EQUINE VETERINARY EDUCATION
Equine vet. Educ. (2005) 17 (1) 39-43
Tutorial Article
Surgical treatment of cervical spinal cord compression in
horses: a European experience
J. P. WALMSLEY
The Liphook Equine Hospital, Forest Mere, Liphook, Hampshire GU30 7JG, UK.
Keywords: horse; cervical vertebral malformation; spinal cord compression; surgical treatment
Introduction
Surgical treatment of cervical spinal cord compression
associated with cervical vertebral malformation (CVM) has
been performed widely in North America but has gained much
less recognition in Europe. The procedure was first reported by
Wagner et al. (1979a,b), who used Cloward’s intervertebral
fusion technique (Cloward 1958). A homologous bone
dowel was implanted into a 16 mm hole drilled from
ventrally into the 2 affected cervical vertebrae at their
articulation (Wagner et al. 1979a). The technique was soon
modified by replacing the dowel with a 25 mm diameter
stainless steel basket (Cloward Bagby basket)1 filled with
an autogenous cancellous bone graft and placed into a
25 mm hole drilled into the 2 vertebrae (Wagner et al.
1979b). In a more recent further modification of the
technique, the basket has been replaced by an open-ended,
threaded, stainless steel cylinder (Kerf Cut Cylinder)2
which offers more secure fixation of the implant and
allows the preservation of a central core of vascularised bone
within it (B.D. Grant, personal communication).
Reasonable results have been achieved surgically
(Grant et al. 1985; Moore et al. 1993) and in North America
the technique seems to have gained acceptance. In Europe,
this is not universally the case and there still appear to be
concerns over the persistent neurological defect manifested
by some surgically treated cases and the perceived risk to the
rider. There is also concern over the heritability of
the condition in breeding animals. This paper
presents experiences with surgical treatment of CVM
in an English hospital and attempts to address
these issues.
Materials and methods
The case records of horses treated by ventral intervertebral
fusion at the Liphook Equine Hospital (LEH) or by the author
at other hospitals were reviewed and the findings, treatment
and outcome are reported.
39
Diagnosis
The history of each case was taken, recording the details of the
horse, duration of the signs, management of the horse, evidence
of other diseases such as osteochondrosis dissecans and any
episode of trauma. A physical and neurological examination was
performed and the neurological deficit graded out of 4 after
Mayhew et al. (1978). If this examination suggested that the
cause of incoordination was likely to be a compressive lesion in
the cervical spinal cord, a full cervical radiographic survey was
performed on the standing horse. The radiographs were
evaluated for bony abnormalities and the inter- and
intravertebral minimum sagittal ratios calculated (Moore et al.
1994; Mayhew and Green 2000). Certain abnormalities were
specifically noted and these included dorsal encroachment of the
caudal vertebral physis into the vertebral canal (‘ski jump’),
caudal extension of the dorsal arch of the vertebral canal over
the cranial physis of the next caudal vertebra, the degree of
intervertebral angulation, and degenerative changes in the
dorsal articular processes (Mayhew et al. 1993). An attempt to
establish the likely region of spinal cord compression was made
from this information but was not relied upon when deciding
which sites required surgical stabilisation.
Myelography was then performed with the horse under
general anaesthesia and in lateral recumbency. The forelimbs
were pulled caudally and either the horse’s head and neck
were raised or the whole horse was tilted with its head end
up. The atlantooccipital region was prepared aseptically and
a 19 gauge, 7 cm spinal needle was inserted into the
subarachnoid space (DeLahunta 1983). Contrast agent
(iohexol 300 mg iodine/ml; Omnipaque3) at a dose rate of
10 ml/100kg bwt was injected over a 5 min period, having
removed an equal quantity of cerebrospinal fluid. In some
cases concurrent lumbosacral centesis was performed to
allow the cerebrospinal fluid and contrast agent to flow
caudally. Five minutes following injection, a series of cervical
radiographs were taken with the neck both extended and
flexed using short scale radiographic technique (high mAs,
low kVp) (Rantanen et al. 1981). The criterion used for
diagnosing intervertebral compression was a 50% reduction
40
Fig 1: Horse placed in position for a cervical intervertebral
fusion with radiography equipment in place.
Fig 2: Intraoperative radiograph of 25 mm drill guide in position.
in both dorsal and ventral dye columns (Papageorges et al.
1987). Cerebrospinal fluid was analysed routinely.
Surgical procedure
Horses were starved for 12 h prior to anaesthesia and given
procaine penicillin (25 mg/kg bwt i.m.), gentamicin (6.6 mg/kg
bwt i.v.) and phenylbutazone (4 mg/kg bwt i.v.) before surgery.
The whole neck and brisket region was clipped with size 40
clippers. Following routine anaesthetic induction and
maintenance of anaesthesia with halothane or isoflurane and
oxygen, the horse was placed in dorsal recumbency with the
forelimbs pulled back and secured, and the neck extended by
lowering the head piece of the operating table (Fig 1). The
neck was placed in a cradle to increase extension and to
maintain accurate positioning and, after placing markers on
the side of the neck closest to the cassette, radiographs were
taken to identify the location of the surgical site. The neck was
then prepared routinely for aseptic surgery and the whole
horse covered with sterile drapes.
A 25 cm midline incision was made centred over the site of
the marker, and the subcutaneous musculature and
sternothyroideus muscles divided longitudinally. Having exposed
the trachea, a careful dissection was made along its right side to
separate the carotid artery, recurrent laryngeal nerve and
vagosympathetic trunk and expose the longus colli muscle
overlying the vertebral column. The carotid artery and associated
nerves were protected with wet sponges throughout the
Surgical treatment of cervical spinal cord compression in horses
Fig 3: Intraoperative view of the lubra plate in position over the
Cloward Bagby basket.
procedure. Having palpated the ventral spine of the cervical
vertebra cranial to the affected joint (except C6), this was
exposed and removed with a curved chisel, creating a platform
for the drill guides. Retraction of the muscles was achieved with
Inge or similar self-retaining retractors. An 18 mm hole was
drilled cranial to the caudal physis of the more cranial vertebral
body to a depth of 10 mm in order to assist positioning of the
25 mm Bagby drill guide1 and to facilitate drilling with the 25 mm
drill. Having placed the 25 mm drill guide, a radiograph was
taken to check its position and if necessary it was readjusted and
further radiographs taken until it was correctly positioned (Fig 2).
Surgical procedure using the stainless steel
Cloward Bagby basket
The 25 mm hole was then drilled deep enough to accept the
basket (30 mm). Drilling was performed slowly using saline
irrigation, the bone debris being collected and separated from
disc material for use later as a bone graft. The depth was
checked frequently with a depth guide and the correct position
confirmed by the presence of the intervertebral disc in the
caudal part of the hole at a depth of approximately 10 mm.
This ensured that at 30 mm the disc would be in the centre of
the hole. Care was taken to avoid drilling within 10 mm of the
vertebral canal. Once the drill hole had been smoothed with a
curette and cleaned of debris, the stainless steel Cloward
Bagby basket1 was filled with cancellous bone from the
drillings. The basket was then attached to the implanter1 and
tamped into place. In most cases the basket was covered with
a lubra plate1 fixed with 30 x 6.5 mm cancellous2 screws either
side of the implant to prevent extrusion (Figs 3 and 4).
Surgical procedure using the Kerf Cut Cylinder (KCC)
Once the position of the drill guide had been confirmed
radiographically, the 25 mm hole was drilled to 10 mm depth.
The 25 mm drill was then replaced by the 25 mm kerf cut saw4
J. P. Walmsley
Fig 4: Intraoperative radiograph of a Cloward Bagby basket and
lubra plate placed at C6/7 in a 6-year-old Thoroughbred gelding.
and drilling continued to the required depth for the implant, but
never closer than 10 mm to the vertebral canal. The drill guide
was removed and the saw cut widened and, if necessary,
deepened with a manual kerf cutter and cleaner4, repeatedly
confirming the depth with a depth gauge and ultimately with a
radiograph. At this stage, as much disc material as possible was
removed from the cylinder of bone left by the core saw, and the
edges of the hole were smoothed. After cutting the thread for
the implant with the pretapping instrument4, the implant was
screwed into place with the dedicated driver4. The KCC2 is an
open cylinder so that bone graft material can be placed inside
the implant once it is in position. When this was completed an
x-ray was taken and the surgical site was closed for both
procedures as described below.
The longus colli muscle was closed with 4 metric
polydioxinone (PDS)5 using a horizontal mattress suture. The
sternothyroideus muscle was sutured with 4 metric PDS and
the cutaneous trunci muscle with 3.5 metric polyglactin
910 (Vicryl)5 using a simple continuous suture pattern for
both. Following a subcuticular suture with 3 metric polyglactin
910, the skin was closed with staples and a stent bandage
sutured over the incision. Drains were used in one case.
Recovery from anaesthesia was carefully supervised. The
recovery room environment was kept as quiet as possible and
xylazine was given i.v. to discourage the horse from attempting to
stand too soon. Assistance was given with a tail rope only, in
order to avoid potentially excessive traction on the neck.
Phenylbutazone was given orally and to effect post operatively
and antibiosis maintained for 5 days. The stent bandage was
removed on the third post operative day. Seroma formation was
treated by open drainage only if it was excessive. An x-ray was
taken post operatively to check the implant placement following
recovery from anaesthesia (Fig 5). Horses were sent home at
7–14 days post operatively and confinement in a stable was
recommended for 2 months with some hand-walking in the
second month. Subsequently, controlled exercise was encouraged
until the horse was fit enough to be turned out to pasture.
41
Fig 5: Post operative radiograph of Kerf Cut Cylinder placed at
C5/6 in a 2-year-old Thoroughbred-cross gelding.
Outcome was determined by telephone conversation with
the referring veterinary surgeon, owner or trainer of the horse.
In the case of racehorses, if the horse trained satisfactorily this
was considered a successful outcome, since only one of the
racehorses had trained previously and therefore post operative
performance could not be compared with preoperative
performance. Riding horses were considered to have a
successful outcome if they were performing at their previous
level and owners were satisfied with their gait.
Results
The records of 38 horses treated surgically for cervical spinal cord
compression were reviewed. These included 14 Thoroughbred,
15 Warmblood and 9 Thoroughbred-cross horses, 15 of which
were entire males, 19 geldings and 4 mares. Their median age
was 2 years (range 6 months–11 years) and median duration of
clinical signs was 2 months (range 1–12 months). Neurological
deficits were recorded in the hindlimb as grade I in 5 horses,
grade II in 20 horses, grade III in 9 horses and grade IV in
4 horses, and in the forelimb as grade I in 9 horses and grade II
in 8 horses. The site of the lesion treated was C3/4 in 8 horses,
C4/5 in 3 horses, C5/6 in 5 horses and C6/7 in 17 horses. Four
horses were treated at 2 sites (C3/4 and C4/5, n = 2; C3/4 and
C5/6, n = 1; C5/6 and C6/7, n = 1) and one horse at 3 sites
(C3/4, 4/5 and 6/7). The Cloward Bagby basket was used in
24 cases and the KCC in 14 cases. Sixteen horses were diagnosed
as having type I CVM (osteochondral disease) and 22 as having
type II CVM (osteoarthritis) (Mayhew and Green 2000). One foal
had compression caused by discospondylitis, which was treated
with antibiotics for several weeks prior to surgery.
At the time of writing, (December 2004) 7 horses were still
convalescing. Five horses had raced or trained satisfactorily and
one of these had won 2 steeplechases. Six riding horses were
performing at the level expected of them. Three horses had
recovered their normal gait but 2 were not yet in full work and
one had been lost to follow-up subsequently. A stallion with
type II CVM returned to full stud duties. Overall, 17 out of
28 horses followed-up regained a satisfactory gait. Three of
these horses could not be used as athletes because of
42
complications, which included 2 horses with right-sided
laryngeal paralysis and one, which had 3 implants, with a stiff
neck. Of the horses that failed to survive the convalescent
period, one foal died of rhodococcus infection unrelated to the
surgery; one horse was subjected to euthanasia because of a
cervical vertebral fracture at the implant site; 3 were subjected
to euthanasia because of a suspected fracture (no post mortem
was performed); a traumatic episode on the journey home from
the hospital provoked severe ataxia in a yearling, necessitating
euthanasia; one foal died of laryngeal oedema 4 days post
operatively; a 4-year-old Warmblood gelding was destroyed
7 months post operatively because of infection at the implant
site (C5/6); a 3-year-old Thoroughbred-cross mare was
subjected to euthanasia due to infection around the implant at
3 weeks; and one horse was lost to follow-up. The only horse
that survived to 12 months post operatively and showed no
improvement was a Warmblood gelding with type II CVM at
C5/6. There was one dressage horse that could be ridden but
was only used for light work due to hindlimb and neck stiffnesss
Of 8 horses treated at C3/4, 2 are convalescing, 4 have
trained or raced satisfactorily, one has a normal gait but has
not yet returned to full work and one died of unrelated
causes. From the 17 horses treated at C6/7, 9 horses have
regained a satisfactory gait and of these 2 are used for
breeding, one has been lost to follow-up and 6 have returned
to ridden work. Two of the 17 horses are convalescing and
5 horses were subjected to euthanasia due to complications.
There were 7 fatal and 3 nonfatal complications related to the
surgery. Fatal complications were fracture or suspected fracture at
the surgical site in 4 horses, 3 of which were treated at C6/7 and
one at C5/6, infection at the implant site in two horses and
laryngeal oedema 4 days post operatively in another horse.
Nonfatal complications included a horse that sustained a fracture
at the surgical site (C6/7) but survived and has returned to work,
2 horses with right-sided laryngeal paralysis and one horse with
neck stiffness. Seroma formation was seen in some cases, but this
resolved satisfactorily without draining in all but one, which was
the horse that developed acute laryngeal oedema.
Discussion
Case selection for surgical intervention with CVM cases is critical.
The possibility of surgery was discussed with the owners after
clinical examination and plain radiography indicated that the
horse was likely to be suffering from cervical spinal cord
compression, and before undertaking myelography. The risks of
the procedure and the possibility of owning an uncoordinated
horse should the treatment fail, as well as the commitment
involved with the convalescence, were all discussed in detail. From
30 to 50% of horses were ruled out from further treatment at this
stage. If horses were required for jumping work, owners were
discouraged from surgical intervention. However, horses have
jumped satisfactorily following surgical treatment by this author
and others (Grant et al. 1985; Nixon and Stashak 1985; Moore et
al. 1993), which perhaps suggests excessive caution. For horses
that underwent myelography, approximately 30% were ruled out
because a compressive lesion could not be diagnosed confidently.
Surgical treatment of cervical spinal cord compression in horses
Plain radiography using sagittal ratios to determine the site
of compression was not relied upon, and a 50% reduction in
the dye column was the main criterion used (Papageorges et
al. 1987). Although this criterion was not validated at post
mortem in the original study, in practice it has been the most
useful guide; it does, however, remain a significant weakness
in the evaluation of myelograms in horses. More recently,
validated studies on the value of using a 50% reduction in the
dorsal myelographic column to diagnose compression have
been undertaken (Van Biervliet et al. 2004). These suggested
that the specificity of this test was more than 73% in all views,
but sensitivity was above 70% only in the neutral view at C6/7
and in the flexed view at C3/4 and C4/5. Since the accuracy of
determination of the site of compression is so crucial to the
success of surgical treatment, any improvement in diagnostic
techniques should be beneficial.
In this series, 17 of the 28 horses followed-up regained a
normal gait. Twelve of these had returned to normal use and
2 of the 17 are not yet in full work. To the author’s knowledge,
one of these horses retained a slight gait deficit that did not
affect his usefulness since he improved considerably when he
was in full work. Moore et al. (1993) used the criteria of
improvement of 2 neurological grades or sufficient improvement
for athletic use and 36/61 fulfilled these criteria, but from these
figures it is not clear how many returned to full use. Nixon and
Stashak (1985) showed a complete recovery in 15/27 horses, but
no details of the lesion sites were given. Grant et al. (1985)
reported 57/72 horses in use. Twenty of these horses were used
for pleasure riding or breeding only, 29 were in training for racing
or showing and 8 were actually racing or showing. In the
author’s series, more horses were treated at C6/7 (17/38)
compared with 15/72 treated by Grant et al. (1985). This may
reflect a higher percentage of older Warmblood and
Thoroughbred-cross horses with type II CVM in the author’s
series, but the publications cited do not detail the age and type
of horses treated. Nixon (2002) reported recovery of normal
neurological status after surgical fusion at sites between C5/6
and C7/T1 of 17 cases and felt that better success was seen since
the diagnosis is more likely to be definitive in these type II CVM
cases. Recovery was slower, but often accompanied by complete
regression of bony arthritic changes. Exercise programmes
appear to be beneficial during convalescence (Grant et al. 1985;
Nixon 2002). Shorter duration of clinical signs prior to surgery
has been shown to improve the prognosis (Moore et al. 1993).
The complication rate for this surgical procedure is high. Six
fatalities out of 63 procedures were recorded by Moore et al.
(1993), including 3 fractures of the vertebral bodies, one spinal
cord oedema and one implant failure. Four of these fatalities
occurred in 5 horses treated at C6/7. Two out of 17 horses
treated surgically between C5/6 and C7/T1 by Nixon (2002)
sustained fractures of the vertebral bodies but eventually
recovered. In the author’s series, fracture or suspected fracture
was also the most common fatal complication, and again it
was most frequently seen at C6/7. Four of these horses were
large Warmbloods and all were earlier cases. Inexperience in
the earlier cases may be a factor, and there was lower post
operative morbidity in the later cases. The use of the KCC,
J. P. Walmsley
which leaves a core of parent bone in the implant, may also
reduce the fracture rate. It also obviates the need for a lubra
plate to prevent extrusion of the implant.
Right-sided laryngeal paralysis occurred in one horse out of
63 treated by Moore et al. (1993), but in 6/75 horses in
another series (Wagner et al. 1981) and 3/72 by Grant et al.
(1985). Again, most authors attribute this to inexperience in
the surgical technique. Great care needs to be taken to avoid
over-retraction of the recurrent laryngeal nerve. Seroma
formation is relatively common and usually resolves
spontaneously, rarely requiring draining. Most surgeons do
not routinely use intraoperative drains. The only case in which
the author used an intraoperative drain was subjected to
euthanasia later because of infection around the implant.
Safety concerns over the use of horses surgically treated for
CVM are frequently voiced by veterinary surgeons in the UK.
Although owners are always carefully advised of this potential
risk, the author does not know of any post operative accident
reported in either Europe or North America (B. Grant and
J.T. Robertson, personal communications). Moore et al. (1993)
calculated that over 1000 horses had had cervical fusion surgery
by 1992, so the present figure could be twice that. It seems
reasonable to suppose that a horse showing enough signs of
ataxia to be unsafe to ride is unlikely to be ridden, in the same
way that a lame horse would not be ridden. Therefore, it could
be argued that the risk is no different for a horse recovering
from cervical fusion surgery than one recovering from lameness.
To the author’s knowledge, there is no proof of heritability
of the condition. Falco et al. (1976) found no evidence of
inheritability of incoordination in a retrospective study of
134 horses. Wagner et al. (1985) bred 22 foals from 12 mares
and 2 stallions with CVM and found no increased incidence of
CVM in the foals, although there was a higher incidence of
osteochondrosis dissecans (OCD), physitis and contracted
tendons. On these grounds, it would seem as reasonable to
breed from mares with CVM as from those with OCD.
Considering that euthanasia is the alternative for surgical
candidates for cervical fusion, experience has shown that the
procedure is worthwhile. Most surgeons seem to achieve a
success rate, measured by the patient returning to use, of
between 45 and 60%. Surgical experience with the procedure
seems to improve success rate and lower post operative
morbidity. Recovery may take over 12 months and an exercise
programme during convalescence is considered beneficial.
Acknowledgements
The author is grateful to Tim Phillips for his contribution of 2 of
the cases performed at the Liphook Equine Hospital, to Rowena
Rogers for her help with the data and to the surgical staff at the
Liphook Equine Hospital for their efficient teamwork.
Manufacturers’ addresses
1Sontec Instruments Inc., Englewood, Colorado, USA.
2StratecMedical Ltd, Welwyn Garden City, Hertfordshire, UK.
3Omnipaque, Nycomed, Oslo, Norway.
4Wilson Tool & MFG, Spokane, Washington, USA.
5Johnson & Johnson Ltd, c/o European Logistics Centre, Brussels, Belgium.
43
References
Cloward, R.B. (1958) The anterior approach for removal of ruptured
cervical disks. J. Neurosurg. 5, 602-617.
DeLahunta, A. (Ed.) (1983) Atlanto-occipital (cerebellomedullary
cistern) CSF collection in the horse. In: Veterinary Neuroanatomy
and Clinical Neurology, 2nd edn., W.B. Saunders Co., Philadelphia.
pp 40-41.
Falco, M.J., Whitwell, K. and Palmer, A.C. (1976) An investigation into
the genetics of ‘wobbler disease’ in Thoroughbred horses in
Britain. Equine vet. J. 8, 165-168.
Grant, B.D., Barbee, D.D., Wagner, P.C., Bayly, W.M., Reed, S.M.,
Gallina, A., Sande, R.D. and Gavin, P.R. (1985) Long term results of
surgery for equine cervical vertebral malformation. Proc. Am. Ass.
equine Practnrs. 31, 91-96.
Mayhew, I.G. and Green, S.L. (2000) Accuracy of diagnosing CVM
from radiographs. In: Proceedings of the 39th Annual Congress of
the British Equine Veterinary Association, Equine Veterinary Journal
Ltd, Newmarket. pp 74-75.
Mayhew, I.G., DeLahunta, A. and Whitlock, R.H. (1978) Spinal cord
disease in the horse. Cornell Vet., Suppl. 68, 6, 24-29.
Mayhew, I.G., Donawick, W.J., Green, S.L., Galligan, D.T., Stanley, E.K.
and Osborne, J. (1993) Diagnosis and prediction of cervical
vertebral malformation in Thoroughbred foals based on semi-
quantitative radiographic indicators. Equine vet. J. 25, 430-440.
Moore, B.R., Reed, S.M. and Robertson, J.T. (1993) Surgical treatment
of cervical stenotic myelopathy in horses: 73 cases (1983-1992). J.
Am. vet. med. Ass. 203, 108-112.
Moore, B.R., Reed, S.M., Biller, D.S., Kohn, C.W. and Weisbrode, S.E.
(1994) Assessment of vertebral canal diameter and bony
malformations of the cervical part of the spine in horses with
cervical stenotic myelopathy. Am. J. vet. Res. 55, 5-13.
Nixon, A.J. (2002) Results of surgical management of Wobbler
syndrome. In: Proceedings of the First World Orthopaedic
Veterinary Congress, Eds: A. Vezzoni, J. Houlton, M. Schramme
and B. Beale, Munich. p 154.
Nixon, A.J. and Stashak, T.S. (1985) Surgical therapy for spinal cord
disease in the horse. Proc. Am. Ass. equine Practnrs. 31, 61-74.
Papageorges, M., Gavin, P.R., Sande, R.D., Barbee, D.D. and Grant,
B.D. (1987) Radiographic and myelographic examination of the
cervical vertebral column in 306 ataxic horses. Vet. Radiol.
28, 53-59.
Rantanen, N.W., Gavin, P.R., Barbee, D.D. and Sande, R.D. (1981)
Ataxia and paresis in horses Part II. Radiographic and myelographic
examination of the cervical vertebral column. Comp. cont. Educ.
pract. Vet. 3, 161-171.
Van Biervliet, J., Scrivani, P.V., Divers, T.J., Herb, H.N., Delahunta, A.
and Nixon A. (2004) Evaluation of decision criteria for detection of
spinal cord compression based on cervical myelography in horses:
38 cases (1981-2001). Equine vet. J. 36, 14-20.
Wagner, P.C., Grant, B.D., Watrous, B.J., Appell, L.H. and Blythe, L.L.
(1985) A study of the heritability of cervical vertebral malformation
in horses. Proc. Am. Ass. equine Practnrs. 31, 43-50.
Wagner, P.C., Grant, B.D., Gallina, A. and Bagby, G.W. (1981)
Ataxia and paresis in horses - part III: surgical treatment of
cervical spinal cord compression. Comp. cont. Educ. pract. Vet.
3, 192-202.
Wagner, P.C., Bagby, G.W., Grant, B.D., Gallina, A., Ratzlaff, M. and
Sande, R. (1979a) Surgical stabilization of the equine cervical
spine. Vet. Surg. 8, 7-12.
Wagner, P.C., Bagby, G.W., Grant, B.D., Gallina, A., Sande, R. and
Ratzlaff, M. (1979b) Evaluation of cervical spinal fusion as a
treatment in the equine ‘wobbler’ syndrome. Vet. Surg. 8, 84-88.