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Figure 5. Bone scan images showing ‘hot’ DSPs (arrows) Image courtesy of Jessica Kidd MRCVS


Treatment options: Fortunately there are several treatment options available to treat horses who suffer from pain relating to kissing spines, and things have come a long way since the classic invasive surgery under general anaesthetic which involved sawing off every other DSP! We would usually try medical management first and then only if this is not successful or the effects wear off quickly, progress onto surgery. The most important thing is that there is no ‘quick fix’ for kissing spines – for any of the treatment options, the critical thing is appropriate rehabilitation aſterwards. Any treatment option will most likely fail without it!


1) Medical treatment: This involves injection of a corticosteroid between the affected DSPs with the aim of reducing inflammation and pain in the area. Greatest effects are felt a couple of weeks aſter medication and attention needs to be paid to withdrawal times in competition horses. In cases where there are financial constrictions and strong suspicion of back pain, I will oſten mix the initial local anaesthetic with steroid (‘medi-blocking’) to reduce the need and cost of a second injection if the horse responds well to blocking. In cases where there is marked muscle spasm or guarding either side of the affected area I will work together with a physiotherapist, oſten proceeding their treatments with ESWT (Shockwave Therapy) of the DSPs and surrounding muscles. Shockwave therapy can be an effective pain killer for the DSPs and also helps to release muscle spasm, thereby allowing the physiotherapist to work more effectively.


2) Surgical treatment I. ISLD (Interspinous ligament desmotomy) This is a relatively non-invasive procedure we perform under standing sedation in our clinic stocks at Hook Norton. The affected area is blocked with local anaesthetic before the ligaments between the affected DSPs are cut. This is not suitable for cases of over riding DSPS as it can only be performed in cases in which a small space still exists between the affected DSPs. It can be a very effective surgery that is thought to function as a form of neurectomy and cause a permanent desensitisation between the affected DSPs. It is not suitable for every case.


II. Wedge ostectomy In this slightly more invasive procedure, part of each DSP in the affected area is removed; creating a gap between adjacent DSPs. A wedge ostectomy can be carried out aſter an ISLD if the ISLD is not effective


Figure 7 . Repeat radiographs aſter wedge ostectomy. Radiographs courtesy of Jessica Kidd MRCVS


Why do some horses show clinical symptoms and not others? In the radiographs shown previously, figure 3 is taken from a high level dressage horse that is showing no clinical symptoms at all. She is sound, working well and her back palpates completely normally. The radiographs were taken at a vetting and did not stop me from ‘passing’ the horse. Because there is such poor correlation between radiographic findings and pain, FEEVA (The Federation of European Equine Veterinary Surgeons) recently published an official statement saying that ‘There is no evidence of correlation between radiographic appearance of the DSPs of the back and future risk of disease in asymptomatic horses…FEEVA does not recommend that such radiography is included in the standard pre purchase radiographic protocol.’


I had no concern in recommending the horse in figure 3 for purchase and she continues to perform well several years later.


The horse from figure 4 appears a more obvious candidate for back pain. However, he was asymptomatic for several years before developing a hind limb lameness and secondary back pain. What happened in this instance was that the hind limb pain caused the horse to stop pushing from behind and instead ‘drag’ himself along with his front legs with his head and neck up. This inverted (‘hollow’) way of moving, combined with the asymmetry of his gait due to the lameness, caused the DSPs to rub together harder and in a different way from previously, and the back became acutely painful. The key to treating this horse was to diagnose and treat the hindlimb lameness in the first instance. His back was then blocked, and medicated following a positive response. He also underwent a course of shockwave and physiotherapy. In the years since then, his hindlimb lameness has been monitored closely and by being proactive in treating this, we have not had to re-medicate his back and he continues to do well.


This highlights an important point – in my experience primary pain from kissing spines is relatively uncommon, and more oſten than not there is another primary condition which has resulted in a change in the way of moving and secondary back pain. With a horse that come in to us with ‘back pain’ as the presenting problem it is always important to look at the whole horse – not just the back!


Take home messages: 1) Many horses with ‘kissing spines’ on x-ray do not actually suffer any pain from them. 2) It is crucial to confirm the diagnosis by blocking. 3) Rehabilitation is a crucial part of any treatment. 4) Pain related to kissing spines oſten develops secondary to another condition; most commonly a hind limb lameness.


Figure 6. Radiographs before surgery. ’ Radiographs courtesy of Jessica Kidd MRCVS


As previously mentioned, rehabilitation is critical to all of these treatment options. Aſter surgery, this would typically consist of: • 1. Two weeks box rest till skin staples removed • 2. Two weeks ascending walking exercise • 3. Two weeks lunging (+/- Pessoa) • (4. Six weeks turnout) • Check saddle fit before ridden work resumes with a suitably qualified saddle fitter


• Regular physiotherapy


Sam is one of a very small handful of Equine Vets ever to have competed at CCI**** level and is thus uniquely placed to understand competition horses and help them to perform at their very best. She has a keen interest in lameness and poor performance, as well as being a key member of our stud and reproduction team. Sam is also an FEI Permitted Treating Veterinarian, Racecourse Veterinary Surgeon working as part of the team at Stratford Races and heads up the HNVS International Export Department.


Please mention Central Horse News What’s On when responding to advertisements THE WINTER SPECIAL 2019 25


ABOUT THE AUTHOR Sam Cutts MA, Vet MB, MRCVS Hook Norton Veterinary Surgeons www.hooknortonvets.co.uk


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