Protocol for neck/back x-rays? - new ? post 15

[Libby2563]

I have never had a horse with known neck/back issues but it seems like it comes up in thread after thread as a source of performance issues, multi-limb/intransigent/repetitive lameness, etc. (Recently read @Peggy’s depressing post on the “OTTB with subtle hind end lameness” thread, and there’s been some discussion in @Jealoushe’s neuro thread as well.) People with experience present it as a relatively inexpensive way to get some more information. I have a few questions (some of which may be pretty dumb, sorry):

What is the protocol for doing this? Can the regular farm vet take the films, and send them to experts for interpretation if there is any gray area? Or would you go to a clinic or lameness expert? Do you take the whole neck and back? Start at one end or the other?

Context: I have wondered a few times whether I should have my 5-year-old’s neck and/or back checked since he has lameness in 3 out of 4 limbs that is so far not responding very well to treatment (stall rest, handwalking, therapeutic shoeing, and shockwave). I have already spent a ton of money on his uninsured butt so a few hundred more for some x-rays that could possibly shed whole new light on his prospects for recovery seem like a drop in the bucket. But, since none of the many lameness experts I’ve taken him to have even broached the topic, I am tempted to ask my regular vet (who would do it on-site and cost significantly less). Bad plan?

His particular issues, FWIW, include a LF collateral ligament injury and desmitis in both medial suspensory branches. He is 2.5/5 lame on the LF. When that’s blocked he becomes 1+/5 lame on the LH. Then when that’s blocked (low 4-point) he becomes 1/5 lame on the RH. He is a rather tall and heavily built Hanoverian.

[IPEsq]

I would go to a clinic if you have one fairly accessible. That will give you a higher powered Xray to be able to see the lumbar facets better as well as lower cervical area. It’s kind of dense in those areas, you have the scapula in the way, etc. Other areas can be seen pretty well with field Xray, but the person shooting them especially for joint views needs to know what they are doing so you don’t get the images at too oblique of an angle. Looking at dorsal spinous processes is harder to mess up. Some sports vets may prefer to look at the area via ultrasound instead of or in addition to Xrays. That lets you look at the discs a little differently, you can see effusion on the joints, you can look at the quality of the nuchal and supraspinous ligaments, but ultrasound also can image arthritis and kissing spines. A good field machine is the same as one they’d use in the clinic. A good radiologist would be able to read both.

What we did with my horse was we suspected a neck thing, farm vet got some help from the university in taking some xrays (this farm vet is more proficient at them now), we saw some iffy things (hello obvious OCD fragment), and then we hauled to the clinic for the full workup where they took high powered Xray of the whole spine and did some ultrasound. The neurology specialist wanted the higher powered images to take detailed measurements. The referral sports med vet preferred to look at the ultrasound (and we also did find some stuff going on in the nuchal ligament). I also wanted a full neuro exam, and the neuro expert did not do farm calls.

[beowulf]

haul to a clinic if you can.

my vet is one of the best sports/lameness vets in the NE (area 1/region 9) and is familiar with reading neck rads, but he had a hard time getting a clear view of my gelding when it was done in the field as well.

that is a litany of discomfort on a 5 year old… this is not the DSLD horse, is it? or am i thinking of a different poster? jingles for answers!

[Peggy]

I’ve had them done in the field and at the clinic. The clinic might actually be cheaper. The one done at the clinic was after scintigraphy and MRI and he was already there. The other one had the scintigraphy done at a facility that only did that (the one st Santa Anita) so the radiographs had to be done at home.

Had follow up rads done on both in the field. Vet was very capable. Typically she’d look at them on her laptop screen, but wait until she was back at home with a big screen to to the measurements to get the ratios. She also sent at least one set to Norm Rantannen (sp?) for consultation.

[Texarkana]

With most vets’ equipment, you are wasting your money trying to shoot them on the farm. You’re better off hauling to a clinic with high powered equipment on a boom.

[ryansgirl]

Haul to a clinic/hospital like others have said. I didn’t waste time having a vet out for my mare. Xrays were done of her back (& all legs) and that’s how we saw her issue…Kissing Spines. It was nice knowing I had a whole team of vets (including the owner of the hospital overseeing everything) working on my mare. I also brought my old gelding in when he had sudden onset Neuro conditions - we xray’d his neck which just showed typical arthritis to see if that was causing his neuro mess.

Thankfully my equine hospital is about 12 miles away (and two others within an hour) so it’s an easy decision.

[Toblersmom]

There are some significant technical limitations to trying to do xrays on any kind of thick part with portable equipment that would be used in an ambulatory vet setting (as opposed to some “bedside” portable equipment that might be used in a human or veterinary hospital). They can’t produce photons energetic enough to penetrate adequately to produce a great image, and you can’t really use some of the devices (specifically, a “focused grid”) that decrease the scatter radiation that comes off of big parts that make the image foggy. Field rads on spine are kinda-sorta OK in situations where you think there’s likely to be a badly displaced fracture in the front part of the neck or something, or in the loin area in a quite lean/small horse or pony, or to screen for “kissing spines” that are very superficial. But anything deeper than that is likely to be a waste of time and radiation exposure. When I used to be more involved in such things, the nebulous multi-limb problem patients would often get a nuclear bone scan, followed by additional imaging of any regions of concern identified, using a track-mount high-power x-ray generator system if it turned out the spine was suspected to be an issue.

[joiedevie99]

Short answer: it depends on the quality of the vet’s machine.

Between PPEs and my own horses, I’ve probably done 15 sets now. (ugh…) Anyway, almost all of those were done in the field. I had one set done in the clinic while my mare was in for a scope. My vet’s mobile x-rays are nearly as good as the ones done at the clinic (same practice). We’ve had local vets shoot some for PPEs, and gotten a wide range in terms of quality.

[tarynls]

Personally, I’d take the horse to a clinic (around here, that usually ends up being less expensive). The quality of rads will be better, and if you find something that could benefit from injections, that can be done right there as well (as opposed to your vet potentially needing to come back with the ultrasound machine to inject).

However, I would ask yourself - if you find something on neck/back X-rays, is it going to change your treatment? Are you willing to inject? What if you find fairly severe kissing spines and the vet recommends the ligament snipping surgery (or something similar)?

If the test results aren’t going to change your treatment or management plan, then I’d say to save your $$$. Certainly the collateral & suspensory pathologies are enough to cause the ongoing lameness and I’m guessing that’s why no vet has broached the subject of checking the neck/back.

[Libby2563]

Thank you all, much food for thought! I will hold off on it for now. I do realize he has enough pathology going on to explain the lameness. I just started wondering if there is anything higher up causing the pathology, like in one of Peggy’s horses.

Beowulf, yes this is the possible DSLD horse. At this point whether he has DSLD or not is a total crap shoot as I have gotten widely divergent opinions from a number of very good vets. If I knew he had it for sure, things would be a little simpler to be honest. At least I would know what I’m dealing with.

[IPEsq]

@Libby2563

Thank you all, much food for thought! I will hold off on it for now. I do realize he has enough pathology going on to explain the lameness. I just started wondering if there is anything higher up causing the pathology, like in one of Peggy’s horses.

This is a very reasonable road to go down. If there are significant findings somewhere in the neck, for example, does it make sense to keep chasing all of the issues in the limbs? Is it likely there will continue to be problems in the limbs that are injuries and issues resulting from the other problems?

In some cases, injecting problem areas in the spine can resolve the gait abnormality or lameness and improve their way of going.

Based on everything you’ve done so far, these images are relatively inexpensive in comparison and at the end of it, at least you will have some useful information, even if that information is that the neck is NOT likely to be causing any of the other problems–of course there are dynamic movement issues that we can’t judge, but if the goal is to look for obvious explanations, this is not so bad.

After all I’ve been through I am including spine rads in my PPE requirements going forward, unless of course the PPE is aborted due to a deal breaker issue found before we get to imaging.

[Libby2563]

@IPEsq

This is a very reasonable road to go down. If there are significant findings somewhere in the neck, for example, does it make sense to keep chasing all of the issues in the limbs? Is it likely there will continue to be problems in the limbs that are injuries and issues resulting from the other problems?

In some cases, injecting problem areas in the spine can resolve the gait abnormality or lameness and improve their way of going.

Based on everything you’ve done so far, these images are relatively inexpensive in comparison and at the end of it, at least you will have some useful information, even if that information is that the neck is NOT likely to be causing any of the other problems–of course there are dynamic movement issues that we can’t judge, but if the goal is to look for obvious explanations, this is not so bad.

That is my thinking in considering it. Although, I am a little reluctant to go ask for spine imaging because I read about it on the internet! :lol: I’m sure vets love that! (Actually, that’s how I ended up in the DSLD mess…I read about it and it seemed to match some of his symptoms so I asked a couple vets if they thought it was a possibility. One said he wouldn’t worry about it but one suggested the nuchal ligament biopsy, so I did that and got a very confusing, stressful, and ultimately uninformative result.)

Does anyone know a vet in the MD/northern VA/southern PA region who has expertise with this? Marion duPont Scott is the closest clinic to me. I want to make sure that if I do explore this it’s with someone well versed in it.

@IPEsq

After all I’ve been through I am including spine rads in my PPE requirements going forward, unless of course the PPE is aborted due to a deal breaker issue found before we get to imaging.

So, out of curiosity, does that mean you will haul horses to a clinic for PPEs (since you and almost everyone else recommended that) or will you do field x-rays and hope they’re at least “good enough” or “better than nothing”?

[Lieslot]

Some vet clinics on the east coast now even have standing sedation robotic CT-scans available for neck X-rays, depends where you are located, but I agree that X-rays taken in the field in all likelihood will be money spent on lesser quality shots.

So sorry to read about your horse, kudos for your determination to help this boy.

[IPEsq]

@Libby2563

So, out of curiosity, does that mean you will haul horses to a clinic for PPEs (since you and almost everyone else recommended that) or will you do field x-rays and hope they’re at least “good enough” or “better than nothing”?

No, I don’t think I’d go that far unless it was a reasonably accessible option with seller approval. I would tend to pick a vet with good lameness evaluation experience and good field equipment. There is a lot that you can see reasonably well, that I am ok with leaving some risk in some of the harder to image areas. I mean, I’m also not likely to do a rectal ultrasound to look at the SI area on a PPE either.

If the vet knows what they are doing and has good equipment, you can see a good amount in the field. I think if I had some question, I’d investigate further with ultrasound of the spine, again using a vet with good lameness diagnostic ability preferably. I’ve looked at enough of these Xrays by now that I can tell at least for the neck when a shot is too oblique to be very useful.

I would also most likely send the images to my vets at the university for second opinion and review of the whole PPE, mostly because we have a good working relationship and because they’d be the ones having to help with the care of the horse in the future. At the same time, how thorough of a review I request could vary. For example, in one place I’m looking at some horses, I asked my vets for a recommendation for a local practice in case there’s one I want to pursue. They recommended a practice for a vet who is renowned for diagnostic ultrasound imaging. If I got that vet, for example, I might just say, hey can you ultrasound the neck vs taking Xrays, or at least have that discussion. For my horse’s checkups, we evaluate how his issues are doing via ultrasound. Cost for the area depends on how the practice breaks up the billing, but I’ve found it often to be cheaper than taking tens of more Xrays.

[Libby2563]

So, another question: how equivocal can neck x-rays be? Or will it be fairly clear whether there is an issue significant enough to be contributing to lameness? It seems like nothing in medicine (human or veterinary!) is totally black and white, and I’m a little worried about another debacle like the nuchal ligament test…where I got an equivocal result and lots of varying veterinary opinions on what it meant, so ultimately it ended up meaning almost nothing, practically speaking (but costing money and lots of stress).

I just scheduled x-rays (at a clinic we’ve been to before). The vet was puzzled, like where did you get the idea he has that? I can’t very well say “the internet,” right? Ugh.

[IPEsq]

LOL well I have mentioned here on one of these threads that we know from human medicine that as far as necks go, the images do not necessarily correlate with the degree of pain. A bunch of radiologists were given MRI results for various human patients with neck issues and asked to grade the patient’s pain/quality of life based on the images. Basically, they could not predict the level of pain or nerve issues from images alone in that some with pretty bad MRIs didn’t necessarily have a lot of problems but some had less severe findings but significant pain issues based on patient feedback.

THAT SAID, I think that if you have symptoms that suggest a neck problem and you find pathology in the neck, it’s reasonable to conclude that the neck is a problem for that horse. Same as if you have kissing spines. Sure, there are horses with kissing spines that don’t appear to be limited by the problem, but that horse’s clinical exam is going to be different from the one that acts like he has a spinal problem.

From personal experience, a neck issue does not necessarily show up as pain on moving the neck, putting the horse on contact, carrot stretches, etc. It can, but my horse for example doesn’t exhibit pain behaviors on these parts of the exam. He might prefer to cheat for the stretch or have reduced ROM, but he doesn’t make any “ow” type response. His Xrays also don’t look all that bad, but there were enough performance, lameness, and behavioral issues adding up to conclude that the neck is a problem for him. Ultrasound confirmed joint effusion and inflammation which supported this.

In contrast, client’s horse had bad findings on Xray most of which had probably been there for quite some time with no noticeable problems. Except he was always a little clumsy, stiff, etc. Then deteriorated to moving lameness that wouldn’t clearly block. Personality change and other behavioral and performance problems. Then some neurological deficits. So, neck has always probably been somewhat of a problem but initially mostly sub-clinical. Until it wasn’t. But we didn’t have 5 or 10 year old Xrays to compare.

At the end of the day, if you do find something, you can decide whether it’s worth trying to treat it. If you treat, you can then see if that has any effect on the lameness. If it doesn’t, that doesn’t necessarily mean it’s not a neck problem. If the X-rays are clean, it’s less likely to be a neck problem (at least in the parts we can see). Might help you make some decisions and overall, it’s less expensive than bone scans and MRIs.

[Write_amp_Ride]

I’m going to put in my two cents worth. My horse had collateral ligament injury 2 yrs ago, which he recovered from. But he continued to have off and off lameness this past year. I had coffin joints injected after 2 vets thought that was the issue. Very soon after he was ataxic and deteriorated quickly. The neck xrays then myelogram gave a definitive and devastating diagnosis. The xrays were enough but the myelogram was unequivocal - the horse was unrideable and couldn’t be made pasture sound. I’m surprised your vet wouldn’t agree that this is an area to explore. Do the xrays- perhaps you can rule out the neck. You’ll get good information regardless. The internet, at least on COTH is a valuable source of knowledge.

[andawaywego]

We did X-rays at New Bolton, not sure if that’s close to you, but they were great. There was a minor finding but at the time, there were other things going on that they thought were causing the lameness so it was not treated. Fast forward 5 months and he was back at our vet clinic for a neck injection when the other injections did not seem to completely solve the problem. All along the horse didn’t block 100% sound at any point all the way up his leg, so that paired with a small hot spot on his bone scan shed some light. His symptoms were not what you would classically think of, had no problem with his neck movement at all, but he had an intermittent front end lameness (1.5-2/5) that he would generally work out of. Once we injected him, he came totally sound and has stayed that way for almost a year. Good luck and update us on what happens!

[2tempe]

I had xrays done on my gelding’s neck at our barn by a mobile vet with pretty fancy equipment. He had not been lame, but some ataxia, unable to hold leads at canter. Ruled out EPM, films showed issues in three areas. Utrasound guided injections helped him enormously for almost two years. Symptoms gradually returned, first under saddle and then later even in the field. Did not do another round given his advanced age and some other health issues

[Libby2563]

@Write&Ride

I’m going to put in my two cents worth. My horse had collateral ligament injury 2 yrs ago, which he recovered from. But he continued to have off and off lameness this past year. I had coffin joints injected after 2 vets thought that was the issue. Very soon after he was ataxic and deteriorated quickly. The neck xrays then myelogram gave a definitive and devastating diagnosis. The xrays were enough but the myelogram was unequivocal - the horse was unrideable and couldn’t be made pasture sound. I’m surprised your vet wouldn’t agree that this is an area to explore. Do the xrays- perhaps you can rule out the neck. You’ll get good information regardless. The internet, at least on COTH is a valuable source of knowledge.

I’m so sorry to hear about your horse! That’s terrible. My guy has also had his coffin joint injected twice already. Based on COTH anecdotes it seems like there is a connection between CA and collateral ligaments (yours, @Peggy’s, and probably some others I can’t remember off the top of my head, but I’m thinking of compiling a list).