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Medical Treatment Options
When diagnostic imaging has shown Kissing Spines and both a physical and motion evaluation have confirmed clinical signs, a first step in the treatment process will often include certain medical modalities prior to exploring a surgical option for more severe cases. “The key to all back treatment, no matter what the problem is, is to break the pain spasm cycle,” says Dr. Williams of the first place he goes in a horse’s treatment for Kissing Spines when they’re presenting with clinical signs. “It’s very often about that surrounding musculature where that pain goes into a spasm. Once that starts, it’s hard to deal with.” Dr. Allen agrees and has a four-step protocol for treating Kissing Spines patients for long-term results. “We have to provide pain relief that’s going to last months,” he says of his goal. “First, as Dr. Williams mentioned, our priority is to break the pain cycle using tools like Shockwave, which is a very intense soundwave beam that hits and immediately down-regulates those pain receptors. We’ll do one to three Shockwave treatments depending on the degree of the problem and the results we see. In some cases, where it’s warranted, we’ll combine Shockwave with Mesotherapy, since we find the two to have a bit of a synergistic effect.” Mesotherapy is a pain suppression technique that can be very effective in the neck and back. “In the case of a horse with arthritis on the bottom of the joint, for instance, we may have a more difficult time penetrating with Shockwave but experience more success with Mesotherapy,” explains Dr. Allen of the protocol.
“Step two will be to develop a plan to start bringing the horse back,” continues Dr. Allen. “This is very similar to human medicine where physicians diagnose, break the pain spasm cycle, and immediately develop a physical therapy plan.” While resting horses can contribute to pain reduction, further rest beyond a stage of approximately 30 days can be a significant detriment due to the loss of musculature that results from inactivity as well as the added weight accumulated by horses turned out on pasture for several months. “You’ve effectively made the problem worse for yourself when you go to bring that horse back,” says Dr. Allen emphatically. “Prescribing rest, especially stall rest, in these cases should be one of the last things we do as clinicians. If at all possible, I try to return the horse to work within the first 30 days.”
As a third step, Dr. Allen and his team turn to joint injections for both Kissing Spines and arthritis of the dorsal articular facet. “We guide the injection via ultrasound right down on top of the joint, then back up a couple of millimeters. We bathe the medication on the top of that joint to relieve inflammation. We do this because the joint is very small and difficult to get into.” While he and his team at Virginia Equine Imaging used cortisone for many years, they have now evolved to using primarily PRP (Platelet Rich Plasma) and sometimes alpha-2-Macroglobulin. “We’re seeing good results with these treatments not only having an anti-inflammatory effect for a period of time, but they actually tighten the joint as well, creating longer-term relief.”
Last in the four-step protocol would be the use of bisphosphonates on select cases for an anti-inflammatory effect in the bone at the cellular level. With much controversy surrounding the use of bisphosphonates, or rather the over-use of the drug class in young horses, veterinarians are increasingly quick to advocate for judicious use. “We have had excellent success with bisphosphonates in back cases,” Dr. Allen states. “The whole bisphosphonate argument is really out there right now, which I think is a good conversation to have in veterinary medicine,” adds Dr. Williams. “They’ve been abused, and people are giving them too frequently, though with some Kissing Spines cases, we have administered either Osphos® or Tildren® to help extend time in between treatments with direct injection.”
For non-surgical cases, these four modalities have become a time-tested protocol for Dr. Allen and his team, often providing months or years of relief for Kissing Spines cases. “For some clients surgery is never going to be an option,” says Dr. Honnas of the importance of sound medical options. “I only want to operate on the cases where I truly believe in my heart that Kissing Spines is the problem and surgery will provide a long-term solution.”
“I use acupuncture along with strengthening and mobilization to keep these horses comfortable and as part of a global approach using nutrition, integrative pain management and strengthening.” –Melinda Story, DVM, DACVS, DACVSMR, cVMA, CIVCA, Colorado State University
Equine acupuncture can not only be a first-line therapy but also part of a long-term management plan.
A Surgical Approach
While many cases can be treated medically with varying degrees of success — some minimal and some exceptional — surgical intervention can yield tremendous results for Kissing Spines cases. “There are two different types of surgeries,” explains Dr. Honnas. “The first is to do what’s called a minimally invasive interspinous ligament desmotomy.” In this procedure surgeons cut the ligaments that span the distance between the two dorsal spinous processes at each impinging space. The procedure is typically radiographically guided with two different ways of being performed. “One technique is to make an incision beside the backbone, a bit toward one side, then tunnel through the musculature and cut the ligament between the two impinging bones,” explains Dr. Honnas. “If there are multiple spaces, then the surgeon will drop back a bit, do the next one, then the next one and so on.” The other approach is to cut directly over the backbone by making a small stab incision, then tunnel down to the ligament between the bones and cut it. The interspinous ligament desmotomy is a surgery that Dr. Honnas does not perform but is quite familiar with. “My concern with this surgery is that there’s a ligament that spans between the bones in question. When you cut that ligament, all you’re doing is cutting the soft tissue, basically performing a neurectomy, so the horse can’t feel the pain where those bones are grinding,” he says. For the surgeon to successfully cut the ligament, the bones must have adequate space between them. “This surgery can have a place if there’s enough space between those bones where the surgeon can actually cut that ligament, but very often there’s just no space there to work with. You can’t physically get between the bones to cut anything.” Another consideration when evaluating the appropriateness of this surgical option is identifying the severity of the case. The more the bones touch or override, the greater the likelihood that the ligaments have sustained considerable damage. “The interspinous ligaments actually degenerate,” explains Dr. Williams of these cases. “In some horses, you wouldn’t even recognize these ligaments anymore because they’ve had so much trauma from this constant contact in that area.”
The second surgical option considered for Kissing Spines patients is a bone reduction procedure. Dr. Honnas is recognized as one of the foremost experts in the country at performing this procedure and garnering impressive long-term results for Kissing Spines patients.
“The bone reduction surgery that I do removes bone at each impinging space, then recreates a space between those adjacent bones,” says Dr. Honnas of the surgical method. While some practitioners prefer to perform this procedure on the standing horse, Dr. Honnas’ preference is to operate on these cases under general anesthesia laying left-side down. A primary reason for this preference is that the position of the horse alleviates the weight of the gut, so it no longer pulls the dorsal spinous processes closer together. “I pull them to the edge of the table, make an incision right on the midline and cut through the skin. I then cut through the dorsal spinous ligament (the ligament over the top of the backbone) and cut away the muscles on either side of the dorsal spinous processes,” he explains of his technique technique. “There’s no way to take away that bone without removing the ligament. Next, I cut the interspinous ligament that’s between each dorsal spinous process, then using my right hand with a pair of bone-cutting forceps, I cut away on the bone that’s behind each impinging space. I cut a piece, and I feel with my left index finger. I’m removing the interspinous ligament and the front edge of the backbone at each impending space.” It’s a gradual process where Dr. Honnas cuts, feels, cuts, feels, and so on, being sure to trim up any rough edges on the bone as he goes. “When finished, I can get my index finger between the bones all the way down to where the space opens up again. Usually, they’re going to be pretty tight for about 1.5 to 2 inches, then open up naturally below that,” he says of the anatomy of the back following surgery.
In cases that have multiple impingements, Dr. Honnas drops back and repeats the process at each impingement. “I typically will operate three to four spaces through one incision before I drop back and make a second incision, leaving a space between the two, so I don’t have one long incision.” A recent case at Texas Equine had a total of nine impingements, requiring three separate incisions that Dr. Honnas spaced three quarters to one-inch apart.
The number of bone reduction procedures that Dr. Honnas performs has risen dramatically in conjunction with improved diagnostics and veterinary familiarity of Kissing Spines. Performing roughly 145 of these procedures in the last year on horses from every corner of the country, Dr. Honnas and his team are known for their exceptional track record. “I tell my clients, if this is a confirmed case of Kissing Spines, then this surgery will fix your horse,” he says with confidence. He and his team have achieved a 90 percent success rate, allowing patients to go on to live and compete free of the pain they once endured as a result of Kissing Spines.
by Jessie Bengoa,
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