerous round to irregularly shaped radiodensities.1 In our original study of 10 horses with ELLs, lameness was attributed to ELLs in 5 horses, whereas ELLs were thought to be incidental findings in the other 5 horses.1 We later learned ELLs of the humerus and femur (see below) were more likely to cause lameness than those of the tibia and radius; those that involved large, focal areas of intense IRU, were more likely to cause lameness than small, relatively inactive ELLs commonly found, for instance, in the Mc/MtIII; and numerous other facts that made us take a closer look at the syndrome. Lameness can be acute, sudden onset and severe (such as seen with a stress fracture) or chronic, and can be unilateral or involve more than one limb simultaneously, or at different times. Two scintigraphic images are required to differentiate medullary from cortical uptake of radiopharmaceutical, a critical step in differentiating ELLs from stress fractures (see below).

The etiology of ELLs remains unclear and the condition has often been referred to as bone islands or bone infarcts. Pathophysiological and radiological findings are similar to dogs with panosteitis and there are characteristics similar to bone infarcts, bone islands and intramedullary osteosclerosis seen in people.1 Unfortunately, our own attempt to investigate etiology by obtaining a bone biopsy sample of an ELL in the distal humerus of a Warmblood with sudden onset lameness revealed changes on the endosteal surface and medullary cavity consistent with what is seen in horses with stress fractures, further confusing the situation.2 The precise etiology remains to this day unclear, but identification of horses with this unique syndrome absolutely requires scintigraphic examination. The close proximity of ELLs to the nutrient foramen of an involved long bone suggests a vascular etiology. Rantanen was the first

to propose that bone islands were possibly associated with a condition known as echocardiogenic contrast (accumulation of platelet aggregates seen ultrasonographically), and this theory remains compelling.2

Stress fractures must be differentiated from ELLs. ELLs are areas of IRU of the medullary cavity of long bones, rather than the cortex, and likely result from some sort of intramedullary accident, hemorrhage, or other insult, causing intense osteoblastic activity to occur (Fig 1).1,4 In a recent study, a horse with acute onset hindlimb lameness was investigated at necropsy examination 3 weeks after developing hindlimb lameness and a scintigraphically-apparent ELL of the femur.5 At necropsy there was a lesion filling the entire medullary cavity, attached to the endosteum, but without involving the cortex, comprised of mature and immature bone matrix with a moderate increase in osteoblasts and few osteoclasts.5 There was no thrombus and no evidence of bone necrosis and the lesion was judged similar to that seen in young dogs with panosteitis.5 It was proposed that pain may have resulted from increased intramedullary pressure subsequent to rapidly forming new bone and compression of Haversian canals, but bone pressure measurements were not made; the authors then advanced the issue of fenestration of bone to relieve pressure, and thus lameness.5 Pain, and perhaps intramedullary lesions, caused by an ELL appear short-lived, findings that should influence clinicians when considering bone biopsy/fenestration procedures for management of horses with ELLs. While horses appear at risk to develop subsequent ELLs in other bones, recurrence in the same bone appears unusual.


Fig A: Lateral (left) and cranial (right) delayed phase scintigraphic images of a Thoroughbred racehorse with acute right forelimb lameness as a result of an enostosis-like lesion of the humerus. Enostosis-like lesions need to be differentiated from stress fractures and usually occur in older horses and those that have previously raced (Modified from Ahern et al, 2009, reference 4)

ENOSTOSIS-LIKE LESIONS: WHERE DO WE STAND?


New findings in horses with Enostosis-Like Lesions 4,6

In a study prompted by an apparent increase in ELLs, particularly in TB racehorses, we chronicled our recent experience. Between 1997 and 2009, we diagnosed ELLs in 79 horses (1.6% of the scintigraphic population). Enostosis-like lesions (different bones) caused lameness and prompted re-referral in 4 horses (5.1%). Lesions were not found in bones in which an original diagnosis was made. In a Warmblood, a diagnosis of an ELL was made on 4 separate occasions. TBs were more likely and STBs less likely to develop ELLs as compared to horses undergoing scintigraphy at our hospital. Horses developing ELLs were older when compared to horses undergoing scintigraphy at our hospital (we suggested racehorses with ELLs are older than those that develop stress fractures). More ELLs occurred in 2008/2009, than in subsequent years (and after the study for that matter), confirming our thoughts that there was a spike in diagnosis of ELLs, but no apparent reasons were found (practitioners had queried if the installation of a synthetic track surface at a local training facility from which many of the cases originated was causative). There were 157 ELLs diagnosed in 85 cases (79 horses). Increased intensity of radiopharmaceutical uptake was associated with increased lameness, but there was no relationship between IRU and radiological assessment (in upper limb bones, soft tissue interposition makes interpretation of intramedullary lesions difficult). The most common locations for ELLs were the tibia and radius, and fewer ELLs were seen in the Mc/MtIII, humerus and femur. ELLs of the tibia and radius were less likely to cause lameness compared to the femur and humerus, and overall, lameness was attributed to ELLs in 49% of cases. Lameness was most prominent in horses with ELL of the humerus and femur. As the number of ELLs increased, the likelihood of racing after diagnosis decreased. Seventy-one percent of TBs and all of the STBs diagnosed with ELLs had raced before diagnosis (higher percentage than those with stress fractures). Of the 43 racehorses in the study, 65% returned to racing. Mean recommended rest period was 83.7 days, but horses with more substantial lameness were often rested longer.

In summary, compared to TB racehorses with stress fractures, those with ELLs are more likely to have raced before lameness develops, and horses were significantly older than the population of horses undergoing scintigraphic examination. Horses with humeral and femoral ELLs were lamer than those with ELLs of the tibia, radius, or Mc/MtIII. While recurrence was not found, a few TB racehorses developed an ELL elsewhere, causing pain that resulted in lameness, and when >1 ELL was present, horses were significantly less likely to race. We speculate it is important to differentiate horses with ELLs from those with stress fractures since the rest period for those with ELLs can likely be reduced. Unfortunately, based on this work we are no closer to determining a cause or a plan for management to prevent recurrence of ELLs.

In an aged Warmblood, lameness caused by an ELL of the humerus was followed by recurrent forelimb lameness as a


result of an ELL of McIII (ELLs of this bone rarely cause lameness).6 The horse was subsequently euthanized 3 months after diagnosis of an ELL of McIII.6 Near complete resolution of ELLs had occurred based on preliminary evaluation of the scintigraphic, radiographic, computed tomographic and magnetic resonance images; histological examination of the involved bones is pending.6

References1. Bassage LH, Ross MW. Enostosis-like lesions in the long bones of 10 horses: scintigraphic and radiographic features. Equine Vet J 1998;30:35-42.

2. Mahony C, Rantanen NW, DeMichael JA, et al. Spontaneous echocardiographic contrast in the thoroughbred: high prevalence in racehorses and a characteristic abnormality in bleeders. Equine Vet J 1992;24:129-133.

3. Ross MW, Boswell R, Pool R. Personal communication (unpublished data), 2000.

4. Ahern BJ, Boston RC, Ross MW. Enostosis-like lesions in 79 horses. Proc Am Assoc Equine Pract 2010;50:392.

5. Stieger-Vanegas, S., Kippenes-Skogmo, H., Nilsson, E. Imaging diagnosis - enostosis-like lesion in the femur of a horse. Vet Rad Ultrasound 2009;50:509-512.

6. Peters S, Ross MW, et al. Unpublished data, 2013.


Dr. Michael W. Ross is a Professor of Surgery at New Bolton Center, University of Pennsylvania, and School of Veterinary Medicine.

He graduated from the College of Veterinary Medicine at Cornell University, N.Y. in 1981, and completed a large animal internship program there. Dr. Ross then completed a three-year large animal surgical residency program at New Bolton Center, where he was appointed Lecturer in Surgery from 1985-1988, Assistant Professor of Surgery from 1988-1993, and Associate Professor of Surgery from 1993-1999. Dr. Ross became a Diplomate of the American College of Veterinary Surgeons in 1986, and is an active member of the American Association of Equine Practitioners.

Dr. Ross has broad clinical interests including equine gastrointestinal, respiratory, and musculoskeletal surgery, but in recent years has concentrated his efforts in the area of orthopedic surgery with a particular interest in arthroscopic surgical techniques. Equine lameness diagnosis and management has always been a clinical focus, with a special emphasis in the Standardbred and Thoroughbred racehorse.

Dr. Ross developed and is Director of the Nuclear Medicine Program at New Bolton Center and is the author of more than 350 scientific papers, proceedings, abstracts and book chapters. Drs. Ross and Dyson’s lameness textbook and companion CD, Diagnosis and Management of Lameness in the Horse, published December 2002, by WB Saunders (Elsevier Science), is the culmination of more than 30 years of study and interest in clinical examination and management of the lame horse. The second edition, with a companion website, www.rossanddyson.com was published November, 2010.

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EquiShield CK SprayChlorhexidine Gluconate 2%, Ketoconazole 1%

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OCTOBER 9– 12, 2014Hilton Head Marriott Resort & Spa

S p e c i a l T h a n k s t o o u r 2 0 14 E d u c a t i o n a l Pa r t n e r s

One Hotel Circle Hilton Head Island, South Carolina

Welcome to Hiton Head Marriott

Resort & Spa,

Discover a crown jewel among Hilton Head Island oceanfront hotels at Hilton Head Marriott Resort & Spa. Our world-class resort in Hilton Head is ready to offer you an escape from the ordinary. Enjoy award-winning dining, three championship golf courses and a lavish new spa, all made even more desirable by our distinctive Hilton Head oceanfront hotel's staff who deliver superior service with elegant surprises at every turn.

at the Hilton Head Marriott Resort & Spa from one of the Special FAEP Room Rates below:

Your Invitation To Attend

Customize your Resort Experience

Ensure Your Room at the Host Hotel, Reserve Today!

PLAT

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10th Annual Promoting Excellence SymposiumAchieving Peak Performance In The Equine Athlete

Offering 14 Nationally & Internationally

Acclaimed Speakers delivering More Than 35 hours of Cutting-Edge

Continuing Education.

• High speed internet access in lobby and guest room-wireless• Unlimited access to our world-class spa facilities including: Sauna • Steam room • Jacuzzi and pools• Resort pool towels• Shuttle service to and from the golf courses and tennis courts in Palmetto Dunes• Use of game room and basketball court• Board games located at the front desk upon request• Local and toll free calls from guest room• Fax service located at the front desk and turn down service upon request.

Complimentary self-parking is offered to attendees or the resort valet is available for $18.00 per day.

Resort View $149.00Ocean View $159.00Ocean Front $179.00

Hilton Head Marriott Resort & Spa

S p e c i a l T h a n k s t o o u r 2 0 14 E d u c a t i o n a l Pa r t n e r s

at the Hilton Head Marriott Resort & Spa from one of the Special FAEP Room Rates below:

Call Group Reservations Department at (888) 511-5086. Request the FAEP’s Special Room Rate!

FAEP Special Room Rates

Your Invitation To Attend

Customize your Resort Experience

Ensure Your Room at the Host Hotel, Reserve Today!

Rates Include the Hotel's $15 Daily Resort Fee.

LUITPOLDA N I M A L H E A L T H EQUINE DIVIS ION

10th Annual Promoting Excellence SymposiumAchieving Peak Performance In The Equine Athlete

Special Group Rates End

September 1, 2014

Saturday, October 11

S C H E D U L E A T - A - G L A N C E

Thursday, October 9 Friday, October 10Time Grand Ballroom J

1:35 p.m. - 2:25 p.m.

Neuro Case Studies Dr. MacKay

2:30 p.m. - 3:20 p.m.

Neuro Case Studies Dr. MacKay

3:20 p.m. - 3:50 p.m.

Break - Visit the Marketplace

3:50 p.m. - 4:40 p.m.

What Are We Talking About with Lower Airway Disease in Horses? Causes, Diagnosis, and Treatment

Dr. Mazan

4:45 p.m. - 5:35 p.m.

Sports Medicine Considerations for the Older Horse – How to Keep the Good Ones Going

Dr. Mazan

Time Grand Ballroom J Ballroom ABC

8:00 a.m. - 8:50 a.m.

8:55 a.m. - 9:45 a.m.

9:45 a.m. - 10:30 a.m.


10:30 a.m. - 11:20 a.m.

Recent Advances inRegenerative Therapies

Dr. Kawcak

Suppressing Undesirable Behavior in the Performance Horse

Dr. Macpherson

11:25 a.m. - 12:15 p.m.

Stifle Injury in the Horse: New Syndromes, Advanced Diagnostics, and Clinical Outcomes

Dr. Nixon

Options for Pregnancy in the Performance Mare

Dr. Macpherson

12:15 p.m. - 1:35 p.m.

Complimentary Lunch in the Marketplace

1:35 p.m. - 2:25 p.m.

Perspectives on Pelvic and Lumbosacroiliac Ultrasonography

Dr. Whitcomb

Newer Findings in Equine Liver Disease

Dr. Divers

2:30 p.m. - 3:20 p.m.

Diagnostic Imaging of the Back and Sacroiliac Region

Dr. Puchalski

Equine Lyme Disease

Dr. Divers

3:20 p.m. - 3:50 p.m.


3:50 p.m. - 4:40 p.m.

Old and New Challenges of Equine Infectious Respiratory Diseases

Dr. Pusterla

4:45 p.m. - 5:35 p.m.

Biosecurity in the Equine Practice

Dr. Pusterla

5:40 p.m. - 6:10 p.m.

Emerging Outbreaks Associated with Equine Coronavirus in Adult Horses

Dr. Pusterla

American Association of Veterinary State Boards RACE Provider #532 This program was reviewed and approved by the AAVSB program for 38.5 hours of continuing education. Participants should be aware that some boards have limitations on the number of hours accepted in certain categories and/or restrictions on certain methods of delivery of continuing education. Please contact the AAVSB/RACE program at [email protected] or 877-698-8482 should you have any comments/concerns regarding this program’s validity or relevancy to the veterinary profession, or if you have questions regarding this notification.

This program has been approved by: New York State Sponsor of Continuing Education FL Board of Veterinary Medicine, DBPR FVMA Provider # 31

Continuing Education Credits

Keep up with the published scientific equine clinical advancements of the past year through brief, yet specific reviews of selected papers presented by our Distinguished FAEP News Hour Speakers at the FAEP’s 10th Annual Promoting Excellence Symposium.

Enjoy the interaction between our distinguished panel members:

Christopher Kawcak, DVM, PhD, DACVS, DACVSMR, is a Professor in the Department of Clinical Sciences at the College of Veterinary Medicine and Biomedical Sciences, Fort Collins, Colorado.

Margo Lee Macpherson, DVM, MS, DACT, is Professor of Large Animal Reproduction at the University of Florida, Gainesville, Florida.

Robert MacKay, BVSc, PhD, DACVIM, is Professor of Large Animal Medicine at the University of Florida, Gainesville, Florida.

Hear what these well-respected and knowledgeable leaders of the equine profession have to say about the latest important clinical information that practitioners need to know. Many of the featured papers to be discussed are either too brief or too new to be included in this year’s scientific program. This is one news program you will not want to miss!

▶ Diagnostic Imaging ▶ Equine Sports Rehabilitation ▶ Internal Medicine ▶ Lameness Case Studies ▶ Neurology ▶ Regenerative Therapies ▶ Reproduction ▶ Surgery

Lecture Topics

NEWS HOUR

NEWS HOUR

Dr. Kawcak Dr. MacKay

Dr. Macpherson

Dr. Kawcak

Sponsored In Part By:

Sponsored In Part By:

Distinguished Panelists

Lameness Case Studies

FAEP’s Annual Golf Tournament

Featuring Bo Brock, presenting a light-hearted

look at the maturation of a small town veterinarian!

q Check Enclosed Charge my credit card q VISA q MC q AMEX q DISCOVERCredit Card # Exp. Date Name on Card Signature

Saturday, October 11 Sunday, October 12Time Grand Ballroom J Ballroom ABC

8:00 a.m. - 8:50 a.m.

LAMINITIS MASTER CLASS The Equine Foot: Normal Structure and Function

Dr. Pollitt

The Science Behind the Development of Rehabilitation Protocols

Dr. Schils

8:55 a.m. - 9:45 a.m.

LAMINITIS MASTER CLASS Laminitis Theory: An Overview

Dr. Pollitt

Comparative Human/Equine Tendon and Ligament Rehabilitation Concepts

Dr. Skeesick

9:45 a.m. - 10:30 a.m.


10:30 a.m. - 11:20 a.m.

LAMINITIS MASTER CLASS Equine Laminitis: New Therapeutic Options

Dr. Pollitt

Equine Tendon and Ligament Rehabilitation Concepts

Dr. Peters

11:25 a.m. - 12:15 p.m.

LAMINITIS MASTER CLASS Chronic Laminitis: The Hidden Dangers

Dr. Pollitt

Tendon and Ligament Rehabilitation Case Studies

Dr. Peters, Dr. van Wessum, Dr. Skeesick and Dr. Schils

12:15 p.m. - 1:35 p.m.


1:35 p.m. - 2:25 p.m.

Foot MRI - Improving our Understanding of Foot Lameness

Dr. Puchalski

Comparative Human/Equine Back and Neck Rehabilitation Concepts

Dr. Skeesick

2:30 p.m. - 3:20 p.m.

A Clinical Perspective on MRI in Lameness and Surgery of the Foot and Ankle

Dr. Nixon

Equine Back Rehabilitation Concepts

Dr. van Wessum

3:20 p.m. - 3:50 p.m.


3:50 p.m. - 4:40 p.m.

Ultrasound of the Carpus and Carpal Canal

Dr. Whitcomb

Equine Neck Rehabilitation Concepts

Dr. van Wessum

4:45 p.m. - 5:35 p.m.

Carpal Tendon Sheath Diseases - New Syndromes and Approaches to Treatment

Dr. Nixon

Back and Neck Rehabilitation Case Studies


Time Grand Ballroom J

8:00 a.m. - 8:50 a.m.

Practical Equine Tendon and Ligament Rehabilitation Protocols

Dr. Peters

8:55 a.m. - 9:45 a.m.

Practical Equine Neck and Back Rehabilitation Protocols

Dr. van Wessum

9:45 a.m. - 10:05 a.m


10:05 a.m. - 10:55 a.m.

Rehabilitation Case Studies


11:00 a.m. - 11:50 a.m.

Rehabilitation Case Studies


Rehabilitation Protocol CASE STUDIES

Get involved! A panel of our rehabilitation speakers will present a series of case studies with videos. They will follow each horse from diagnosis through the completion of their rehabilitation protocols – what worked, what didn’t, what could have been tried? We want to hear about your experiences and we encourage everyone to participate!

In addition, one of the most distinguished clinicians currently in human rehabilitation will be on hand to discuss another perspective – what would the treatment be if this horse were a human?

Attendees will leave with some solid ideas on protocols that can be used in their practices!


Friday, October 10Time Grand Ballroom J Ballroom ABC

8:00 a.m. - 8:50 a.m.

8:55 a.m. - 9:45 a.m.

9:45 a.m. - 10:30 a.m.


10:30 a.m. - 11:20 a.m.

Recent Advances inRegenerative Therapies

Dr. Kawcak

Suppressing Undesirable Behavior in the Performance Horse

Dr. Macpherson

11:25 a.m. - 12:15 p.m.

Stifle Injury in the Horse: New Syndromes, Advanced Diagnostics, and Clinical Outcomes

Dr. Nixon

Options for Pregnancy in the Performance Mare

Dr. Macpherson

12:15 p.m. - 1:35 p.m.


1:35 p.m. - 2:25 p.m.

Perspectives on Pelvic and Lumbosacroiliac Ultrasonography

Dr. Whitcomb

Newer Findings in Equine Liver Disease

Dr. Divers

2:30 p.m. - 3:20 p.m.

Diagnostic Imaging of the Back and Sacroiliac Region

Dr. Puchalski

Equine Lyme Disease

Dr. Divers

3:20 p.m. - 3:50 p.m.


3:50 p.m. - 4:40 p.m.

Old and New Challenges of Equine Infectious Respiratory Diseases

Dr. Pusterla

4:45 p.m. - 5:35 p.m.

Biosecurity in the Equine Practice

Dr. Pusterla

5:40 p.m. - 6:10 p.m.

Emerging Outbreaks Associated with Equine Coronavirus in Adult Horses

Dr. Pusterla

American Association of Veterinary State Boards RACE Provider #532 This program was reviewed and approved by the AAVSB program for 38.5 hours of continuing education. Participants should be aware that some boards have limitations on the number of hours accepted in certain categories and/or restrictions on certain methods of delivery of continuing education. Please contact the AAVSB/RACE program at [email protected] or 877-698-8482 should you have any comments/concerns regarding this program’s validity or relevancy to the veterinary profession, or if you have questions regarding this notification.


▶ Diagnostic Imaging ▶ Equine Sports Rehabilitation ▶ Internal Medicine ▶ Lameness Case Studies ▶ Neurology ▶ Regenerative Therapies ▶ Reproduction ▶ Surgery

Lecture Topics

FAEP’s Annual Fishing Tournament Thursday, October 9th , 7:30 AM - 12:00 PMIncludes - Transportation, License, Tackle, Bait and 1/2 Day of Fun!

$175.00

FAEP’s Annual Golf Tournament (Palmetto Dunes Golf Course) Thursday, October 9th Handicap _____ $125.00

Tournament Fee $

One registration per form. Please duplicate this form for additional registrants.

q My FAEP/FVMA membership is currentq Yes, I would like to take advantage of the FAEP/FVMA joint membership special offer and register for the 10th Annual Promoting Excellence Symposium as a member! I qualify for the following Membership Category: (please check one) q Regular Member $248.00 q Recent Graduate (within last 2 years) $137.00 q State/Federal Employee $137.00 q Part-Time Employed $137.00 q Non-Resident 101.00

FAEP/FVMA New Membership Fee

$

FAEP/FVMA Member On or Before September 1 q $495.00 After September 1 q $545.00To register at the discounted member rate, your 2014 FAEP/FVMA dues must be current! $

FAEP/FVMA Recent Graduate Member

2014 Year of Graduation On or Before September 1 q $195.00 After September 1 q $245.00

2011-13 Year of Graduation On or Before September 1 q $345.00 After September 1 q $395.00

$

Non-Member On or Before September 1 q $695.00 After September 1 q $745.00 $

Student Registration – Currently enrolled in an AVMA-Accredited Veterinary College q $145.00

School Attending ____________________________________________________________________________________

$

Symposium Registration Fee $

Spouse/Guest Registration – Includes Lunch on Friday and Saturday and allows entrance to the Marketplace and social events. Spouses who wish to attend C.E. sessions must pay full registration fee.

Spouse/Guest Name ____________________________________________________________________

$95.00

Spouse/Guest Registration Fee

$

Friday Evening Dinner & Entertainment – Friday, October 10th , 7:00 PM - 10:00 PM Adults

$65.00 _____ (Quantity)

Children Ages 4-11

$30.00 _____ (Quantity)

Children ages 1-3

N/A _____ (Quantity)$

Social Event Total $

Rehab Track Only – Rehab Professionals (Non-Veterinarians). Includes Marketplace access & Lunch on Saturday (Veterinarians who wish to attend the Rehab Track only, must pay full registration fee.)

$295.00

Rehab Only Fee $

Total Fees $A DB C

Christopher C. Pollitt, BVSc, PhD

Presented by

LAMINITIS MASTER CLASS NEWS HOUR

Christopher Kawcak, DVM, PhD, DACVS,

DACVSMR

Robert MacKay, BVSc, PhD, DACVIM

Margo Lee Macpherson, DVM, MS, DACT

Panelists will review published scientific equine clinical advancements of the past year in: ■Surgery/Lameness ■ Reproduction ■ Internal Medicine

Distinguished Panelists

Thomas J. Divers, DVM, DACVIM,

DACVECC

Melissa R. Mazan, BA, DVM, DACVIM

Nicola Pusterla, Dr. Med. Vet.,

DACVIM

Sheila Schils, PhD

Alan Nixon,BVSc, PhD

JenniferSkeesick, PT, DPT, SCS

Rob van Wessum, DVM, MS, Cert Pract

KNMvD (Equine)

Mary Beth Whitcomb, DVM, MBA, ECVDI (LA-Assoc)

Duncan Peters, DVM, MS,

DACVSMR

Sarah M. Puchalski, BSc, DVM, DACVR

Dis

tin

gu

ish

ed

Spea

ker

sS C H E D U L E A T - A - G L A N C E


Lecture Topics

FAEP’s Annual Fishing Tournament

Limited Availability - Reserve Your Reel Today!

Thursday, October 9, 7:30 a.m. - 12:00 p.m.Boats depart promptly at 8:00 a.m.

Cost: $175 per person (6 people per boat)

FAEP’s Low Country Boil & BBQFriday, October 10, 7:00 p.m. - 10:00 p.m The Basshead, Marriott’s Oceanside Deck

Co- Sponsored By:

FAEP’s Annual Golf TournamentThursday, October 9Cost: $125 per personIncludes BBQ Lunch BuffetFormat: 4-man scramble (Best Ball)

Cost: $65 per personChildren 4-11 - $30.00Children 3 & Under Free

In celebration of the 10th Anniversary of the Promoting Excellence Symposium, the FAEP invites attendees to this special feature of our Hilton Head meeting. The occasion promises a hospitable networking and social event with excellent cultural food, music and entertainment, as we commemorate this very important milestone.

Featuring Bo Brock, presenting a light-hearted

look at the maturation of a small town veterinarian!

Only$175

Only$125

Only$65

At this world-class golf resort, we’ve achieved exceptional golf results from taking a beautiful natural setting on a coastal sea island, engaging three legendary golf architects to create challenging masterpieces, and infusing the entire golf program with a lasting commitment to quality and customer service.

Fishing Tournament Includes:Transportation, License, Tackle, Bait and ½ day of Fun! Anglers will compete for prizes for the largest fish caught, the most fish and the most unusual!

Please include your handicap with your registration formTeams will be determined based upon handicap

Red Drum Spanish Mackerel Bluefish Ladyfish Jack

q Check Enclosed Charge my credit card q VISA q MC q AMEX q DISCOVERCredit Card # Exp. Date Name on Card Signature



FAEP’s Annual Fishing Tournament Thursday, October 9th , 7:30 AM - 12:00 PMIncludes - Transportation, License, Tackle, Bait and 1/2 Day of Fun!

$175.00

FAEP’s Annual Golf Tournament (Palmetto Dunes Golf Course) Thursday, October 9th Handicap _____ $125.00

Tournament Fee $F

Name

Address

City State Zip

Phone Fax Email

College Year of Graduation

Personal Information

One registration per form. Please duplicate this form for additional registrants.

REGISTER Before September 1st, 2014 & SAVE $50 !!

Membership q My FAEP/FVMA membership is currentq Yes, I would like to take advantage of the FAEP/FVMA joint membership special offer and register for the 10th Annual Promoting Excellence Symposium as a member! I qualify for the following Membership Category: (please check one) q Regular Member $248.00 q Recent Graduate (within last 2 years) $137.00 q State/Federal Employee $137.00 q Part-Time Employed $137.00 q Non-Resident 101.00

FAEP/FVMA New Membership Fee

$RegistrationFAEP/FVMA Member On or Before September 1 q $495.00 After September 1 q $545.00To register at the discounted member rate, your 2014 FAEP/FVMA dues must be current! $

FAEP/FVMA Recent Graduate Member

2014 Year of Graduation On or Before September 1 q $195.00 After September 1 q $245.00

2011-13 Year of Graduation On or Before September 1 q $345.00 After September 1 q $395.00

$

Non-Member On or Before September 1 q $695.00 After September 1 q $745.00 $

Student Registration – Currently enrolled in an AVMA-Accredited Veterinary College q $145.00

School Attending ____________________________________________________________________________________

$

Symposium Registration Fee $BSpouse/Guest Registration – Includes Lunch on Friday and Saturday and allows entrance to the Marketplace and social events. Spouses who wish to attend C.E. sessions must pay full registration fee.

Spouse/Guest Name ____________________________________________________________________

$95.00

Spouse/Guest Registration Fee

$C

Friday Evening Dinner & Entertainment – Friday, October 10th , 7:00 PM - 10:00 PM Adults

$65.00 _____ (Quantity)

Children Ages 4-11

$30.00 _____ (Quantity)

Children ages 1-3

N/A _____ (Quantity)$

Social Event Total $E

Rehab Track Only – Rehab Professionals (Non-Veterinarians). Includes Marketplace access & Lunch on Saturday (Veterinarians who wish to attend the Rehab Track only, must pay full registration fee.)

$295.00

Rehab Only Fee $D

A

CE Lectures DVD/Electronic Proceedings All Social Events Friday Lunch Buffet Saturday Lunch Buffet Admission to the Marketplace

Your Registration IncludesAll of the Following Functions

4 Online:[email protected]

Fax:(407) 240-3710

Mail:FAEP/FVMA7207 Monetary Dr.Orlando, FL 32809

Phone:(800) 992-3862(407) 851-3862

Easy Ways To REgisTER

Payment Information

( Make checks payable to the FAEP/FVMA) (US funds drawn on US banks)

Total Fees $A DB C E F

S Y M P O S I U MPROMOTING EXCELLENCE

A N N U A L10TH

Hilton Head Island,South Carolina

BACK EXAMINATION AND MEDICAL THERAPEUTIC OPTIONS FOR HORSES

Philippe H. Benoit, DVM, MS

It’s That Time of YearEquine allergies can be caused by allergens like mold, spores and insect bites. A horse experiencing an allergic reaction may display a variety of symptoms such as teary eyes, itchy skin, or hives.

See the difference it can make in your patients this allergy season.

Call 1-866-553-2400 or visit PlatinumPerformance.com.

Platinum Skin & Allergy contains a powerful blend of:

• Quercetin to help maintain normal histamine levels

• Thymus Extract to support immune response to allergens

• Algal DHA to support normal, healthy skin

©2014 Platinum Performance, inc.

An FDA-approved product must have the studies to back up every claim

it makes.1 No exceptions. That’s why you’ll see reference numbers

and disclaimers in the ads. These items provide you with proof that

the product works. If you don’t see any fine print, you likely aren’t

getting what you’re paying for – even if it’s less expensive. And

worse yet, your horse may not get the treatment it deserves.

1 Animal Health Institute, American Veterinary Medical Association, American Veterinary Distributors Association. Veterinary Compounding. Available at: http://www.aaep.org/siteadmin/modules/page_editor/images/files/AHI%20Compounding.pdf. Accessed April 4, 2012.

©2013 Merial Limited, Duluth, GA. All rights reserved. EQUIUGD1226-A (07/12)

»Learn more at equineDrugFacts.com

28531_Counterfeit_A_PRACTITIONER MAGAZINE_FA.indd 1 11/19/13 2:06 PM20 The Practitioner Issue 2 • 2014

Introduction:In sport horses, back and neck problems have become a common diagnosis. Pain in the neck and back may have various origins. Back soreness has previously been considered to be secondary to lower limb lameness problems, but can also be caused by primary back or neck lesions. The clinical exam of the back has been described by few authors, and may include palpation of spinous processes and back musculature, evaluation of back movement abnormalities (static and dynamic), and transrectal palpation.

Clinical exam of the back: Review of the main stepsThe exam includes physical palpation on a standing horse and observation of the back movement using different tests performed with or without a rider.

Physical/Static exam:The exam should be done in a quiet stall or room and includes careful palpation of the neck, withers, thoracic spines and lumbar area. Conformation, muscle soreness, spasm or atrophy, and induced movement should be evaluated in order to find superficial areas of pain or restrictions in movement. Movement in longitudinal and lateral flexion and extension is evaluated in the neck, back, and pelvic areas. Deep pain is evaluated by rectal palpation of the sub lumbar and psoas muscles, preferably in the non-sedated horse.

Dynamic exam:Initially this should be done without any tack in order to see spontaneous movement of each part of the back. Begin the exam with the horse walking on a straight line and then on a figure 8. This allows us to evaluate normal symmetry of the gait, and the ability of the horse to bend on both sides. At the trot on a circle, the horse should show good lateroflexion in the thoracic area and a nice balance of the pelvis. The practitioner should note restriction of motion of specific areas of the spine. At the canter on a longe line, the horse should bend both ways and progressively show good amplitude of its gait. Changing leads, lack of bending, or showing no amplitude of movement of the neck, back or pelvis should be noted. Two additional tests can be done:• Surcingle test: The girth is tightened and the horse

canters on a circle. If the horse immediately slows its gait or suddenly bucks, the test is considered to be positive. The response to this test can be indicative of thoracic pain (around the withers up to 16th or 18th dorsal spinous processes).

• Saddle test: This test is similar to the surcingle test. Tighten the girth and canter the horse on a circle as with the surcingle test. A positive response can be a defensive

reaction, such as bucking, or stopping, and is more indicative of deep lumbar pain.

During these last 2 tests, if the horse suddenly shows a limb lameness, a back problem should be considered in the diagnostic approach.

DIAGNOSTIC APPROACH:Different imaging techniques have been developed to diagnose back problems, including bone scintigraphy, radiography, and more recently, ultrasound examination. Each of these techniques has certain limitations, but each can be helpful in providing a more specific diagnosis and more accurate treatment of the horse’s problem.

Radiographic Examination Radiographic examination in current practice allows us to diagnose spinous process lesions such as fractures, kissing or over reaching spines, as well as bone remodeling/osteolysis. The diagnosis of vertebral lesions, including spondylosis and articular process joint disease, requires a very powerful X-ray unit.

Ultrasonographic ExamUltrasound examination of the neck and back is an easy procedure to perform in the field since the equipment is now more accurate and transportable. Examination is normally done on a standing horse without sedation, and enables us to have immediate diagnostic information to base our treatment strategies on. It allows the practitioner to be more accurate in treatment when using ultrasound-guided injections.

Treatment of dorsal pain by local injections: Muscle injections:This is the most commonly used technique today. It is based on the idea of muscle spasms or inflamed trigger points, which need to be locally injected. There is no relation between superficial or deep pain, and most practitioners inject with a 3 to 5 cm length needle into the longissimus muscle in the neck or back. Most of the drugs used are steroids (dexamethasone or prednisolone salts) or NSAIDS (Ketoprofen). In our experience, long acting steroids can result in calcifications in the muscle fibers and are therefore not indicated.

Subcutaneous injections:These injections are precise and located on the trigger points themselves. They can be done over or under the longissimus fascia. A small amount of lidocaine can be injected, as well as anti-inflammatory medication to enhance a muscular or metameric relaxation. This technique is useful for diagnostic or treatment purposes. Needles used are 25 mm long and 0.6 mm diameter. The results of injection are rapid (10 min),

BACK EXAMINATION AND MEDICAL THERAPEUTIC OPTIONS FOR HORSES

Philippe H. Benoit, DVM, MS


and back sensitivity or motion can then be reevaluated. This treatment can be done around the neck, the thoracic spines, lumbar areas, as well as the sacrum. The surcingle or saddle test can be repeated to see the difference in reaction, and the horse can be worked the same day.

Mesotherapy:This technique was invented in 1952 by Michel Pistor. A small amount of drug is injected with a specialized set of needles into the mesoderm. Mesotherapy is indicated for treatment of myofascial pain syndrome or enthesopathy of the supraspinous ligament. It has been shown by Pitzura that the drug concentration in a local injection area is higher with mesotherapy than with an IM injection. The aim is to find the target area where the majority of the inflammation is. The drugs routinely used in mesotherapy on horses are Sarapin ND(c), lidocaine and flumethasone. A small amount of these drugs results in back relaxation that lasts up to 4 months. This can be tested by superficial reaction, rectal palpation, and the tests mentioned above.

The Mesotherapy technique: Fig. 1• Use of a mesotherapy set with 5 needles• Prepare 1 to 3 syringes of 20 ml lidocaine 2% and 1 ml

flumethasone. (Be sure not to use more than a total of 15 mg of this steroid, including other injections done the same day.)

• Surgical scrub of the area to be treated.• Inject on longitudinal parallel lines on each side of the

back (3 to 4 lines) including areas of major pain.• A small papule or bleb of approximately 6 mm diameter

should arise to confirm that you are in the mesoderm (if you are on the fascia you can feel a scratching sensation with the needles).

During mesotherapy, it is possible to recheck the trigger points that were significantly painful during physical exam. They can then be injected if local pain is still present at the time you inject one of the two sides of the back. The horse is hand walked with no tack for 2 days. During grooming, one should be careful not to rub the small papules (these will disappear within 24 to 48 hours). Under FEI rules, drug testing can detect lidocaine from 15 to 21 days post-injection depending on the amount used.

Mesotherapy Follow-up:No brushing or grooming of the skin for 48 hours to avoid local inflammation of the papule.Do not use long lasting steroids because of potential skin calcifications or white spots where the bleb was made.

Spinous process injectionsThis technique is now widely described. The practitioner injects either kissing or over reaching spinous processes. The aim of the treatment is to not be aggressive with the interspinous ligament while injecting the drug (mostly steroids) around the kissing lesion.

The needle, 5 cm long, and 0.8 mm diameter, is injected on the parasagittal line of the affected area, and obliquely oriented to hit the spinous process. A small amount of medication (2 ml) is injected in several spots.

Lumbar paravertebral injectionsThese injections are indicated for deep lumbar pain, which has been diagnosed by physical and dynamic exam, and more accurately with rectal palpation. Lesions that can cause deep lumbar pain include transverse process kissing lesions, nerve root inflammation, radiculitis, or just deep muscle pain. The needle (105 mm long and 0.7 mm diameter) is injected vertically approximately 5 cm from the midline of the affected area and should hit the transverse process (normally between 9 to 10 cm deep in the adult saddle horse). The drug is injected over the transverse processes and will then penetrate into deeper muscles, without the risk of the needle hitting one of the lumbar nerve branches.

Rectal palpation can be repeated to assess the result of this injection in the next 10 days. A blend of flumethasone and Sarapin ND(c) can be used in this technique.

Ultrasound guided injection techniquesMaterial and methods:Ultrasound exam and guided injections are made using a linear convex 3.5 MHz probe for external examination and a linear straight 7.5 or 5 MHz probe of 5 cm length for rectal examination. The use of a rectal probe is more accurate to obtain images of the pelvis through the rectal wall. After local preparation with gel and rectum emptying, the probe is placed on the lumbosacral joint and moved forward and then laterally on each side to progressively examine the ventral intervertebral spaces and discs, intertransverse joints, and the sacroiliac joints.

Fig. 3 - Illustration of needle position for lumbar paravertebral injection.

Fig. 2 - Illustration of thoracic spinous processes.


Fig. 1 - Illustration of mesotherapy needle set (A) and proper positioning for injection. (B)

A B

On the midline, this procedure allows one to obtain images of the ventral part of the lumbar vertebrae (from L4 to L6), and the lumbosacral joint. While moving the probe 2 cm to 4 cm on a paravertebral line, one can image the nerve root fossae, and sacroiliac joint. It is then possible to assess any sacroiliac joint remodeling and hence use the external probe to more precisely inject this specific joint.

Sacroiliac injection:Most sacroiliac joint inflammation can be suspected by clinical exam. Local blocks have been described, but can cause hind limb weakness or paresia and therefore should be avoided. Imaging techniques such as bone scan and ultrasound examination are very accurate in the diagnosis of sacroiliac pathology.

Before injecting the lumbar area, the preparation includes clipping, warm water and betadine scrub, and application of alcohol to obtain better ultrasound penetration. The 3.5 MHz probe is then placed on a longitudinal line approximately 3 to 5 cm from the midline, on a transverse axis running between both hips.

There are 3 ways to inject each sacroiliac joint:

Cranial approach:This approach can be performed by moving the probe in the lumbar area from the cranial to the caudal part of the pelvis, on a parallel line approximately 8 cm from the midline, until the edge of the ilium wing is seen. The cranial part of the probe is gently lifted in order to maintain the previous image and see the penetration angle of the needle. Anatomically, the sacroiliac joint is under this wing, and the probe is placed in order to guide the needle cranially to the edge of the ilium, and should penetrate ventrally and caudally as close as possible to the sacroiliac and intertransverse lumbosacral area.

Parasagittal approach:This is performed by having a transverse view of the ilium wing, and having the needle penetrate under the wing from the opposite side. Ultrasound allows us to check positioning of the needle below the dorsal edge of the ilium.

Caudal approach: This is performed by moving the probe on a longitudinal axis, caudally from the ilium wing to the sacrum. The needle penetrates in a vertical line going through the intersection of the caudal edge of the ilium wing and the sacrum.

Lumbosacral Joint:The approach is very similar to the cranial approach of the sacroiliac joint, but is performed closer to the midline. When the needle is positioned parallel to the midline on a line which is 5 to 8 cm from the midline, the practitioner will be injecting the lumbosacral joint. The needle will be inserted under the cranial border of the ilium wing and hit the sacrum next to the sacroiliac space (which is more lateral). The practitioner must avoid being too close to the midline in order to be away from the epiaxial foramen of the sciatic nerve root.

Articular processes:To image the articular processes of the back, the probe can be placed first on a longitudinal axis, and then transversely. The articular processes appear on the longitudinal axis as waves approximately 3 cm apart from each other. The transverse view can be done in 2 images on the same screen in order to see left and right side at the same time and compare the size, shape and echogenicity of the articular processes. In order to inject these articular facets, the probe is placed transversely and close to the midline. With the triangular field images of a convex probe, the needle penetration can be followed through the skin and longissimus muscle. The needle is placed almost perpendicular to the skin, parallel to the spinous processes as if we wanted to inject their base. The needle goes through the longissimus and the multifidus muscle (thin layer around the articular process) before hitting the synovial joint. Depending on each individual muscle shape and size, the depth can be between 6 and 9 cm.

Needles and drugs used:For articular process and lumbar paravertebral injections we use an IV catheter of 105 mm length and 0.7 mm diameter(b). The drugs injected can vary. We mostly use a 50/50 blend of a sterile aqueous extract of soluble salts from Sarraceniaceae(c)

Fig. 6 - (A) Illustration of needle positioning for injection of a lumbar articular facet joint. (B) Ultrasound image of the corresponding area. The 2 small arrows on the left side of the ultrasound image indicate a facet joint with bony remodelling.

A B


Fig. 5 - Illustration of the needle positioning and appropriate ul-trasonographic image for injection of the sacroiliac joint from the caudal approach.

Fig. 4 - Illustration of the needle positioning and appropriate ultrasonographic image for injection of the sacroiliac joint from the cranial approach. The dotted line indicates the path of the needle passing ventral to the cranial border of the ilium.

(10 ml), and dexamethasone isonicotinate (0.80 mg/ml)(d) (10 ml). Each spot or lesion is injected with 5 ml of this blend. The total amount of drug injected usually does not exceed 20 ml. For the neck, we use the same catheter as for the articular processes of the back or 50 mm length, 0.8 mm diameter needles.

Results:Between 1997 and 2012, over 10,000 horses have been injected in our practice with this ultrasound-guided method without any side effects. The therapeutic response has been successful most of the time, but response is dependent on early diagnosis of the source of pain and area of the lesion, as well as appropriate rehabilitation of the horse.

Follow-up:Most often, we do a follow up exam in 3 to 6 months before new injections are performed. Prognosis depends upon further remodeling on X-rays and ultrasound, or bone scan activity. Follow-up of local pain can be assessed by external or trans-rectal palpation depending on the area of pain, especially if focused on lumbar or sacroiliac joints. If pain is absent or decreased, and back motion improved, we normally wait for rider information, or if local pain becomes significant before we inject again.

Local mesotherapy, paravertebral muscle (longissimus) injection, or alternative therapies can help prolong the interval between injections to more than 3 to 6 months.

Discussion:The main advantages of these ultrasound-guided methods are:• Ultrasound guided injections are easy and safe procedures

when the anatomical structures are clearly imaged.• Allows the veterinarian to offer an alternative to more

conservative back treatment such as oral or injectable NSAIDS (which are not always successful).

• Provides a more precise method of performing local injections and allows evaluation of the clinical significance of various lesions in the back.

With this ultrasound-guided protocol for sacroiliac injection, we can avoid injecting above the ilium wing, which has no effect, and make sure that the needle is going under the wing. Similarly, for articular process injection, ultrasound helps us to inject over the fascia of the multifidus muscle and have better drug penetration, instead of a less efficient injection of the longissimus muscle. From our point of view, it seems difficult to actually inject into the synovial joint between the articular processes. As with the sacroiliac injection, we are performing a peri-articular injection in order to decrease local pain, and to try and restore better motion of the affected area. Treatment of the associated muscle spasm can be done by various methods such as mesotherapy, paravertebral muscle injection, or physiotherapeutic work.

Rehabilitation program:For most of the back and neck injections, the follow-up includes hand walking for 2 days. If the horse shows significant amyotrophy, and if there are no other lameness issues, we recommend lunging the horse for a period of 7 to 14 days. Most

of the time with horses showing acceptable muscling and with experienced riders, we recommend 2 days hand walking, and then progressive work under tack.

Depending upon the discipline, and especially if sacroiliac joints have been injected, we avoid jumping, or high-level dressage exercises for 15 days. This is done to help restore good proprioception in the back, and to aid the horse in finding his new balance if treatment has been successful. A detailed warm up protocol is provided so there is a very progressive increase in motion of the back. This can include massage of the affected area, then a gentle tightening of the girth, and finally a long period of walking with progressive lateral movement. The use of walking and then cantering with rider not fully sitting in his saddle has been proposed and seems to reduce any major stiffness during the recovery period. When possible, we like to have horses back in work with long reins or longe line with a Pessoa or Gogue rig. We recommend avoiding paddock turn out to limit abnormal or uncoordinated movements of the back.

Alternative treatments:In addition to these medical treatments, we can combine rehabilitation with some alternative treatments such as massage, physiotherapy, external shock wave treatments, chiropractic or acupuncture. As we have done most of the diagnostic work, we try to coordinate the other people involved. We also try to have reports from each of them in order to obtain more information as the horse goes back in work and progresses.

Conclusion:When evaluating back problems, careful physical examination allows us to assess the degree and area of pain. To confirm and document such pathology, a combination of bone scan, X-ray and ultrasound imaging is certainly the best we can offer before making therapeutic decisions. Ultrasound imaging has a great advantage of being a simple and safe way to help obtain a rapid diagnosis and to treat specific lesions of the back with outstanding precision and efficacy. Most colleagues working in clinics and in the field, can master these techniques with the appropriate ultrasound equipment and training.

This approach to treatment of back pain provides more information on the clinical significance of primary vertebral and sacroiliac lesions.

Fig. 7 - Illustration of long lining and riding techniques used in rehabilitation of back problems.


(a) SSD 2000, ALOKA Company, Japan(b) Intranule ref 112.12, Catheter IV, VYGON, Ecouen 95440, France (c)Sarapin®, High Chemical Company, Levitown, PA 19056, USA(d) Voren Suspension®, Boehringer Ingelheim, Paris 75116, France

References:Denoix J.M.: Ultrasonographic evaluation of back lesions. Vet. Clin. North Am. - Equine Pract. 1999,15 (1), 131-160

Denoix J.M.: Diagnosis of the cause of back pain in horses. In Proceedings of the Conference of Equine Sport Medicine and Science. Cordoba 1998, 97-110

Desbrosse F.: Traitement des dorsalgies par injections du dos. In Proccedings Journées de l’AVEF. Pau 2001. Tome II.

Jeffcott L.B.: The diagnosis of diseases of the horse's back. Equine vet J 1975, 7 (2), 69-78

Pistor, MichelTravaux sur la mésothérapie (1958) Presse Médicale N°44 1958

Pistor M. What is mesotherapy? Chir Dent Fr1976; 46: 9-60.

Pitzurra M, Marconi P. Immunogenesis and mesotherapy: the immunoresponse to antigens inoculated intradermally. J Mesother 1981; 1: 9-14

Philippe Benoit, DVM, MSDr. Philippe Benoit is a 1989 graduate of Alfort Vet School of Paris, France. He earned a Master of Science Degree in nutrition and exercise physiology in 1991.Dr. Benoit was the team Vet for the French equestrian team between 1992 and 1999, and has consulted for other international teams since 2000.He established an Equine Clinic in Les Breviaires, near Versailles, France in 1995. His practice specializes in ultrasound imaging, orthopaedics and sport medicine.Dr. Benoit’s main interest is in sport horses, mostly jumpers. He has been riding since 1971. He placed 5th at the student world championships in 1985.

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