Neck pain is often suspected as an underlying cause of lameness and poor performance. The American Association of Equine Practitioners (AAEP) hosted a Table Topic session on the clinical importance of neck pain during its 2022 Convention held Nov. 18-22 in San Antonio, Texas. Cooper Williams, VMD, Dipl. ACVSMR, of Equine Sports Medicine of Maryland, in Hampstead, and Melinda Story, DVM, PhD, Dipl. ACVS-LA, ACVSMR, assistant professor of clinical sciences at Colorado State University’s Translational Medicine Institute, in Fort Collins, moderated.

To begin the conversation, attendees first asked the moderators, “What are clues we should be looking at the neck?”

Williams and Story agreed that even if a horse has obvious neck pain or the owner/trainer is insisting the horse has neck pain, veterinarians must insist on a whole-horse exam.

“I really take my time and go through all the steps, going through the whole horse, palpating, manipulating, and mobilizing the neck, back, pelvis, and all four limbs,” said Williams.

“To successfully evaluate a horse with neck pain, you need to perform full physical, neurologic, lameness, and myofascial examination,” added Story.

After the exam, session attendees were particularly interested in how to image the neck.

Radiographing the Neck

Story said radiographs (X rays) are often indicated as part of the work-up for a horse with a suspected neck issue. She did warn attendees, however, not to expect an obvious answer for every radiographic exam.

“You must be aware that many times the radiographs will be normal,” she said. “But all that means is those particular X rays were normal, it doesn’t mean that the neck isn’t the source of pain and dysfunction.”

She did warn attendees, however, that nondiagnostic neck radiographs can be very misleading, stating, “Poor-quality radiographs or an incomplete study does not really add any value to the examination.”

“You need good alignment for laterolateral radiographs so the articular process joints are superimposed on one another,” she continued. “If laterolaterals are unintentionally obliqued, the foramen (the opening between vertebrae) may appear small and be mistaken as pathologic (causing disease or dysfunction).”

In some cases, however, oblique views might be exactly what you want to take.

“Oblique views are very helpful because laterolateral views superimpose information from right and left sides,” said Williams. “Oblique views are helpful in isolating asymmetric information, but you need to practice these views to get diagnostic quality images.”

Story added, “A common error for beginners is that they’re not obliqued enough or labeled incorrectly. Make sure you use your markers! It can be hard to understand exactly where you are in the neck, especially if there is transposition.”

Story and Williams recommended a neutral neck position for lateral radiographs. Sometimes, however, additional imaging in flexion or extension can elucidate abnormalities that these positions might potentially have on positionally induced impingements and malalignments.

Regardless of which views practitioners elect to use, Story and Williams said, “Consistency is key.”

Further, Story recommended wording of the report very carefully. She suggested writing, “No abnormalities were noted on the neck radiographs,” rather than, “Neck radiographs were normal.”

Ultrasounding the Neck

Williams said ultrasound is one of the most important tools available for imaging the neck, because it allows you to evaluate soft tissues. It is also the most sensitive tool for bone surface detail.

“When imaging any area like the neck or back, think in terms of a sonographic survey, imaging all structures in a methodical fashion bilaterally (on both sides),” he said. “The practitioner should always start with the poll and even include the cervicothoracobrachial region where the neck transitions into the thoracic region.”

Treatments for Neck Pain

Once she’s localized the pain to the neck, Story said she commonly reaches for acupuncture first.

“Shockwave therapy is also a valid option, but frequently second tier,” she said. “Mesotherapy (injecting pharmaceuticals into the middle layer of the skin- the mesoderm- on either side of the spine to block sensory-pain fibers) may also be beneficial.”

Veterinarians also commonly perform ultrasound-guided injections of the articular process joints as well as perineural injections with corticosteroids or orthobiologics.

“But there are a lot of physical therapy tools available to ‘manage’ and augment our other procedures,” Williams reminded the audience.

“Strength is a big part of treating neck pain, but if they’re not comfortable it’s hard to do the exercises,” he said. “Practitioners need to get the pain under control to break the pain cycle.”

He suggested using a TENS unit, which uses a low-voltage electrical current to manage pain.

Take-Home Considerations

Near the end of the discussion, one audience member reminded participants not to over-diagnose and make everything a neck issue.

Story agreed, adding, “When I say a horse has a neck problem, I don’t necessarily mean he has disc disease or articular process joint arthritis. I may simply mean he has fascial (connective tissue) pain. The pain could even be due to a vaccine they got yesterday. Localizing the pain and dysfunction to the cervical region is simply a place to start, to then try and narrow down what tissues may be involved and then how to treat it. Even if there is something wrong with the neck, it doesn’t mean there is terrible pathology and the horse needs retiring or injections. Again, a full physical exam—a whole horse exam—is necessary.”

“It is important to use a whole-horse approach to know the “baseline” condition of our patients, make diagnoses, know how those diagnoses interplay, know how to best approach both treatment and management of these conditions, and be able to monitor how these conditions evolve or devolve,” Cooper said.