Practitioner Issue 2, 2014 by FVMA

Published by the Florida Association of Equine Practitioners, an Equine-Exclusive Division of the Florida Veterinary Medical Association Issue 2 â&#x20AC;˘ 2014

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The President's Line

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

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. 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. 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! 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. 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!

• EXECUTIVE COUNCIL •

•

Corey Miller, DVM, MS, Diplomate ACT

Anne L Moretta, VMD, MS

Mr. Philip J. Hinkle

FAEP Council Past President

phinkle@fvma.org

President-Elect

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cmiller@emcocala.com

Executive Director

Armon Blair, DVM abeqdoc@aol.com

Gregory D. BonenClark, DVM, Diplomate ACVS gbonenclark@fevaocala.com

•

Adam Cayot, DVM adamcayot@hotmail.com

Amanda M. House, DVM, Diplomate ACVIM Representative to FVMA Executive Board housea@ufl.edu

Liane D. Puccia, DVM pucciavet@aol.com

Ruth-Anne Richter, BSc (Hon), DVM, MS rrichter@surgi-carecenter.com

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CONTROVERSIES OF CERVICAL VERTEBRAL STENOTIC MYELOPATHY Stephen M. Reed, DVM, DACVIM Cervical vertebral stenotic myelopathy (CVSM) occurs in spinal cord compression will result in false positive diagnoses. two forms. The first is a developmental disease observed in Therefore, myelography remains the diagnostic tool of choice young growing horses where it appears to be a multifactorial for antemortem diagnosis of CVSM and location of specific disease. The second form is in older horses where stenosis is sites of compression. due to osteoarthritis of the articular process joints leading to impingement of the spinal cord. The developmental form Myelography is an important antemortem diagnostic tool and occurs in young, often rapidly growing horses and appears is essential prior to surgical intervention. Interpretation of most frequently in Thoroughbreds. Attempts to confirm an myelographic results represents the second area of controversy inherited basis have been unsuccessful to this point, although regarding CVSM. Myelography is required to confirm diagnosis there appears to be some genetic predisposition combined of focal spinal cord compression and to identify the location with diet, rate of growth, trauma and gender. The most and number of lesions, particularly if surgical treatment is common sites for dynamic lesions are in the mid-cervical pursued. Radiographs are performed with the neck in neutral, region, while static stenosis is more often observed at C5-6 flexed, and extended positions. Criteria for evaluating equine and C6-7. Clinical signs are characterized by ataxia and myelographic radiographs include a reduction of thickness weakness, caused by narrowing of the cervical vertebral canal of the contrast columns to less than 2 millimeters and in combination with malformation of the cervical vertebrae. attenuation of both the dorsal and ventral contrast columns This results in intermittent or continuous compression of the by greater than 50% at diametrically opposed sites. Currently, spinal cord and subsequent neurologic disease. Generally the we use combinations of all published information regarding age of onset of clinical signs is between 3 months and 1 year of interpretation of myelographic studies combined with two independent reader opinions along with our clinical experience. 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.

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.

Neurologic examination reveals upper motor neuron signs For horses less than one year of age, changes in management, and general proprioceptive deficits. Symmetric ataxia, paresis, including restricted exercise and diet, are recommended. dysmetria, and spasticity will be present in all four limbs, The “paced growth” program, of which the efficacy has usually more noticeable in the pelvic limbs than in the thoracic been demonstrated in young horses with early clinical or limbs. Horses with significant degenerative joint disease of radiographic signs of CVSM, includes stall rest and a diet that the articular processes may have lateral compression of the is aimed at reducing protein and carbohydrate intake, and thus spinal cord causing asymmetry of the clinical signs. Ataxia reducing growth and allowing the vertebral canal to “catch and paresis can be noted at a walk during which the horse up.” This study however, did not have control groups or any may demonstrate truncal sway, circumduction of the pelvic histopathologic evidence of compression of the spinal cord. It limbs, toe-dragging, and stumbling. Signs will be exacerbated is important that these diets meet minimum requirements of when the horse is circled, led up and down a hill or over other essential nutrients, and it is recommended that this type obstacles, or when the horse’s head is elevated during the of growth retardation be confined to selected individuals and neurologic examination. Signs can wax and wane in severity is professionally supervised. A recent publication by Hoffman or have periods of stabilization. Confirmation of the diagnosis and Clark showed 30% of horses with a presumptive diagnosis requires radiography and myelography. of CVM that were managed conservatively were able to race. Most of the horses that were able to race had signs that were less Standing lateral radiographs of the cervical vertebrae often than or equal to grade 1 in the thoracic limbs and less than or reveal bony malformations and probable narrowing of equal to grade 2 in the pelvic limbs (JVIM March/April 2013). the vertebral canal. The sagittal ratio method is accurate Although this was a retrospective study, the outcome indicates for identification of stenosis of the cervical vertebral canal, that conservative management may be successful in some however, the use of this method to identify specific sites of horses. 6 The Practitioner Issue 2 • 2014

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.

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.

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 Following surgery, an improvement of 1-2 out of 5 grades that is present would make a horse unsuitable for performance is expected. Since the likelihood of a horse improving more activities. In humans, 80% of patients with cervical spondylotic than 3 grades is minimal, we believe that horses with grade myelopathy that had cervical laminectomy with posterior 1 to 3 degree of severity are the best candidates for surgical lateral mass fusion/fixation showed improvement, and 80-90% correction, although we have operated on horses that were of humans with discogenic radiculopathy of the cervical spine grade 4 and two that were grade 5 just prior to the time of showed improvement following anterior interbody fusion. In surgery. When possible, we recommend surgery for horses that dogs with caudal cervical spondylomyelopathy, 89% showed have only 1 or 2 sites of compression, but we have performed improvement after surgical intervention and 77% of horses surgery on at least one horse affected at 3 sites. 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.

www.faep.netâ&#x20AC;

Stephen M. Reed, DVM, DACVIM 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. Reedâ&#x20AC;&#x2122;s career has predominantly been dedicated to teaching, with an emphasis in Equine Neurologic Diseases.

The Practitionerâ&#x20AC;&#x201A; 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.

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 In some horses they were likely incidental, but by using areas of IRU of the medullary cavity of long bones, rather than bone scintigraphy combined with lameness examinations the cortex, and likely result from some sort of intramedullary we described a new clinical syndrome causing lameness accident, hemorrhage, or other insult, causing intense in some horses. We coined the name enostosis-like lesions osteoblastic activity to occur (Fig 1).1,4 In a recent study, a (ELLs) to describe these medullary opacities (this was horse with acute onset hindlimb lameness was investigated actually capitulation given the fact the reviewers/editors were at necropsy examination 3 weeks after developing hindlimb not convinced we had proven the lesions to be “enostosis” lameness and a scintigraphically-apparent ELL of the femur.5 since neither biopsies nor necropsy examinations had been At necropsy there was a lesion filling the entire medullary performed). Enostosis-like lesions are focal or multifocal cavity, attached to the endosteum, but without involving the areas of increased radiopharmaceutical uptake (IRU) within cortex, comprised of mature and immature bone matrix with the medullary cavity of long bones often corresponding a moderate increase in osteoblasts and few osteoclasts.5 There radiologically to numerous round to irregularly shaped was no thrombus and no evidence of bone necrosis and the radiodensities.1 In our original study of 10 horses with lesion was judged similar to that seen in young dogs with ELLs, lameness was attributed to ELLs in 5 horses, whereas panosteitis.5 It was proposed that pain may have resulted ELLs were thought to be incidental findings in the other 5 from increased intramedullary pressure subsequent to rapidly horses.1 We later learned ELLs of the humerus and femur forming new bone and compression of Haversian canals, but (see below) were more likely to cause lameness than those of bone pressure measurements were not made; the authors then the tibia and radius; those that involved large, focal areas of advanced the issue of fenestration of bone to relieve pressure, intense IRU, were more likely to cause lameness than small, and thus lameness.5 Pain, and perhaps intramedullary relatively inactive ELLs commonly found, for instance, in lesions, caused by an ELL appear short-lived, findings that the Mc/MtIII; and numerous other facts that made us take a should influence clinicians when considering bone biopsy/ closer look at the syndrome. Lameness can be acute, sudden fenestration procedures for management of horses with ELLs. onset and severe (such as seen with a stress fracture) or While horses appear at risk to develop subsequent ELLs in chronic, and can be unilateral or involve more than one limb other bones, recurrence in the same bone appears unusual. 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 10 The Practitioner

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)

Issue 2 • 2014

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). Enostosislike 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 www.faep.net

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 References 1. 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. Michael W. Ross, DVM, DACVS 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 19881993, 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.

The Practitioner 11

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Ensure Your Room at the Host Hotel, Reserve Today! FAEP Special Room Rates Rates Include the Hotel's $15 Daily Resort Fee.

Ocean View

Resort View

Ocean Front

$149.00 $159.00 $179.00

• 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.

Call Group Reservations Department at (888) 511-5086. Request the FAEP’s Special Room Rate! up Rates End l Gro a i ec Sp

mber 1, 2014 e t p Se

4 Educ at ion a l Pa rtn er s LUITPOLD ANIMAL HEALTH

EQUINE D IVIS ION

SCHEDULE

Lecture ▶ Diagnostic Imaging

Thursday, October 9 Time

Grand Ballroom J

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

Neuro Case Studies Dr. MacKay

Time

Grand Ballroom J

3:20 p.m. 3:50 p.m. 3:50 p.m. 4:40 p.m.

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

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

Distinguished Panelists Dr. MacKay

Dr. Macpherson

Sponsored In Part By:

Break - Visit the Marketplace

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.

Ballroom ABC

NEWS HOUR Dr. Kawcak

Neuro Case Studies Dr. MacKay

▶ Lamenes

Friday, October 10

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

▶ Internal Medicine

▶ Equine Sports Rehabilitation

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

NEWS HOUR 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.

9:45 a.m. 10:30 a.m. 10:30 a.m. 11:20 a.m.

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! Sponsored In Part By:

Recent Advances in Regenerative Therapies Dr. Kawcak

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

Suppressing Undesirable Behavior in the Performance Horse Dr. Macpherson

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

Options for Pregnancy in the Performance Mare Dr. Macpherson

Dr. Nixon 12:15 p.m. 1:35 p.m. 1:35 p.m. 2:25 p.m.

Complimentary Lunch in the Marketplace

Perspectives on Pelvic and Lumbosacroiliac Ultrasonography Dr. Whitcomb

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.

Break - Visit the Marketplace

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

Diagnostic Imaging of the Back and Sacroiliac Region Dr. Puchalski

3:20 p.m. 3:50 p.m. 3:50 p.m. 4:40 p.m.

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

Dr. Divers

Equine Lyme Disease Dr. Divers

Break - Visit the Marketplace

Lameness Case Studies Dr. Kawcak

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

Newer Findings in Equine Liver Disease

Old and New Challenges of Equine Infectious Respiratory Diseases Dr. Pusterla Biosecurity in the Equine Practice Dr. Pusterla Emerging Outbreaks Associated with Equine Coronavirus in Adult Horses Dr. Pusterla

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

 American Association of Veterinary State Boards RACE Provider #5

This program was reviewed and approved by the AAVSB program for 38.5 hou on certain methods of delivery of continuing education. Please contact the AAV profession, or if you have questions regarding this notification.

AT-A-GLANCE Topics ▶ Neurology

ness Case Studies

▶ Regenerative Therapies ▶ Reproduction

Saturday, October 11 Time

Grand Ballroom J

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

LAMINITIS MASTER CLASS The Equine Foot: Normal Structure and Function

The Science Behind the Development of Rehabilitation Protocols

Dr. Pollitt

Dr. Schils

LAMINITIS MASTER CLASS Laminitis Theory: An Overview

Comparative Human/Equine Tendon and Ligament Rehabilitation Concepts

Dr. Pollitt

Dr. Skeesick

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

9:45 a.m. 10:30 a.m. 10:30 a.m. 11:20 a.m.

LAMINITIS MASTER CLASS Equine Laminitis: New Therapeutic Options

LAMINITIS MASTER CLASS Chronic Laminitis: The Hidden Dangers Dr. Pollitt

12:15 p.m. 1:35 p.m. 1:35 p.m. 2:25 p.m.

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

Equine Tendon and Ligament Rehabilitation Concepts

Tendon and Ligament Rehabilitation Case Studies Dr. Peters, Dr. van Wessum, Dr. Skeesick and Dr. Schils

Complimentary Lunch in the Marketplace

Foot MRI - Improving our Understanding of Foot Lameness

Comparative Human/ Equine Back and Neck Rehabilitation Concepts

Dr. Puchalski

Dr. Skeesick

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

Equine Back Rehabilitation Concepts

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

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

Time

Grand Ballroom J

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

Practical Equine Tendon and Ligament Rehabilitation Protocols

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

Practical Equine Neck and Back Rehabilitation Protocols

Dr. van Wessum

Break - Visit the Marketplace

Ultrasound of the Carpus and Carpal Canal

Equine Neck Rehabilitation Concepts

Dr. Whitcomb

Dr. van Wessum

Carpal Tendon Sheath Diseases - New Syndromes and Approaches to Treatment

Back and Neck Rehabilitation Case Studies

Dr. Nixon

Dr. Peters

Dr. van Wessum

9:45 a.m. 10:05 a.m 10:05 a.m. 10:55 a.m.

Break - Visit the Marketplace

Rehabilitation Case Studies Dr. Peters, Dr. van Wessum, Dr. Skeesick and Dr. Schils

Dr. Peters

Dr. Nixon

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

Sunday, October 12

Break - Visit the Marketplace

Dr. Pollitt 11:25 a.m. 12:15 p.m.

Ballroom ABC

▶ Surgery

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

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

Rehabilitation Case Studies Dr. Peters, Dr. van Wessum, Dr. Skeesick and Dr. Schils

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!

ucation Credits

der #532

.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 e AAVSB/RACE program at race@aavsb.org or 877-698-8482 should you have any comments/concerns regarding this program’s validity or relevancy to the veterinary

q C N S

NEWS HOUR

LAMINITIS MASTER CLASS

Distinguished Panelists

Christopher Kawcak,

Presented by

DVM, PhD, DACVS, DACVSMR

Thomas J. Divers,

BA, DVM, DACVIM

Nicola Pusterla,

Sheila Schils,

Dr. Med. Vet., DACVIM

BVSc, PhD, DACVIM

DVM, MS, DACT

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

Melissa R. Mazan,

DVM, DACVIM, DACVECC

Robert MacKay,

PhD

Duncan Peters,

Alan Nixon,

Sarah M. Puchalski,

DVM, MS, DACVSMR

BVSc, PhD

BSc, DVM, DACVR

Rob van Wessum,

JenniferSkeesick,

DVM, MS, Cert Pract KNMvD (Equine)

PT, DPT, SCS

Mary Beth Whitcomb,

DVM, MBA, ECVDI (LA-Assoc)

FAEP’s Annual Golf Tournament Thursday, October 9

At this world-class golf resort, we’ve achieved exceptional

Distinguished Speakers

Christopher C. Pollitt, BVSc, PhD

Margo Lee Macpherson,

golf results from taking a beautiful natural setting on a Cost: $125 per person coastal sea island, engaging three legendary golf architects Includes BBQ Lunch Buffet Format: 4-man scramble (Best Ball) to create challenging masterpieces, and infusing the

Please include your handicap with your registration form Teams will be determined based upon handicap

FAEP’s Annual Fishing Tournament Fishing Tournament Includes: Transportation, License, Tackle, Bait and ½ day of Fun!

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) Anglers will compete for prizes for the largest fish caught, the most fish and the most unusual! Limited Availability - Reserve Your Reel Today! Red Drum Spanish Mackerel

Only

$175

Bluefish Ladyfish Jack

FAEP’s Low Country Boil & BBQ Only

$65

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

Friday, October 10, 7:00 p.m. - 10:00 p.m The Basshead, Marriott’s Oceanside Deck 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!

$125

entire golf program with a lasting commitment to quality and customer service.

Co- Sponsored By:

Only

Personal Information

10 THA N N U A L

Name

PROMOTING EXCELLENCE

Address City

State

Phone

SYM POSI UM

Zip

Fax

College

Hilton Head Island,

Year of Graduation

South Carolina

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

Membership q My FAEP/FVMA membership is current q 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

Registration

FAEP/FVMA Member On or Before September 1 q $495.00 After September 1 q $545.00 To 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

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.)

Rehab Only Fee

$295.00 $

Friday Evening Dinner & Entertainment – Friday, October 10th , 7:00 PM - 10:00 PM Children Ages 4-11

Adults $65.00 _____ (Quantity)

$30.00 _____ (Quantity)

Social Event Total

FAEP’s Annual Fishing Tournament Thursday, October 9th , 7:30 AM - 12:00 PM Includes - Transportation, License, Tackle, Bait and 1/2 Day of Fun! FAEP’s Annual Golf Tournament (Palmetto Dunes Golf Course) Thursday, October 9th Handicap _____

Payment Information Total Fees

Tournament Fee

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

E a sy Ways To R egister  Mail:

Children ages 1-3 N/A _____ (Quantity)

     

$175.00 $125.00

FAEP/FVMA 7207 Monetary Dr. Orlando, FL 32809

 Online:

www.fvma.org info@fvma.org

 Phone:

(800) 992-3862 (407) 851-3862  Fax:

( Make checks payable to the FAEP/FVMA)

(US funds drawn on US banks)

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

(407) 240-3710

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» Learn more at equineDrugFacts.com

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)

MAGAZINE_FA.indd 20 28531_Counterfeit_A_PRACTITIONER The Practitioner

11/19/13 2:06 PM

Issue 2 • 2014

BACK EXAMINATION AND MEDICAL THERAPEUTIC OPTIONS FOR HORSES Philippe H. Benoit, DVM, MS 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 steps The 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 www.faep.net

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 Exam Ultrasound 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), The Practitioner 21

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). A

Spinous process injections This 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.

Fig. 2 - Illustration of thoracic spinous processes.

Lumbar paravertebral injections These 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.

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

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. 22 The Practitioner

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

Ultrasound guided injection techniques Material 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. Issue 2 • 2014

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.

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

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. A

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.

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. www.faep.netâ&#x20AC;

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.

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) The Practitionerâ&#x20AC;&#x201A; 23â&#x20AC;&#x201A;

(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 transrectal 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.

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.

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 24 The Practitioner

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

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.

Issue 2 • 2014

(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, Michel Travaux sur la mésothérapie (1958) Presse Médicale N°44 1958

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

Philippe Benoit, DVM, MS Dr. 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.

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

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