Make sense of the challenges surrounding neck pain in horses

“A pain in the neck” is a saying for a reason. Neck issues can derail your day in a hurry and are just as painful for your horse. Cervical pain and deficits in horses can be confusing, difficult to pinpoint, and even the end of a sport horse career.

But don’t despair if you are dealing with equine neck pain. We’re here to help make sense of the challenges surrounding it. Sue Dyson, MA, Vet MB, PhD, DEO, Dipl. ECVSMR, FRCVS, an independent consultant and former head of Clinical Orthopaedics at the Animal Health Trust Centre for Equine Studies, in Newmarket, U.K., and José M. García-López, VMD, BS, Dipl. ACVS, ACVSMR, associate professor of large animal surgery and director of equine sports medicine at the University of Pennsylvania’s New Bolton Center, in Kennett Square, explain what you need to know.

Neck Problems Aren’t New, Just Tricky

With equine veterinarians diagnosing more neck problems than they used to, it might seem that these issues are increasingly common. The more likely explanation, however, is advancements in research and technology are making it easier to diagnose issues that have always been present.

“I think we are becoming more accustomed to looking at areas like the poll and cervical vertebrae, which make up the neck region, and have a better understanding of how they can influence a horse’s level of soundness,” García-López says. “With the great improvements and increased accessibility to advanced imaging modalities such as nuclear scintigraphy and computed tomography (CT), we have been able to look at this region beyond what historically was the norm, which was plain radiographs and ultrasound.”

Still, neck issues can be challenging to definitively identify. They don’t discriminate; they can plague all ages and breeds of horses. Potential causes—“genetic, conformational, level of use, how the neck is carried during exercise, adequate muscle development or lack thereof, external trauma, and such,” García-López says—and clinical signs can be all over the board. In fact, some clinical signs that might scream “neck problem” to a horse owner are rooted in a completely different part of the body. That’s why he and Dyson agree that a whole-horse exam is key.

“One of the big misconceptions is that there are ‘classic’ signs that tell you that you have neck issues,” he says. “We always, as part of our examination for any lameness, should look carefully at the conformation of the neck region—just as we do when looking at the limbs—(the) level of muscle development and how the horse likes to carry his or her head during rest, low-rein-contact exercise, and moderate or high degree of neck flexion and contact with the bit. In addition, doing range-of-motion tests—both lateral to medial (side to side) and in dorsi- and ventroflexion (up and down)—is ­important.”

But our sources agree we need to interpret results with caution. “Some horses will turn very easily both to the left and to the right, and other horses turn less easily to the left and to the right,” Dyson says. “Assuming that’s symmetrical, I think we need to be careful not to overinterpret the significance of that. … If there is a marked difference in range of motion to the left and to the right, then I would think that’s far more significant than the horse which has a similar range of motion to the left and to the right, unless the horse obviously shows signs of discomfort turning both to the left and to the right.”

Once the veterinarian has completed a physical exam, he or she might turn to other methods of localizing lameness (such as nerve blocks) and, later, imaging to help confirm a suspected issue or identify something still hidden beneath the surface.

Imaging Advancements

Today’s imaging modalities are far better than those of the past, which makes identifying potential problems significantly easier.

Dyson says advancements in X ray technology allow veterinarians to image further back in the neck—even to the first and second thoracic vertebrae. And ultrasonography, she says, can be used in conjunction with X rays to evaluate related issues, such as the amount of fluid in a joint capsule. Of course, she adds, veterinarians must master the art of collecting easy-to-read diagnostic-quality images, which are key to an accurate diagnosis.

Three-dimensional imaging technologies such as CT and contrast-enhanced CT are helping veterinarians identify degenerative conditions that could result in nerve root compression and create pain and/or lameness, García-López says.

Dyson agrees, noting it’s a work in progress: “I think (CT is) unquestionably advancing our knowledge of things that we couldn’t detect at all on X ray or we didn’t quite know where they were, but we also find things we don’t know quite how to interpret. … We still are not good at being able to definitively diagnose nerve root compression using CT, although we can better visualize narrowing of the space through which the nerves have to pass from the spinal cord out to the periphery. I think we’ve still got a lot to learn about CT.”

Nuclear scintigraphy—bone scan—can also help veterinarians identify potential problem areas, but Dyson urges caution in interpreting results. For example, “some articular process joints which have some degree of arthritic change, but are asymptomatic, will have an increased rate of radiopharmaceutical uptake, or a ‘hot spot.’ That can be absolutely normal, but time and time again gets overinterpreted as being of clinical significance.”

Common Conditions

Dyson and García-López weighed in on some of the most common primary neck issues veterinarians encounter:

Neck joint issues As with any joint, osteoarthritis of the vertebrae can cause primary neck pain. Dyson cautions that osteoarthritis of the caudal cervical articular process joints (those located closer to the horse’s back than his skull) is very common and, in many horses, an incidental finding rather than a significant cause of neck pain. However, she says, “in a minority of horses it is of significance and would be one of the more common primary problems.”

García-López adds that dorsal facet osteoarthritis—degeneration of the upper part of the cervical vertebral joints—can also cause compression or pressure on nerve roots, which can have painful implications and a poor prognosis.

One positive? Dyson says there’s a sign that nearly always points to nerve root compression. “There’s something called root posture,” she says. “So that’s when the horse stands with one of the forelimbs semiflexed, knuckling over on the fetlock. That is almost always a reflection of nerve root pain in the neck region. The horse may have been working normally and suddenly it pulls up very lame on one leg and starts knuckling over like that. That tells you there’s probably nothing else it can be other than nerve root ­compression.”

Wobbler syndrome Stenotic myelopathy, often referred to as wobbler syndrome, is ataxia (incoordination) caused by spinal cord compression—another common neck issue horses of all breeds and ages can face. Owners typically notice their horse is “moving in a rather odd way,” Dyson says, symmetrically, generally, with the hind limbs more noticeably affected and signs more obvious at slower speeds. This can be caused by vertebral malformation, malalignment, or trauma.

Surgical correction can help some horses return to soundness; however, the prognosis depends on the lesions’ severity.

Nuchal bursitis García-López says inflammation of the nuchal bursa (which lies between the nuchal ligament, running along the top of the horse’s neck, and the first cervical vertebrae) is another common issue he sees.

Mild acute cases might benefit from corticosteroid injections, while chronic cases usually need surgical debridement, with variable results, says Dyson.

Traumatic injuries We all know horses are masters of injuring themselves, so it’s little wonder that a horse with no other predisposing factors can sustain a neck injury in an accidental fashion, whether it’s a fall, kick, or another incident.

Treatment and prognosis depend on the injury’s severity and can range from rest and anti-inflammatories to ­euthanasia.

Neck soreness Yes, horses can just have sore neck muscles, especially from working improperly. When this is a primary problem, Dyson says it’s easily treatable with physiotherapy. However, it can also occur secondary to other issues, including limb lamenesses unrelated to the neck, so a full veterinary evaluation is crucial to obtaining an accurate ­diagnosis.

Training-Related Neck Issues

Correlations between neck issues and training or riding problems range from apparent stiffness to a lack of muscling. But they’re not always as straightforward as owners might assume, says Dyson.

“The development of the neck muscles is entirely related to the way in which the horse has been carrying its whole body and how correctly it’s been working,” she says. “And if it’s not been working correctly, then the muscles don’t develop in a correct fashion. Some people will say, ‘Oh my horse isn’t going right,’ or ‘There’s this dip just in front of the withers; it must have a primary neck problem.’ ”

Often, however, such issues are due to a horse not using his head and neck properly due to pain elsewhere or improper training.

“I think that we see increasingly in all sorts of horses, but particularly in dressage horses, that there seems to be a large proportion that are not trained in that correct way and, therefore, don’t develop the appropriate muscles,” Dyson says. “I think, as a result, they’re being predisposed to other musculoskeletal problems such as the development of hind-limb lameness because they’re not carrying themselves properly.”

She says horses need time and proper training to develop their musculoskeletal systems to gain balance and the ability to push properly from behind and establish a properly mobile back and correct head and neck posture.

“I think people are too quick to shorten the neck frame and raise the neck frame, and that blocks the movement through the back and hind end,” she says. “The horse has to be allowed to stretch forward and downward and so the front of the head is slightly in front of a vertical position and the neck is not too high, which can be done through some groundwork but also by the appropriate ridden exercise. The rider has to have a mental picture of what they’re trying to achieve and why.”

Is He Safe to Ride?

Working with and riding perfectly sound horses can be dangerous. So, what about riding a horse with neck problems, which can affect everything from balance to proprioception? Are they safe to ride after appropriate veterinary treatment?

“I think that depends entirely what the underlying clinical problem is,” Dyson says.

García-López agrees. “Lots of horses with conditions such as osteoarthritis and nuchal bursitis—especially when the nuchal bursitis is treated surgically—can be managed and continue being ridden or go back to ­competition.”

He says ultrasound-guided intra-­articular treatment with anti-­inflammatory medications, such as corticosteroids and hyaluronic-acid-like products, or orthobiologics (IRAP, for example) can be highly effective for treating horses with osteoarthritis of the facet joints and returning them to competition.

Dyson adds that some young horses with mild neck lesions and ataxia that aren’t progressive “actually do very well in young horse classes because they’re extravagant, big, and loose movers. But in my experience those horses generally don’t have the necessary strength and coordination to go on to be upper-level athletes. But at lower levels they can still perform satisfactorily and probably reasonably safely.”

Wobbler syndrome can be career-limiting or -ending, García-López says, but “if it’s identified early and addressed effectively by means of surgical intervention (vertebral fusion), they can return to exercise.” He said veterinarians should still discuss with owners the potential risks associated with riding, even if surgical correction is 100% successful.

However, some horses with neck issues are not suitable for riding. “If there is more severe ataxia, that horse is potentially more likely to trip and fall than the normal horse and, therefore, has to be regarded as a potential risk,” Dyson says. (For more on whether neurologic horses are safe to ride, see TheHorse.com/19122/.)

Horses with caudal neck pain associated with episodic stumbling, with or without forelimb lameness, also pose a serious rider safety risk, she adds.

“I don’t think we can successfully manage most of those horses,” she says. “I’ve seen some who are potentially very dangerous horses in that they have, for example, jumped a fence and crashed forward on landing (due to ataxia, not hitting the jump) or in the first nonjumping stride after landing. Those are horrible falls and catapult the rider into the ground.

“I, personally, would not advocate attempting to treat those horses because even if you get temporary resolution, you don’t know when it’s going to happen again,” Dyson says.

Take-Home Message

Thanks to advancements in research, practical knowledge, and scientific technology, veterinarians can diagnose and treat equine neck problems much more readily than in the past. And while these issues can still be challenging to pinpoint, an accurate diagnosis can help get some affected horses on the road to recovery.

Once you’ve identified the issue, you and your veterinarian can establish a treatment plan. Depending on the problem, says García-López, with proper diagnosis and management the prognosis can be very good to excellent.

This article was originally published in June 2021.