Neck injections vs shockwave

[Libby2563]

Short version: are neck injections worth trying for a horse that shows some signs of neck pain but has clean X-rays/ultrasounds? Shockwave has already been done with no improvement.

This is regarding my 15-yo TB eventer who suffers from sleep-deprivation (original thread here: Sleep deprivation in the dominant/hypervigilant horse UPDATE 11/4). The summary is that last May I had an internal medicine specialist examine him thinking maybe he had ulcers or another gut health issue, but she zeroed in on his neck and back being painful. His neck ultrasound was clean and at worst two sets of X-rays (one in the field and one at New Bolton) showed “equivocal mild enlargement of the C3-4, 4-5, 5-6 and 6-7 vertebrae, thought to most likely represent normal age related change as opposed to true osteoarthropathy, and mild nuchal enthesopathy (incidental). Intra- and intervertebral sagittal ratios were within normal limits, not suggestive of narrowing of the spinal canal.” He’s not a touchy-feely guy but no other vet has been able to replicate the pain responses the first vet got on neck/back palpation. New Bolton wasn’t overly concerned about neck/back either, though they noted low/stiff neck carriage, which is also part of what the first vet noted. They found ulcers that were treated successfully according to re-scope but with no changes in behavior with treatment.

My regular vet has shockwaved his lower neck three times this spring at 2-week intervals and said if it were going to help it would have by now. He does react to the shockwave, mostly on the right side in the C6/7 area, with muscle twitching and other pain signs, so I asked about injections at the last shockwave treatment and my vet said I could try them but he’d want me to ship to a clinic. Is this worth trying? On the one hand there’s no known pathology. On the other he does seem to be painful there and I’m not sure what else to do.

He got 3 months of just hacking over the winter and is now back in full work. He’s going and jumping well. He’s never been an elastic mover or super soft/straight in the contact in dressage, so it’s tough to say if there’s an issue we just haven’t found. I’ve frequently gotten the “that’s just him” line from vets and trainers. He had a pre-season soundness check and the vet said he looked great and to keep doing what I’m doing.

I still think his refusal to lie down for more than a couple minutes at a time is largely about herd dynamics, but there does seem to maybe be some lower neck pain too. The question is whether it’s worth trying to treat. Any thoughts?

[2tempe]

Neck injections are worth considering. It is worth noting that they sometimes work very well, sometimes less well. There is also evidence -not sure if anecdotal or scientific - that they work less well in second or third rounds. (off subject but I looked into them for myself due to lumbar issues, and was told the exact same thing)
I did them on an older TB years ago who had neuro symptoms and arthritic changes c5-c7. Did bilateral injections (they are ultrasound guided) and they worked really well, he was comfortable and wanting to do stuff for well over a year, maybe closer to 18 months before I felt hind end issues. At that point he was about 25. I did not do a second round, as he had some other health issues as well.

[Bonnie2]

Neck injections can be nothing short of miraculous - if in fact that was what was bothering the horse. Generally speaking, ultrasound is the best imaging modality for the neck. Ultrasound is also used to place the needles when the neck is injected. If the ultrasound was done by a highly experienced practitioner and nothing of note was found then injections would literally be a shot in the dark. If you believe he has an issue, speak to your vet about a trial with NSAIDs or steroids. I would be tempted to try him on Dex for a few days to see if it made a difference. Disclaimer: with veterinary supervision of course!

[IPEsq]

I am right there with you with my younger horse. I have not injected yet. I tried shockwave once with mild, temporary improvement. Based on a horse I had many, clear neck problems, I wouldn’t say that lack of response to shockwave means there’s nothing to be helped by injections potentially. But I am also hesitant to inject without a clear sign of pathology. There’s risk in that too. Yet I also can’t pinpoint the cause of his current issues, and my gut has been saying neck for a while. Another vet is looking at him next week.

[Libby2563]

@2tempe

There is also evidence -not sure if anecdotal or scientific - that they work less well in second or third rounds.

I’ve heard that too and it’s part of my hesitation. What if I “waste” the most beneficial round now and he really needs it more sometime down the road? Not sure if that even makes sense but it’s a consideration.

[Libby2563]

@Bonnie2

If you believe he has an issue, speak to your vet about a trial with NSAIDs or steroids. I would be tempted to try him on Dex for a few days to see if it made a difference.

Interesting idea, thanks. I hadn’t thought of steroids and it hasn’t been suggested. No Bute or Banamine trial because of the ulcers but I’ve tried Equioxx, Robaxin, Tylenol, EPM meds, Trazadone, SmartCalm Ultra, and probably some other stuff I can’t recall right now. I’ve asked two vets about a gabapentin trial. One said he hasn’t done that before and didn’t seem interested in trying. The other said it has both sedative and analgesic properties so we wouldn’t know which was helping him; he is also the one who said, “he looks great and I wouldn’t change a thing,” so he wasn’t exactly recommending it. I feel a bit on my own with this.

[Libby2563]

He has this dent on the right side of his neck that I’ve always thought of as just a prophet’s thumbprint, but since that’s also the area that seems to be painful I wonder if it’s evidence of an old injury that has continued to disrupt the muscles or nerves in that area? If so I have no idea what I would do about it that I haven’t already tried though. And no vets have expressed concern about it, including the one who ultrasounded the neck and the one who was convinced that his neck/back were super painful. Sigh, I wish he could tell me!

[NaturallyHappy]

Have you tried PEMF or laser therapy in that area? I apologize if it was mentioned above.

[IPEsq]

There is a horse at my barn who gets neck injections every 6ish months for the past few years (a couple of times more frequent due to the need to treat additional areas) who is an upper level dressage horse doing better than ever. He is not neurologic but at one show got “stuck” and couldn’t move his neck which prompted the diagnostics. In my experience (including with my own horse who we injected several times successfully), when neck injections don’t work or stop working, the horse has neurological signs already and probably the diagnosis and injections should have started some time beforehand to be able to have a positive effect. Where the degenerative changes are progressing fast, the first round might provide a lot of symptom relief but won’t last that long and won’t slow the disease progression, making subsequent injections appear to not work.

[Simkie]

I was one one of those people who found neck injections very effective for my horse in the first round, and not very effective at all after that. She’s been very stable in her deficit with no progression for the ten or twelve or whatever years since then.

@Libby2563 I’m sorry to hear you’re still dealing with, and you’ve sure turned over every rock. I would push harder for a gabapentin trial before invading the neck. If it works to get your guy lying down to sleep, would it really matter exactly why? You’ve tried things with a sedative effect before, right?

[Feathered_Feet]

I would try the injection and see if it helps. If it does, try again later with PRP. I know some vets are skeptical, but my vet has had some good responses with PRP in the neck, and since it’s therapeutic and chondroprotective (vs steroids being on the more degradative side of the scale), if it worked you could feel comfortable giving that regularly.

But I would use the steroids to diagnosis/assess whether the neck needs injections to begin with. Plus sometimes one injection goes a long way.

[2tempe]

I think there is some truth to your post. We have a 20ish year old arab who had neck issues w/ no neuro symptoms and he as done very well even after the 2nd round. Now lets be clear, his life is not particularly hard, he has an 85 yr old owner who rides him a couple times a week, mostly walk/trot, and a little girl - 10ish - who lessons occasionally.

[Pennywell_Bay]

Our 1.4-1.50 jumper gets ultrasound guided neck injections and it has been a game changer for her. We have noticed no difference in subsequent injections as far as decreased efficacy. Not discounting others anecdotal stories, just adding one for a high performance mare.

[Libby2563]

@NaturallyHappy

Have you tried PEMF or laser therapy in that area? I apologize if it was mentioned above.

I’ve tried a bodyworker who does myofascial work with some laser and acupressure. He’s had PEMF twice, not specifically on the neck but IIRC the blanket had a neck piece. Also tried a few sessions with a DVM chiropractor. No apparent effects of any of this. He kinda seems the same no matter what I do. That’s not the worst news ever because he’s an awesome horse, but if there’s a way to make him even better I wish I could find it!

[Libby2563]

@Pennywell_Bay

Our 1.4-1.50 jumper gets ultrasound guided neck injections and it has been a game changer for her. We have noticed no difference in subsequent injections as far as decreased efficacy. Not discounting others anecdotal stories, just adding one for a high performance mare.

Thanks! If you don’t mind sharing, does she have any findings on x-ray or ultrasound? Did you also try shockwave?

[Pennywell_Bay]

Shockwave was our first go to. I’m talking to my vet tomorrow so I’ll ask her. I’m a co-owner and she lives with the trainer so I don’t remember all the details on her treatment/medical findings (though I do get all the paperwork). I do know we found it through exclusions . We thought it was front end being tentative landing so injected her coffin joints. The trainer still felt like there was something off so our sports medicine vet did a work up. I’m happy to share my n=1 experience.

[IPEsq]

I will also add that with my horse with neck arthritis, we injected the first time with very noticeable improvement. Then he had an unrelated injury and when rehabbing from that we got to a point about a year or so from the first injections of, we know we will need to continue maintenance on the neck and need to be proactive about it but do we do it now or do we try something less invasive? So I tried shockwave once at that time. Vet said if we got 3 or more months of improvement, he would consider that a success. I think we maybe got a few weeks. So we did inject again (and then about every 6 months thereafter, confirming via ultrasound which sites had the most effusion before selecting which sites to treat. He had 3 sites with changes bilaterally at first but developed more arthritis, but some of them looked relatively stable. We never wanted to do more than 6 sites (3 per side) at a time.

[Pennywell_Bay]

So my vet said she found arthritis in the neck and that is why she injected (after hunting down some front end issues).

She said that the first injection is typically like “WOW OMG WHAT A DIFFERENCE”, typically because the horse has gone for so long moderately dealing with the progression of the neck issues. So the feeling when they first get treated is much more noticable.

She disagress with “it stops working”, the efficacy of the injection just is not as noticable in subsequent injections because (hopefully) the discomfort never returns to the prior level. That is not medical advice just a sports medicine vet’s opinon and each is on a case by case basis ( that is my disclaimer for her ha ha) . It also depends on the progression and actual cause)

Shockwave was our first go-to and our horse still receives it pre circuit and post circuit. The shock wave is now used in combination with the injections (not at the same time) because the shock wave treats/decreases the inflamation, increases circulation. We are not on a “schedule” for either persay for injections. The trainer can now tell when it is becoming and issue and knows her baseline and subsequent “tells” when she is getting sore. (of course we do not let her get sore, she sees the vet after big competitions and prior). We do keep her on a relative bi annual/ sometimes quarterly shockwave.

We really did a comprehensive exam when we found the neck- kind of a chicken and the egg thing. We has been chasing front end soreness, injected her bursas, coffin joints etc. Then found the neck issue. I will say that all of the front end issues abated to some extent after treating her neck but we stay on top of those issues. Did carrying herself weird because her neck hurt? Did her neck hurt because her feet were aggravated? We don’t know but it all ties together so I am so appreciative of our vet.