Veterinary Vertex
Veterinary Vertex is a weekly podcast that takes you behind the scenes of the clinical and research discoveries published in the Journal of the American Veterinary Medical Association (JAVMA) and the American Journal of Veterinary Research (AJVR). Tune in to learn about cutting-edge veterinary research and gain in-depth insights you won’t find anywhere else. Come away with knowledge you can put to use in your own practice – along with a healthy dose of inspiration to remind you what you love about veterinary medicine.
Veterinary Vertex
Advancing Equine Health Through Neck Pain Research
Curious about the complexities of equine neck pain? In this episode of Veterinary Vertex, we discuss neck pain in horses caused by the transposition of the ventral lamina from C6 to C7. Join us as we speak with Dr. Yvette Nout-Lomas, who delves into her team’s groundbreaking research. You'll uncover how their interest sparked from real-life clinical cases and led to discovering a higher prevalence of neck pain in warmblood horses with TC67, yet surprisingly no significant connection to lameness or neurologic signs. Yvette also shares the limitations of their retrospective study and the critical need for proper diagnosis to enhance the welfare of our equine friends.
In our enlightening discussion, Yvette helps us untangle the often-misunderstood terminology around equine cervical vertebral anatomy, particularly differentiating between morphological variations and malformations. We stress the importance of precise language to better educate both clients and veterinarians. The episode also underscores the necessity for prospective research and well-matched control groups to fully comprehend the health impacts of TC67. Moreover, we delve into the vital role of advanced training and mentorship in propelling equine veterinary research forward. Tune in for a thoughtful exploration of neck pain in horses and its broader implications on their health and behavior.
Open access article: https://doi.org/10.2460/javma.24.04.0230
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You are listening to Veterinary Vertex, a podcast of the AVMA Journals. In this episode we chat about how neck pain, but not neurologic disease, occurs more frequently in horses with transposition of the ventral lamina from C6 to C7, with our guest Yvette Naut-Lomas.
Speaker 2:Welcome to Veterinary Vertex. I'm Editor-in-Chief Lisa Fortier, and I'm joined by Associate Editor Sarah Wright. Today, we have Yvette joining us. I'm super excited about this, yvette. I learned a lot reading your manuscript. Thank you again for being here with us today.
Speaker 3:Thank you, Lisa. Thank you, Sarah, for inviting me to present some additional information and a review of this paper. I'm really excited to be here and hopefully talk about the details.
Speaker 1:All right, let's trot on over. So, Yvette, your JAVMA article discusses neck pain in horses with transposition of the ventral lamina from C6 to C7. Please share with our listeners the background on this study.
Speaker 3:Well, the background is that our group has really developed an interest in neck pain, especially since Mindy Story joined our team here about 10 years ago and worked on her PhD regarding neck pain and finding the cause for this and eventually hopefully leading to improvement in treatments. And then we had Caitlin Henderson here doing an internship. So between Caitlin Mindy and myself we thought this was a good topic to bring up and learn more on.
Speaker 1:What are some of the important take-home messages from this JAPMA article?
Speaker 3:messages from the Shafma article. So one of the important take-home messages is that our results were relatively similar to some of the other studies that have been published regarding this topic, where we found neck pain or the transposition, most commonly in warm bloods. About 60% of our cases were warm bloods and when you look at the warm bloods, about 60% of our cases were warm bloods and when you look at the warm bloods, about 28% of warm bloods are affected with this TC67. And we looked at about 135 horses, of which 27 were these TC67 cases. The real take-homes are that we did not find any evidence to support an increased number of horses that were lame or displayed neurologic signs in this group of horses with TC67. But in a smaller subset of horses that displayed pain, we did see that there seemed to be an increased number of horses within the TC67 group that had pain.
Speaker 2:Yeah, so important for pre-purchases. You know it's almost reminiscent of overriding dorsal spinous processes. You know people go looking and then anything that their horse does, they blame it on the radiographic signs, without any clinical signs.
Speaker 3:Yep correct, and I think it's important for this particular paper to realize that the number of horses with neck pain were relatively small. There were about 16 that were in the group of TC67 horses that were supposed. Actually there were 16 horses in total that were reported to have neck pain and with that come the limitations of this study, which is that it was a retrospective study. So number one were people looking for pain and then number two were they putting it in the record when they were or were not discovering it. So I think that is a big limitation of this study and hopefully further research can further elucidate this. But it is an important aspect, I think, especially now that we're learning more about neck function and how imaging findings may relate to pain and identifying the source, because ultimately we need to get to the source to hopefully help the horses and eliminate the pain 100%.
Speaker 2:You know it's a lot of times when you said it's a limitation of retrospective study. If they weren't looking for pain, why were they taking radiographs of C6-7?
Speaker 3:Yeah, that's a really good question. So that was. Another topic of this paper is finding out why horses were presented for neck radiographs. And most horses were presented for neck radiographs because of suspect neurologic disease which can stem from the neck, for lamenesses that were not localized to the legs, and so then there could also be a concern that neck disease leads to lameness. And then finally, horses that literally did present for neck pain, and those are kind of the obvious ones that one would want to do some imaging of the neck for.
Speaker 2:You're clearly passionate now in training some really great up and coming next neck specialists. What sparked your research interest in neck pain in horses?
Speaker 3:Well, I am interested in mostly the neurologic side of things and most commonly when we think about our horses with Wobbler's disease, wobbler's syndrome, we usually see these horses clumsy but happy horses. But there are some that are not, and that's always been interesting to me to find out why some horses have this disease and have no problems with pain or don't show any signs of pain and others are very, very painful. So that was kind of my background behind, being interested in neck pain. And then Dr Story comes from the lameness aspect. So we have a nice combined expertise between internal medicine, neurology, sports medicine and surgery and as a team we've really approached this to delve into identifying other causes that are not necessarily right in front of us.
Speaker 3:And then the other concern is behavior. A number of these horses display what we call undesired behaviors that can become dangerous under saddle, so thinking about riggering up, bucking, explosive behaviors. And sometimes these horses undergo all kinds of diagnostics, even treatments with no improvement, even treatments with no improvement, and obviously that is very disheartening to everybody involved and sometimes leads to euthanasia of horses. And then the question is can we find anything on postmortem exams? And to that extent this is one of the reasons why we wanted to evaluate this particular condition.
Speaker 2:You guys are certainly a powerhouse with your collaborations. You're really fun to watch and keep learning. Hopefully we get more of your manuscripts, thank you. You said earlier, yvette, which I think is good, that some of the findings corroborated what was previously published, and then you mentioned some other take-home messages in the manuscript, but every time we published something we're like, huh, I didn't expect to find that. What were some of the surprising findings from this article?
Speaker 3:Well, I think one of the comforting things about this paper were that indeed this particular morphological variation the transposition of C6 to C7, does not appear to be more prevalent in horses with neurologic disease and in horses with lameness and in horses with cervical orthopedic disease, as far as that we can identify from radiographs.
Speaker 3:So thinking about arthropathies affecting the articular process joints. But what was surprising was indeed the fact that we found pain more so in the horses with TC67. Again, it's a small number so it has to be looked at more carefully, but it seemed to. Our data showed that in the TC67 group 30% of horses were painful versus 70% were not painful and in the non-pain horses about 20% had TC67 and 80% did not. So those results were surprising to me and again I do. I would like to look into that further, to determine, you know um essentially, who was evaluating the horses, who discovered the pain um and were owners appreciating pain um and andating pain and so forth. What was interesting to me is that when we looked at the horses with neck pain, most of the horses that were presented for neck pain by the clients did not have TC67, but the horses that were identified with neck pain by us sometimes did have TC67. So there's a bit of a discrepancy as far as what clients perceive as neck pain versus what we diagnosed as horses with neck pain.
Speaker 2:Yeah, interesting, there's a lot to learn on both sides of that fence. Yeah, you've dropped a couple teasers in here about what you're thinking of for next steps. What are you and your whole team, your interns, your residents, your graduate students? What are the next steps for research in this topic?
Speaker 3:no-transcript and ECVM ie equine cervical vertebral malformation would imply that the vertebral changes are bad malformation. But this specific variation is called a morphological variation, so the transposition from C6 to C7. And morphological variations are not necessarily malformations and it's, in my opinion, really important to make that distinction and to also educate our clients and veterinarians of that difference. Morphological variations, for example, are seen in Arab horses where they have five lumbar vertebral bodies instead of six or they have 17 ribs instead of 18. And that can be completely normal. They are functionally normal. For this particular thing that we're seeing on C6 and C7, we call it a morphological variation because I do not think that we truly know whether or not it is associated with pathological changes and indeed is a cause for pain or other syndromes, and that is the aspect that needs further evaluation. In some of the literature that is out there, morphological variations, or when they group it with malformations, often gets blurred, for example when it comes to the neurologic signs. Neurologic disease can be caused by cervical vertebral malformations, but those are usually affecting C1, c2, c3, c4. I don't think I've ever seen a malformation at C6, c7 that is causing cervical spinal cord compression. And that is what I think is really important here is making that distinction, making sure that people use the correct terminology to describe what we're seeing.
Speaker 3:And at this point in time I don't think we have enough evidence to say that TC67 is a malformation. It is a morphological variation and to look at that more closely we need to do prospective research. For example, one of the things that I'd really like to do is take x-rays of horses that are actually functioning great. So have horses that have a three-year history of performing as expected, take x-rays and find out how many of those are affected by TC67 to really have a good control group. Because one of the things that we're lacking in all the studies that have been done up till now really is that there's no good control group used. The control groups that are used are horses that are still coming into the clinic for whatever reason, even pre-purchase exams. We don't know why the horses are being sold, what their backstory is, so I think one can argue that pre-purchase exam horses are not necessarily a good control group. So those are some of my thoughts on future studies here.
Speaker 1:Yeah, I see Lisa put in the chat that that could be a good idea for a Morris Animal Foundation grant. That was something to keep in mind.
Speaker 3:I actually submitted one.
Speaker 2:Yeah, yeah, that's right up there, Allie, and you know there's nothing better than a good control group. You know, and I agree, I've never seen a true malformation that caused a clinical sign at 6-7.
Speaker 3:Yep, yep, and so the hypothesis is that having that transposition, so that morphological variation at the base, essentially, of these vertebral bodies could alter the adhesion of muscles, tendons, pathways that affect, of course, the neck biomechanics, and to that extent there could be change, a change in the way the horse is carried, the way the horse moves, the way nerves perhaps move through that region, and so that is the hypothesis to why some people think that this can lead to pain. I think, though, though, there are so many things that go into pain, and we need to be very careful making associations between imaging, findings and function, and one of the things that we've recently learned, too, is that cervical articular facet joint changes are common, and they're certainly not always associated with clinical signs, so there's an example of radiographic abnormalities that are not necessarily translated to function.
Speaker 1:So it's very interesting. I feel like that's a really important point honestly to consider when evaluating radiographs in general, saying is this a clinically relevant lesion that we're seeing? Exactly. So, for those of you just joining us, we're discussing how neck pain, but not neurologic disease, occurs more frequently in horses with transposition of the ventral lamina from C6 to C7, with our guest Yvette. So, yvette, how did your advanced training prepare you to write this manuscript?
Speaker 3:Oh, that's well.
Speaker 3:That's, of course, an interesting question. Caitlin was an intern here and wanted to become, wants to become, an equine surgeon, and so a lot of this is mentoring and trying to help somebody in an early career with a busy life work through collecting the data and then dividing them up into different groups and finally evaluating the data and making something out of it. And I think my experience in, you know, basic research and I did a PhD in neuroscience that was pretty hardcore basic science work, I think helped me work through that process. And then my experience here on faculty at CSU, where I work with a lot of students, residents and interns, allows you to come up with ideas and try to help them to find time to dedicate to some of this work, to some of this work. So it's a combination of being in there yourself and having gone through these things and hopefully transmitting some of that to the newer generation to help them along. And ultimately, you know, the whole reason for doing this is to help the horse, to help the client and to improve everyone's lives.
Speaker 2:I always have to interject and say go Rams, I'm a CSU 91 grad. There you go. Yes go Rams and I don't know if you know that in JAVMA and AJVR we have journal awards. So this year we gave away six intern, resident and student. We have six in both journals. We had so many nominations this year, so nominations are open and rolling. You can just go to the website and nominate anybody for these awards. Well, student, intern, resident, for these awards oh, that's great to know. I had not realized that.
Speaker 2:Thank you for letting me know, yeah, they get a really nice cash prize. So cash in their paw and they get a certificate and we recognize them at convention. It's really cool, okay, yeah.
Speaker 3:I will have to do that.
Speaker 1:Yeah, I think we had over 60 nominations this year. It was not standing turnout 60 nominations this year.
Speaker 3:It was not standing turnout. Well, I mean, it's another way to motivate them and to have incentives to do some of this work, because it is work that goes over and beyond, you know, our job expectations, if you will, definitely.
Speaker 1:So you've got this next set of questions. It's going to be really important for our listeners. And for the first one, I'd like for you to just pick one fact, if you're able to, from your manuscript. So what is one piece of information the veterinarian should know about neck pain in horses?
Speaker 3:Well, I think the most important thing is that neck pain and pain in general is not normal, and horses are kind animals and if they are showing signs of pain, if they're displaying what we call undesired behaviors, I think that is a real thing that we need to look at and identify and, foremost, remember that the horse does not mean to be bad. They are not bad animals. So it's our job to find out what's going on and in this study, it is possible that TC67, you know, increases the chance of a horse displaying some pain related to the neck. But I think it's also important to rule out other causes.
Speaker 1:And then on the other side of the relationship, what's one thing clients should consider around neck pain in horses.
Speaker 3:So the same with clients. It's important to recognize it and to also be proactive with getting it looked at. I would say don't miss too long with different things different bridles, bits, different riders, saddles, etc.
Speaker 2:At some point. The horse has got to be seen and might have to undergo some diagnostics to delve into what's the underlying cause. Amen to that. Thanks again, Yvette. I've learned a ton from your manuscript and your whole group at CSU, so I'm really excited to see what the future brings. As we wind down, we'd like to ask a fun question, and for you we would like to know, if Yvette could have a superpower, what would it be, and why?
Speaker 3:well, a super. I think the best superpower to have, and especially when it comes to this topic, is to be able to understand what the horse says, to really understand. Are they sad, are they happy are? Are they painful? What is it that is going on in their little brain of theirs?
Speaker 2:Yeah, I always like when human doctors, mds, say to me you've got it easy, your patients can't talk, and I'm like, well, their owners and their trainers can, and that makes it worse, that makes me a pediatrician, basically.
Speaker 3:And you know, what is so interesting to me, too, is that if you look at the human literature on this topic of pain neck pain, back pain they're almost in the same boat as we are, where they can't find the cause in many of these cases. And I'm thinking, wow, and you're working with animals that can talk. And I'm thinking, wow, and you're working with animals that can talk. You know, you'd think that they can be more specific in finding the location or thinking about the cause, but yeah, I would love if they could talk as a veterinarian.
Speaker 2:I'm not so sure as a rider. I think my horse would say like keep your legs still. Like come on how many more circles?
Speaker 3:do we have to do? Yeah, that's true. Yeah, as a writer, it would be less. Although when you're outside and I like endurance writing and you're running and you know chasing the next horse, I always wonder do they really like it or do they see it as an effort to get home as quick as possible? True.
Speaker 2:True, probably both. Yeah, yeah.
Speaker 1:I like to extend the same sentiments of cats too. There's so many times where my husband and I are like what are they thinking? Yeah, exactly, yeah, just. Thank you so much. I really appreciate you being here and for also contributing your manuscript to JAPMA.
Speaker 3:Thank you again for having me. I've enjoyed talking with you and I'm glad that you guys are giving this topic a profile to reach larger audiences that maybe read the journal and I hope that the message gets across to as many veterinarians and clients as possible.
Speaker 1:Well, we sure hope so too. So to our listeners, you can read Yvette's article and print Javma using your favorite search engine. I'm Sarah Wright with Lisa Fortier. We want to thank each of you for joining us on this episode of the Veterinary Vertex podcast. We love sharing cutting edge veterinary research with you and we want to hear from you. Be sure to leave us a rating and review on Apple podcasts or whatever platform you listen to.