Received: 16 November 2020 | Accepted: 1 April 2021

DOI: 10.1111/evj.13449

GENERAL ARTICLE

Outcomes after cervical vertebral interbody fusion using an

interbody fusion device and polyaxial pedicle screw and rod
construct in 10 horses (2015-­2019)

Lynn M. Pezzanite1 | Jeremiah T. Easley2 | Rosemary Bayless3 | Ellison Aldrich4 |

Brad B. Nelson1,2 | Howard B. Seim III2 | Yvette S. Nout-­Lomas1

1
Department of Clinical Sciences, College
of Veterinary Medicine and Biomedical Abstract
Sciences, Colorado State University, Fort Background: Further development of surgical techniques for equine cervical stabili-
Collins, CO, USA
2 sation is necessary to make the procedure less technically demanding, reduce com-
Preclinical Surgical Research Laboratory,
Department of Clinical Sciences, plications and improve outcomes.
Translational Medicine Institute, Veterinary
Objective: To describe clinical outcomes and owner reports in horses undergoing
Teaching Hospital, Colorado State
University, Fort Collins, CO, USA placement of an interbody fusion device and polyaxial pedicle screw and rod con-
3
Department of Clinical Sciences, College of struct for cervical vertebral fusion in horses with cervical vertebral compressive
Veterinary Medicine and the Comparative
Medicine Institute, North Carolina State
myelopathy.
University, Raleigh, NC, USA Study design: Retrospective case series.
4
Institute for Veterinary and Biomedical Methods: Data were retrieved from medical records of 10 horses undergoing cervi-
Sciences, School of Veterinary Medicine,
Massey University, Palmerston North, New cal vertebral fusion (2015-­2019). Records were evaluated for signalment, duration of
Zealand clinical signs, number and location of compression sites, grade of ataxia, duration of
Correspondence hospitalisation and complications. Long-­term follow-­up was obtained through clinical
Yvette S. Nout-­Lomas, Department of re-­evaluation, postoperative radiographs and owner contact.
Clinical Sciences, College of Veterinary
Medicine and Biomedical Sciences, Colorado Results: Breeds were mixed. Median age was 24 (range 12-­168) months. There were
State University, 300 West Drake Road, Fort 2/10 mares, 4/10 geldings and 4/10 stallions. Preoperative grade of ataxia ranged
Collins, Colorado 80523, USA.
Email: Yvette.Nout-Lomas@colostate.edu from 1-­3/5. Fusion was performed at one (n = 3) or two (n = 7) sites. Two horses
were euthanised within the first year. In 6 of 8 horses with ≥1-­year follow-­up, ataxia
Funding information
The study was supported by the Initiative for improved by 1-­3 grades, with an average improvement of 1.25 grades. In four horses,
Equine Neurologic Disease at Colorado State ataxia improved to grade 0-­1. In two horses the gait was unaffected, but neck com-
University and the Colorado State University
College Research Council. Stipend support fort improved. Complications included seroma formation (n = 9), pain (n = 5), fever
for L. Pezzanite was provided by the CCTSI (n = 4), upper respiratory tract obstruction (n = 2), azotemia (n = 2), screw breakage
NIH/NCATS CTSA 5TL1TR002533-­02,
NIH 5T32 OD010437-­19 and Carolyn (n = 2), progression of neurological signs (n = 1), Horner's Syndrome (n = 1), dysphagia
Quan and Porter Bennett. Stipend support (n = 1), hives (n = 1), implant infection (n = 1) and nondisplaced fracture (n = 1).
for R. Bayless was provided by the NIH
T32 OD011130. The reported findings of Main limitations: Small case series, heterogeneous patient population.
this study were in part presented at the Conclusions: This technique resulted in ≥1 grade gait improvement in 6/10 cases op-
American College of Veterinary Surgeons
Conference 2020, online due to COVID19. erated and 6/8 cases for which ≥1-­year follow-­up was available, similar to other meth-
ods. Fatal complications related to implant placement did not occur. This technique

The abstract is available in French and Portuguese in the Supporting Information section of the online version of this article.

Equine Vet J. 2022;54:347–358. wileyonlinelibrary.com/journal/evj © 2021 EVJ Ltd | 347

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348
may represent a safer alternative to current techniques of ventral interbody fusion
with similar outcomes.
KEYWORDS
cervical compressive myelopathy, cervical vertebral instability, cervical vertebral
malformation, complications, equine neurology, equine neurosurgery, horse, ventral
stabilisation, Wobbler's syndrome
1 | I NTRO D U C TI O N
Cervical vertebral compressive myelopathy (CVCM) is the only con-
dition of the spinal cord for which surgical intervention in horses is
consistently performed. Extradural compression of the spinal cord
due to narrowing of the cervical vertebral canal or malformation
of cervical vertebrae results in neurological deficits including sym-
metrical ataxia, dysmetria and weakness.1-­4 This condition has been
described in many breeds, and with a relatively high prevalence in
male horses (75%-­8 0%) and Thoroughbreds (1.3%-­2%). CVCM often
results in loss of athletic function in animals intended for compe-
tition,5-­7 and studies have shown that between 33%8 and 66%9 of
horses that have confirmed or suspected CVCM are euthanised.
Treatment of CVCM remains controversial due to lack of ability to
predict magnitude of improvement and future horse use, costs and
invasiveness of the described surgical procedures. Also, there is
dispute over significance of functional recovery from neurological
injury, and relative improvement gained with either medical or surgi-
cal intervention.8-­22 Despite these concerns, there are many horses
that have shown improvement with return to previous use following
13,17,18,19,20
cervical vertebral surgery. These findings highlight the
need to develop surgical techniques that are more accessible and
procedures that are less technically demanding while reducing cata-
strophic complications with the goal to improve outcomes and safely
return horses affected by CVCM to their intended use.
Current surgical treatments for CVCM include ventral interbody
fusion with kerf cut cylinders, ventrally placed locking compres-
sion plate fixation and dorsal laminectomy.1,5,6,14-­18,21,22 The kerf
cut cylinder remains the most commonly performed surgical pro-
cedure for cervical stabilisation but relies entirely on compression
and does not provide stability in tension.10,23 Locking compression
plate technology may be difficult to apply due to the anatomical
shape of the ventral vertebral body and limited flexibility in screw
placement with the construct. 20,24 Despite great advancements in
the field, these surgical methods for equine cervical stabilisation
require specialised equipment and surgeon experience and have a
high risk of intra-­or postoperative complications, including implant
migration or failure and vertebral fracture.1,17,25 Pedicle screws and
connecting rods inserted in combination with an interbody fusion
device (IFD) are considered the standard technique for lumbar fusion
in human patients, and their clinical implementation has resulted in
improvement in success rates in neurological function and return
to activity. 26-­3 0 These studies have prompted evaluation of alterna-
tive methods for use in equine CVCM. In a recent proof-­of-­concept
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PEZZANITE et al.
study, an IFD in conjunction with a polyaxial pedicle screw and rod
construct (Figure 1) was evaluated for cervical stabilisation in nor-
mal horses. 31 When applied in four sound adult Quarter Horses
without CVCM, this construct resulted in osseointegration within
8 months with no severe complications such as implant failure, mi-
gration or spinal unit instability reported. Furthermore, the polya­
xial pedicle screw head allowed for increased screw placement
options compared to previously described techniques, particularly
locking compression plate technology which is limited by the con-
formation of the ventral keel of the cervical vertebrae. 21,24,31 The
results obtained in this pilot study prompted further investigation
of polyaxial pedicle screw and rod technology in equine patients
clinically affected by CVCM.
Overall, there remains room for improvement in surgical treat-
ment of CVCM to both increase biomechanical stability and reduce
complications associated with implant placement. Our objectives for
this study were to describe clinical outcomes and complications in 10
horses with CVCM undergoing placement of an IFD with a polyax-
ial pedicle screw and rod construct to stabilise the cervical verte-
bral column. We hypothesised that this novel technique of cervical
stabilisation would result in similar or greater level of improvement
postoperatively compared to other described methods, and that
this technique would be associated with fewer catastrophic compli-
cations related to implant placement because less bone is removed
in this procedure allowing for a thicker vertebral canal floor to be
maintained.
2 | M ATE R I A L S A N D M E TH O DS
2.1 | Study design
Retrospective data were retrieved from medical records of 10 horses
undergoing cervical vertebral fusion at the Colorado State University
between 2015 and 2019. All horses that underwent ventral cervical
fusion with an IFD and a polyaxial pedicle screw and rod construct at
our institution during the time frame evaluated were included. Records
were examined for signalment, bodyweight, duration of clinical signs
prior to presentation, number and location of cervical compression
sites, grade of ataxia pre-­and postoperatively, surgical technique, an-
aesthesia length, duration of hospitalisation, postoperative manage-
ment, complications and outcomes. Ataxia was graded from 1 to 5 as
previously described.32 Long-­term follow-­up was obtained through
clinical re-­evaluation, post-­operative radiographs, and owner contact.
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PEZZANITE et al. 349

F I G U R E 1 Titanium polyaxial pedicle screw kit, consisting of pedicle screws, connecting rod and set screws. (A) Porous metal interbody
fusion device measuring 15 x 15 x 35 mm. (B) Drawing of polyaxial pedicle screw and rod construct with screws placed on right and left
side of ventral keel and placement of a porous metal interbody fusion device in situ. The connecting rod is placed within the tulip heads of
the pedicle screws. Set screws are then placed on top of the connecting rods and locked in place using a torque-­limited driver, resulting in
angulation capacity of 50 degrees of the shaft of each pedicle screw. (Image courtesy of Kelsea Ericksen, Fort Collins, Colorado)

Diagnosis of CVCM was made based on clinical and neurolog-
ical examination findings in combination with diagnostic imaging,
including radiographs obtained from the standing horse and radio-
graphic and computed tomographic myelography obtained from
the horse under general anaesthesia. Images were evaluated by
board-­certified ACVR, ACVIM and ACVS diplomates.
2.2 | Surgical technique and considerations
Horses were premedicated with systemic antibiotics which con-
sisted of potassium penicillin (500 000 IU/mL) 22 000 IU/kg IV
and gentamicin (100 mg/mL) 6.6 mg/kg IV, and non-­steroidal anti-­
inflammatory phenylbutazone (200 mg/mL) 4.4 mg/kg IV. Horses
were sedated with xylazine (0.5-­1.0 mg/kg IV) for premedication and
induced under general anaesthesia with ketamine (2.2 mg/kg IV) and
diazepam (0.1 mg/kg IV) and maintained using sevoflurane inhalant
in oxygen. Intraoperatively, horses received constant-­rate infusion
of dexmedetomidine (1 µg/kg/h IV) and dobutamine (0-­1 µg/kg/min)
when mean pressures were <65 mmgHg.
The surgical procedure was performed as previously described
by Aldrich et al31 Horses were positioned in dorsal recumbency with
the head and neck in a slightly extended position. An approximately
20-­cm incision was created on midline over the cervical region in-
tended to be operated using fluoroscopic guidance. The sternothy-
roideus muscles were separated on midline using blunt dissection to
expose the trachea, which was reflected to the left side. The ven-
tral aspect of the cervical vertebrae was then identified by digital
palpation. A combination of blunt and sharp dissection was used to
reflect the longus colli muscles from the vertebral bodies. A needle
(1.5-­inch, 18-­gauge) was placed into the disc space intended for fu-
sion, and a threaded K-­wire was placed in the ventral body of the
cranial vertebra at the most cranial extent of the intended inter-
vertebral defect, approximately 8mm cranial to the cranial endplate
in order to centre the defect in the disk, determined fluoroscop-
ically. A high-­speed surgical drill (Midas Rex Legend, Medtronic,
Minneapolis, Minnesota, USA) and 6-­mm cylindrical diamond burr
were used to create a rectangular intervertebral defect in the inter-
vertebral space. Approximately 5 mm of the cranial and caudal ad-
jacent vertebral end plates were removed under saline irrigation to
create a centrally located defect approximately 35-­mm long × 15-­
mm wide × 15-­mm deep to accommodate placement of the metal
IFD (Figure 1). Using an inserter tool and mallet, the IFD was placed
in the defect and placement confirmed fluoroscopically.
Next, four 4.5-­mm diameter × 30-­mm long polyaxial titanium
self-­t apping pedicle screws (ArteMedics, Minneapolis, MN, USA)
with dual core bodies were placed in the cranial and caudal verte-
brae, 1-­cm from the defect on either side of midline and 1-­cm cranial
or caudal to the edge of the disk space. Two 5.5-­mm diameter precut
titanium rods (ArteMedics) approximately 80-­mm long were placed
through the heads of the pedicle screws, spanning the disk on both
sides of midline. A pedicle screw compression tool (MedTronic,
Memphis, TN, USA) was applied to reduce dead space on the cranial
and caudal edges of the IFD. Set screws were inserted into the tulip
heads of the pedicle screws to lock the rods in place. Position was
confirmed fluoroscopically intraoperatively prior to closure.
The incision was lavaged and closed in three layers. The deep mus-
culature was closed in simple continuous pattern with 1 polyglyconate
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350
(Maxon, Covidien, Mansfield, MA, USA). The superficial musculature
and subcuticular layers were closed in simple continuous pattern using
2-­0 glycomer 631 (Biosyn, Covidien). The skin was closed in simple
continuous pattern using 2-­0 nylon (Monosof, Covidien). An adhesive
bandage was placed over the incision region. Horses were moved to
the recovery stall and recovered from general anaesthesia. Head and
tail ropes were used to assist recovery if tolerated by the horse.
2.3 | Post-­operative care
Horses were administered post-­operative systemic antimicrobial (po-
tassium penicillin 22 000 IU/kg IV every 6 hours, gentamicin 6.6 mg/
kg IV every 24 hours) and nonsteroidal anti-­inflammatory medica-
tions (phenylbutazone 4.4 mg/kg IV every 12 hours) for at least
4 days. Additional treatments were based on clinical assessment.
Horses were confined to a stall for the first 4 weeks post-­operatively,
followed by stall/run turnout with hand-­walking 10 minutes twice daily.
At 8 weeks post-­operatively, horses were allowed access to small pad-
dock turnout (no larger than 40 × 40 feet), with hand-­walking 20 min-
utes twice daily. At 12 weeks post-­operatively, horses were allowed to
resume normal activity, training and turnout, with exercise gradually
being increased, beginning with work on the lunge.
Short-­term complications were identified as those that occurred
during hospitalisation. Long-­term complications were defined as
those that occurred following discharge from the hospital.
2.4 | Neurological and radiographic assessment
Follow-­up information was obtained by clinical, neurological and
radiographic re-­examination. Neurological examinations based on
the modified Mayhew scale32 were performed prior to surgery and
at 1 year and between 2-­5 years post-­operatively. All examinations
were videotaped and assessed by two board-­certified equine inter-
nal medicine specialists who were blinded to timepoint. Ataxia was
graded (1-­5) for pelvic and thoracic limbs and overall. The overall
grade was reported as the more severe of the two values when the
grade differed between pelvic versus thoracic limbs. Any discrepan-
cies were rounded up to the highest grade of ataxia. Outcome was
defined in terms of improvement in ataxia from baseline at 1 year and
2-­5 years post-­operatively. Cervical radiographs were performed
prior to surgery and post-­operatively following recovery from gen-
eral anaesthesia prior to discharge from the hospital, and examined
for implant failure, implant migration, IFD stability and angulation of
the spinal unit. Further clinical and radiographic examinations were
obtained when possible post-­operatively.
2.5 | Owner follow-­up
Additional follow-­up information was obtained via a structured
owner survey (Item S1).
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PEZZANITE et al.
3 | R E S U LT S
3.1 | Horses
Cervical vertebral fusion was performed in 10 horses using the pol-
yaxial pedicle screw and rod construct between the years 2015 and
2019 at Colorado State University. The population of horses was
heterogeneous in age (median 24, range 12-­168) months), weight
(median 409, range 315-­520) kg) and breed (2 Warmbloods, 2
Tennessee Walkers, 2 Arabians, 4 Quarter Horses). Two horses were
mares, four were stallions and four were geldings. Median duration
of clinical signs prior to presentation was 10 (range 0.1-­24) months.
Median grade of ataxia at presentation was 2/5 (range 1-­3). Eight of
the 10 horses were juvenile (<4 years) at the time of initial evalu-
ation to CSU VTH and were not in training or being used for their
intended purpose at that time. Four horses had been ridden prior
to surgery. The stated intended uses of the horses presented were
pleasure riding (n = 3), English sport-­horse/dressage (n = 3), ranch/
working cow-­horse (n = 3) and reining/breeding stallion (n = 1).
Signalment, duration of clinical signs and intended use are summa-
rised in Table S1. None of the horses had developed ataxia related
to witnessed trauma, but one horse (Case 10) became acutely ataxic
precipitating presentation for neurological evaluation. Two horses
(Cases 1, 6) were managed conservatively with diet and exercise re-
striction prior to representing (450 and 330 days later, respectively)
for surgery.
3.2 | Diagnostic imaging
Radiographic findings included osteoarthritis or ossification around
the articular processes and extension of the dorsal lamina, flare of
the caudal epiphysis of the vertebral body, and subluxation of the
adjacent vertebrae. Myelography with neutral, flexed and extended
radiographic views under general anaesthesia was performed in all
cases to determine sites of compression preoperatively based on
50% reduction of dorsal contrast column. Computed tomographic
(CT) myelography was performed preoperatively in seven cases.
No horses were operated on a site identified by CT that was not
identified on radiographic myelogram. Recheck radiographs were
obtained periodically but repeat myelography or CT myelography
post-­operatively was not performed in any case.
3.3 | Surgery
Cervical vertebral fusion was successfully performed at one (n = 3)
or two (n = 7) sites by polyaxial pedicle screw and rod construct
(Figure 2). Surgery time ranged from 120 to 240 minutes (median
185 minutes; mean 178 minutes). Total anaesthesia time ranged
from 135 to 295 minutes (median 220 minutes; mean 213 minutes).
Recovery from general anaesthesia with head and tail rope assis-
tance was performed without complication in all cases.
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PEZZANITE et al. 351

F I G U R E 2 Radiographs of a 9-­year-­old Tennessee Walker gelding (Horse 2) taken 6 days (A), 6 months (B), 1 year (C) and 4 years (D)
post-­operatively, following stabilisation of C4-­5 and C5-­6, demonstrating progressive bone remodelling surrounding cervical stabilisation
implants. At 1-­year post-­operatively, the previously noted lucencies surrounding the screws placed within the cranial aspect of C5, and along
the caudal margin of the intervertebral fusion device within the C5-­6 intervertebral space were less noticeable and diffusely increased in
opacity. There was mildly increased sclerosis along the caudal margin of the screws within cranial C5 and unchanged mild sclerosis along
caudal C4, caudal C5 and cranial C6

3.4 | Perioperative medications laryngeal hemiplegia requiring tracheostomy (n = 1), right-­sided

Four horses were administered systemic intravenous antimicrobi-
als (potassium penicillin, gentamicin) for 4 days and the other five
received intravenous antimicrobials for 5-­8 days. Additional oral
antibiotics (trimethoprim sulfamethoxazole, 30 mg/kg, PO every
12 hours) were used in six cases, ranging from seven to 14 days dura-
tion following discontinuation of intravenous antimicrobials. Vitamin
E supplementation (5000 units by mouth every 24 hours) was pre-
scribed in three cases post-­operatively. Gabapentin (15 mg/kg by
mouth every 8 hours) was used for post-­operative pain management
in two cases.
3.5 | Short-­term complications
Seroma formation along the incision was recorded in all horses
(Table S2). Other short-­term complications that occurred while
in hospital affected eight horses and included evidence of post-­
operative pain (n = 5), fever (n = 4), post-­anaesthetic upper res-
piratory tract obstruction requiring tracheostomy (n = 1) and right
Horner's Syndrome (n = 1), dysphagia (n = 1), azotemia (n = 1) and
hives (n = 1). Antibiotic therapy was prolonged in two cases of se-
roma formation (trimethoprim sulfamethoxazole 30 mg/kg by mouth
every 12 hours for 2 weeks), and no further complications were en-
countered in either case. The cause of the fever was suspected to
be related to the intravenous catheter (n = 1), seroma formation and
intravenous catheter (n = 1), seroma formation alone (n = 1) and
post-­surgical inflammation as no other cause was identified (n = 1).
In the two horses requiring tracheostomy, Horse 8 developed
post-­anaesthetic upper respiratory tract obstruction and subse-
quent pulmonary oedema in the immediate post-­operative period
for which euthanasia was elected by the owners. Post-­m ortem
evaluation showed no evidence of pre-­existing recurrent laryngeal
nerve or cricoarytenoideus dorsalis muscle abnormalities. The
horse's airway obstruction was attributed to a prolonged period in
dorsal recumbency, over-­extension of the neck and post-­operative
vocalisation when he was returned to the stall. In Horse 9, dyspha-
gia in the early post-­operative period prompted endoscopic evalu-
ation which revealed right laryngeal hemiplegia and the horse was
maintained with a tracheostomy until discharge from the hospital.
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352
Endoscopic reexamination at 1 year post-­operatively showed
resolution of the right laryngeal hemiplegia. The same horse also
developed pain, fever and mild azotemia in the early postop-
erative period. He was fed soft soaked grass hay pellet mashes,
was administered 10 litres IV crystalloid fluids containing DMSO
(1 mL/kg) twice and the dysphagia resolved within 2 days post-­
operatively. He improved clinically over the next several days. The
azotemia was resolved by the time the horse was discharged from
the hospital. Horse 5 developed right-­sided Horner's Syndrome
post-­operative which was resolved when he was re-­examined
3 months post-­operatively. Horse 2 developed hives 3 days post-­
operative which resolved after treatment with antihistamines (di-
phenhydramine, 0.6 mg/kg, intramuscularly every 12 hours twice
and hydroxyzine, 1 mg/kg, by mouth once).
Five horses developed signs of post-­operative discomfort, and
further evaluation and treatment was pursued in three horses.
Horse 1 was pacing and pawing when returned to his stall imme-
diately post-­operative and stopped that behaviour when he was
fed. Horse 2 developed signs of mild colic 15 days after surgery for
which no cause was determined by abdominal ultrasound and tran-
srectal abdominal palpation. Horse 3 was frequently recumbent
during the first 2 weeks post-­operatively, at times demonstrating
difficulty rising and difficulty using his thoracic limbs. On exam-
ination he was found to be tight and had hypertonic musculature,
particularly through the thoracic and lumbar epaxial muscles and
gluteal muscles. Neck radiographs showed no abnormalities asso-
ciated with the implant and muscle enzyme concentrations were
not consistent with a myopathy or myositis. Neurological evalu-
ation did not show change in ataxia. The horse was administered
vitamin E (10 IU/kg by mouth every 24 hours) and received acu-
puncture and cold laser treatment for 20 minutes along the lumbar
musculature, twice. Follow-­up care at home included a rehabilita-
tion program consisting of hand walking and massage. The horse's
recovery of function was remarkable with a change of ataxia score
from 3 to 1 at 1-­year post-­operative and no obvious ataxia noticed
at 3-­years post-­operative (Table S3).
Horse 9 developed signs of mild colic after surgery for which
no cause was determined by abdominal ultrasound and transrectal
abdominal palpation. On day 8 post-­operatively he was observed
to be unwilling to bear weight fully on his right thoracic limb. Neck
radiographs showed no abnormalities associated with the implant
and muscle enzyme concentrations were not consistent with a
muscular origin of the pain. Neurological evaluation did not show
change in ataxia. He was administered butorphanol (0.02 mg/kg in-
tramuscularly every 4 hours for 24 hours followed by every 6 hours
for 24 hours) and gabapentin (15 mg/kg by mouth every 8 hours
for 14 days) and vitamin E (10 IU/kg by mouth every 24 hours for
14 days). Signs gradually resolved.
Horse 10 demonstrated signs of discomfort with tachycardia
(88 bpm) immediately upon returning to his stall post-­operatively.
Evaluation of the abdomen showed gastric distention with the
stomach visible at the 15th intercostal space (normal: 8-­10th inter-
costal space) and no further abnormalities on ultrasound evaluation
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PEZZANITE et al.
or examination per rectum. Signs of discomfort soon resolved, how-
ever, the horse remained tachycardic for several more hours. From
day four to nine post-­operatively, the horse demonstrated signs of
discomfort consisting of occasional pawing and pacing as well as
with more specific signs of thoracic limb pain. He showed signs of
muscle spasms and was reluctant to use his thoracic limbs. He also
would elevate and apparently rest his thoracic limbs on the auto-
matic waterer in his stall. Neck radiographs showed no abnormali-
ties associated with the implant and muscle enzyme concentrations
were not consistent with a muscular origin of the pain. Neurological
evaluation did not show change in ataxia. Horse 10 was treated
with acupuncture three times and gabapentin (15 mg/kg by mouth
every 8 hours) and butorphanol (0.02 mg/kg intramuscularly every
6 hours) in addition to phenylbutazone (2.2 mg/kg intravenously
every 12 hours) for a total of 14 days, including at home administra-
tion by the owner.
3.6 | Long-­term complications
Long-­term complications that occurred following hospital discharge
affected four horses and included excessive recumbency and sub-
sequent euthanasia (Horse 7), suspected implant infection, screw
breakage and nondisplaced fracture cranial aspect C5 (Horse 6),
screw breakage without other abnormalities (Horse 9) and mild
azotemia (Horse 10) (Table S2).
Horse 7 presented with grade 3 ataxia and was diagnosed with
CVCM at C6-­C7 and a questionable site of compression at C7-­T1.
Fusion was performed only at C6-­C7. The horse did well post-­
operatively in hospital but developed periods of excessive recum-
bency and difficulty rising around 21 days after surgery and was
euthanised 40 days after surgery. No further diagnostics or post-­
mortem evaluation were performed, and it is conceivable that the
horse continued to deteriorate neurologically because of CVCM at
C7-­T1. The clinical signs and time post-­operatively made it less likely
that pain was the cause of recumbency.
In Horse 6, a non-­displaced fracture, screw breakage and im-
plant infection were identified at 10 months post-­operatively
(Figure 3) when the horse was evaluated for lethargy, stiff neck,
and abnormal posture and gait, and evidence on complete blood
count of chronic inflammation 2 months following odontoplasty/
dental flotation. No pain on palpation of the fused vertebral bodies
or instability on radiographs was apparent; however, examination
findings indicated that the source of clinical signs was the neck. The
horse was treated for 6 weeks with oral antibiotics (trimethoprim
sulfamethoxazole 30 mg/kg PO q12h) resulting in improvement in
clinical signs and radiographic evidence of infection. The horse con-
tinued to do well.
In Horse 9, screw breakage was noted incidentally on recheck
radiographs at 15-­months post-­operatively (Figure 4); no treatment
was needed and the horse continued to do well. Horse 10 developed
mild azotemia after returning home, most likely related to restarting
anti-­inflammatory treatment used to manage arthritis. Non-­steroidal

PEZZANITE et al.
anti-­inflammatory drug administration was discontinued, and the
azotemia resolved. The horse continued to do well. Short-­and long-­
term complications are summarised in Table S2.
3.7 | Neurological and radiographic assessment
Post-­operative neurological evaluation was available for eight horses
for at least 1 year post-­operatively. The number of vertebrae fused,
vertebral fusion sites and grade of ataxia are summarised in Table S3.
For eight horses with ≥1-­year follow-­up, improvement of ataxia was
seen in 6 (3/6:1 grade, 2/6:2 grades; 1/6:3 grades) with average im-
provement of 1.25 grades. Although in two horses the gait did not
improve following surgery, neck comfort did improve. In five horses,
ataxia improved to grade 0-­1. Overall, this technique resulted in at
least one grade gait improvement in 6/10 of cases operated and 6/8
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353
F I G U R E 3 Radiographs of a 1-­year-­old Quarter Horse filly
(Horse 6) taken immediately following cervical interbody fusion
of C3-­4 and C4-­5 (A) and at 10 months post-­operatively (B). The
patient had represented at that time for lethargy, abnormal posture
and gait and had evidence on complete blood count of chronic
inflammation. Radiographs revealed an irregular oblique lucent
fracture line extending from the mid aspect of the C5 cranial
endplate extending caudally and ventrally, with mild sclerosis of the
C5 endplate. Both screws in the cranial ventral aspect of C5 were
fractured with slight caudal displacement. C5 was mildly ventrally
displaced in relation to C4, with mild focal asymmetric lucency
surrounding the caudal dorsal aspect of the intervertebral implant
and focal well-­defined lysis along the ventral caudal aspect of the
C4 endplate. Mild soft tissue swelling deviated the trachea ventrally
at the level of the C4-­5 orthopaedic implant, with suspected
regional infection of those implants. The cervical fusion implant
at C3-­4 was unchanged in position and appearance from previous
radiographs. The patient was treated with 6 weeks oral antibiotics
(trimethoprim sulfamethoxazole) resulting in improvement of
clinical signs and radiographic evidence of infection (C). Four years
post-­operatively the horse is doing well and used for ranch work
of cases for which ≥1-­year follow-­up was available. At the time that
long-­term owner follow-­up was sought, 7 of 10 horses were alive.
Two mature Tennessee Walking horses (Horses 2 and 10) were
noted to have the least improvement in ataxia over the time period
evaluated; however, neck comfort was reportedly improved with in-
creased range of motion and willingness to eat off the ground in both
cases. One of these horses, Horse 2, tested negative on serum for
Equine Protozoal Myeloencephalitis, but was treated with ponazuril
for a period of time 3 months prior to presentation. No response to
this treatment was noticed. Two horses were euthanised because
of complications related to surgery (Horse 8, airway obstruction)
or the primary disease (Horse 7, progressive neurological disease)
on days 0 and 40 post-­operatively, respectively. Horse 2 was eu-
thanised 4 years post-­operatively due to development of intestinal
lymphoma.
3.8 | Owner follow-­up
Long-­term owner follow-­up with survey consultation was available in
eight of 10 cases, excluding those that were euthanised in the early
post-­operative period. All eight owners reported that their horse's
clinical signs and quality of life were improved post-­operatively, and
all horses had increased in level of exercise since before surgery. Five
horses were being ridden at the time of follow-­up and one additional
juvenile horse was reportedly beginning training in the near future.
All four horses that had been ridden prior to surgery had reported
improvement. Two owners reported retiring or not pursuing ridden
competitive work, with one horse transitioning to an alternate ca-
reer in equine-­assisted therapy and the second horse being on pas-
ture turnout at the time of follow-­up. The length of time following
surgery until the highest level of exercise was achieved ranged from
5 to 24 months (median 16 months). Seven owners further reported
 |
354
F I G U R E 4 Radiographs of a 3-­year-­old Quarter Horse gelding
(Horse 9) taken immediately following cervical interbody fusion of
C3-­4 and C4-­5 (A) and at 15 months post-­operatively (B). Breakage
and slight displacement of the two caudal pedicle screws of the C3-­
4 stabilisation in the cranial C4 vertebral body was noted on routine
follow-­up radiographs. The cranial pedicle screws in the caudal C3
vertebral body, screws and interbody fusion device of C4-­5 were
unchanged with no evidence of failure. No treatment was indicated
and on recheck radiographs performed 6 months later no changes
were seen
either improvement in overall neck comfort, increased ability or will-
ingness to eat off the ground or improved neck comfort and range
of motion under saddle. Three owners noted that complications had
occurred associated with the surgical procedure, including implant
infection (Horse 6), airway obstruction requiring tracheotomy, neck
pain resulting in a thoracic limb gait deficit and mildly elevated cre-
atinine (Horse 9), and post-­operative pain (Horse 10). Overall, owner
satisfaction with the procedure was reported as excellent (n = 5) or
good (n = 2), with one owner not responding to this question. All
eight owners reported that they were overall very positive about
the procedure and would recommend this surgery to other horse-­
owners in the future.
4 | D I S CU S S I O N
This study describes a series of horses diagnosed with CVCM
that underwent cervical vertebral interbody fusion with an IFD in
conjunction with a polyaxial pedicle screw and rod construct, and
reports on clinical, radiographic and owner-­reported long-­term fol-
low-­up. Advantages of the studied technique compared to the other
currently used methods include that the IFD used here requires less
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PEZZANITE et al.
bone removal and leaves a thicker vertebral canal floor and that the
polyaxial screw head design allows for consistent application to the
variable shape of the ventral aspect of the cervical vertebral body.31
Furthermore, previous data has shown that the technique described
here leads to a variable amount of osseointegration at 8 months
post-­operative.31 Importantly, this technique provides stabilisation
in tension and compression, which is not afforded by the Bagby
basket or kerf-­cut cylinder implants.12,23,31 The technique reported
here was safely applied to stabilise one or two spinal units in 10
clinical cases of equine CVCM and resulted in improvement of ataxia
in 6/10 of cases overall and 6/8 of cases for which at least one year's
follow-­up was available. Although this technique resulted in screw
breakage in two cases, no catastrophic complications were encoun-
tered with implant placement. This is in contrast with failure of the
kerf-­cut cylinder, which typically results in vertebral body fracture
and worsening of neurological signs and may necessitate euthana-
sia.1,17 With regards to safety our result is promising; however, it
is important that this finding is corroborated in a larger number of
animals because fortunately catastrophic injuries are uncommon.
Clinical outcomes reported here are comparable to previous find-
ings describing surgical methods in obtaining one to two grades of
long-­term clinical improvement in ataxia.13,17-­20 Based on the ob-
servation of continued recovery of function after the 1-­year post-­
operative timepoint, we believe that it is important for clinicians to
continue monitoring horses that undergo this procedure beyond 1-­
year post-­operative.
Optimal treatment of equine CVCM remains controversial.
Medical management aims to reduce spinal cord compression and
resulting oedema through restricted diets and exercise in younger
horses (<1 year), in addition to nonsteroidal anti-­inflammatories,
corticosteroids and intra-­articular injections of any arthritic cer-
vical articular process joints. While improvement of neurological
signs was observed in 75% of mildly affected foals or yearlings
with equivocal radiographic changes that were subjected to stall
rest and restricted calorie diets, 8,9 one of these studies further
demonstrated that only 30% of Thoroughbreds conservatively
managed were able to return to racing. 8 Surgical cervical interbody
fusion carries a higher success rate when compared to conserva-
tive management in all but the lowest grades of ataxia, with higher
likelihood of greater improvement in younger horses (≤18 months)
with dynamic lesions.13 Of note, the definition of success has var-
ied between studies and has previously included improvement or
resolution of neurological deficits, return to intended athletic abil-
ity or use for breeding purposes.1,14-­19,21 Grant et al reported both
improvement in neurological function (92% 1 grade, 75% 2 grades)
and return to ridden work (83%) in 12 horses (median age 1 year)
undergoing myelographically confirmed triple-­level cord decom-
pression using Bagby basket arthrodesis. 20 Kuhnle et al further re-
ported on outcomes following ventral fusion of cervical vertebrae
using locking compression plates. This technique was associated
with side effects in a portion of cases, with 2/8 horses re-­operated
for implant loosening, 2/8 cases of plate breakage, 4/8 with ventral
screw migration and 1/8 suffering spinal cord injury. 22

PEZZANITE et al.
Enhanced techniques in diagnostic imaging have advanced the
understanding of pathology associated with CVCM causing spinal
cord compression, which has contributed to improved surgical out-
comes in stabilisation and was important for the successful imple-
mentation of the surgical techniques described here. Radiographic
findings identified in this case series were consistent with previously
described findings in horses with CVCM.33 Although no horses were
operated on a site identified by computed tomographic scan that was
not identified on radiographic myelogram, CT remained valuable for
assessment of the presence of axial compression. The identification
of the presence of axial versus abaxially located bony pathology or
lateralised versus ventral to dorsal compression may guide treat-
ment decisions. Horses with degenerative changes affecting the
axial surfaces of the articular process joints resulting in spinal cord
compression are much less likely to respond to conservative manage-
ment.13 All horses reported here underwent myelography preopera-
tively prior to vertebral stabilisation, including flexed and extended
radiographic views in all cases and CT myelography in seven cases.
Despite the inclusion of advanced imaging with every clinical case
and subsequent evaluation by board-­certified equine radiologists,
there remained question of additional spinal cord compression at one
site (Cases 7,8) or two sites (Case 9) that were not stabilised surgi-
cally. These findings highlight the difficulty clinicians face in defini-
tively determining sites of compression in some horses with CVCM as
well as determining the clinical relevance of each site of compression
in horses with multiple sites of compression, even with the benefit
of advanced imaging availability. Outcomes from surgical interven-
tions are likely to be adversely affected if clinically relevant sites of
compression are not recognised or addressed. Furthermore, recheck
myelography or CT myelography was not performed in any case in
this series, and may have been beneficial, particularly in the case eu-
thanised at day 40 post-­operatively for suspected continued deterio-
ration of neurological deficits.
Although one horse developed fatal upper airway obstruction
during the immediate post-­operative phase, complications associ-
ated specifically with placement of the IFD and polyaxial pedicle
screw and rod construct in this study were generally considered
relatively mild and did not necessitate reoperation in any of the
cases. Implant failure (screw breakage) was identified incidentally
in two cases but did not require treatment or euthanasia as have
been described following implant breakage with other methods
1,17,22,25
to stabilise the cervical spine. It was suspected that these
screws broke at this stage in the rehabilitation program due to fa-
tigue. It is also possible that the screws were placed at a shallower
depth in these horses compared to others in the case series, making
the lever arm longer and at higher risk for breakage. Anatomical
variation between cervical vertebrae may have also had an impact
on the depth to which screws could be placed resulting in their
location having greater motion than in others. Furthermore, im-
plant infection occurred in only 1/10 cases treated with polyaxial
pedicle screw and rod construct, which did not require reopera-
tion and resolved with oral antibiotic therapy. Similar to what has
been described for other cervical vertebral fusion techniques the
|
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355
development of seromas following this surgery was common, 22,34
but these recovered fast without the need for drainage. However,
the pain that was recognised in five horses in the short-­term after
surgery warrants further discussion. All five of these horses under-
went fusion surgery at two sites. For only one horse that underwent
fusion at two sites no pain in the short-­term was reported. In three
of the horses, signs of colic were appreciated that occurred within
hours of recovery from anaesthesia and that resolved without spe-
cific treatment. One horse developed signs of colic 2 weeks after
surgery that also resolved without further treatment. Three horses,
however, developed signs of discomfort characterised by excessive
recumbency, reluctance to move, and thoracic limb placement and
gait deficits. These three horses developed evidence of pain during
the first week post-­operative and signs resolved within 3 weeks
post-­operative. It is unclear regarding the exact cause of this post-­
operative pain but it could be related to changes in mechanical
forces to the spine following stabilisation potentially resulting in
nerve root impingement.
In only one case, euthanasia was elected by the owners follow-
ing development of post-­anaesthetic upper respiratory tract ob-
struction and pulmonary oedema in the immediate post-­operative
period. Extensive post-­mortem evaluation showed no evidence of
pre-­existing recurrent laryngeal nerve or cricoarytenoideus dorsalis
muscle abnormalities. The horse's airway obstruction was attributed
to a prolonged period in dorsal recumbency, over-­extension of the
neck and post-­operative vocalisation when he was returned to the
stall, risk factors that have previously been reported to result in this
complication.35 Histology of the cervical spinal cord identified that
moderate degenerative changes in the white matter is consistent
with Wallerian degeneration seen in CVCM. Surgical exposure of
the ventral aspect of the cervical vertebrae requires retraction of
the vagosympathetic nerve trunk and the recurrent laryngeal nerve,
both of which lie in close proximity to the carotid artery. Dysfunction
and damage to these nerves can occur when trauma occurs to the
carotid artery or directly to these nerves during retraction and the
surgical approach (B. Grant, personal communication).35 Moreover,
a review of post-­anaesthetic upper airway obstruction in horses
suggested that large body size, prolonged duration of anaesthesia,
hyperextension of the horse's neck in dorsal recumbency, hypoten-
sion, hypoventilation and hypoxemia are risk factors for this com-
plication.35 Evidence of a neuropathy such as Horner's Syndrome
or right laryngeal hemiplegia is usually not recognised until the
recovery period, such as the case in two horses described in this
report. In addition to airway obstruction developing secondary to
laryngeal oedema and swelling, it is possible for horses with pre-­
existing left laryngeal hemiplegia to develop bilateral hemiplegia if
the right laryngeal nerve has become dysfunctional following this
surgical procedure. Identification of left laryngeal hemiplegia prior
to this surgery is warranted, and in those cases a surgical approach
from the left side should be considered (B. Grant, personal commu-
nication). In order to minimise these complications in future cases,
efforts have been made to improve surgical positioning and reduce
time associated with the procedure. In recent cases, the authors
 |
356
have moved away from implementing the interbody device to re-
duce surgical time with greater attention paid to positioning of the
cervical region. It has not been the authors' impression that location
of operated sites has affected outcomes, but it is suspected that
single versus double-­level fusions are less disposed to development
of complications.
Minimal improvement in ataxia was noted in two of the eight
cases for which at least 1-­year follow-­up was available. Of inter-
est, both cases were the oldest horses evaluated in this case se-
ries, operated at 9 and 14 years of age, and both were Tennessee
Walking Horses. For Horse 9, it is possible that the spinal cord
damage was long-­s tanding and permanent that any occurrences
of regeneration or plasticity were insufficient and did not result
in recognisable change in gait. For Horse 10, it remains possible
that improvement will be detected during the second year post-­
operative as the horse continues rehabilitation. Both horses
reportedly did improve subjectively in neck comfort, range of mo-
tion and overall quality of life on owner follow-­up. These findings
suggest that this procedure also affects aspects of horse health
that we do not include in our neurological examination and that re-
covery of function is likely affected by the length of time the spinal
cord has undergone compressive injury. Both natural growth and
development of the animal as well as post-­operative neuromus-
cular repair mechanisms contribute to recovery of function, both
of which are likely affected by duration of dysfunction. All other
horses included in this case series underwent surgery at 4 years of
age or younger. While further enrolment of cases would be nec-
essary to draw conclusions regarding the relative efficacy of this
method of stabilisation in younger versus older horses, these find-
ings suggest that improvement in ataxia may be less likely to occur
in mature horses, although for some horses and clients, improve-
ment in comfort and exercise level would be considered a very
positive outcome. Furthermore, inability to detect small levels of
improvement are inherent to the relatively crude and subjective
assessment of ataxia using the modified Mayhew scale. Further
development of objective tools of gait analysis to detect ataxia
and minor differences remains an important area of development
36-­39
in equine neurology.
Several limitations in reporting study outcomes for this surgery
deserve further consideration. The patient population evaluated
was small (n = 10) and heterogeneous in age, breed, sex and in-
tended athletic purpose, which is reflective of the typical patient
population at this tertiary referral institution, but notably different
from previous reports regarding surgical management of CVCM
in that none of the horses in this case population were intended
to be racehorses. Improvement post-­operatively has historically
been defined differently across various studies, ranging from im-
proved neurological function, resolved ataxia, return to intended
use, competitive use, ridden work or racing,13-­21 and therefore the
intended purpose of the patients undergoing cervical interbody
fusion is important in determining and evaluating what is consid-
ered a successful outcome and difficult to compare across studies.
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PEZZANITE et al.
Enrolment of additional cases is necessary for full comparison to
more commonly employed techniques of cervical spinal stabilisa-
tion. A randomised prospective clinical trial with respect to other
cervical vertebral stabilisation techniques in the case population
evaluated would be necessary to fully compare outcomes between
methods.
In conclusion, polyaxial pedicle screw and rod systems for cer-
vical fusion should be considered as an alternative to minimise fatal
complications associated with implant placement while achieving one
to three grades of improvement in ataxia in the surgical treatment
of CVCM. Even in cases where we discovered screw breakage, this
complication did not affect the horse's life, which is in contrast with
what occurs when the basket or kerf-­cut cylinder fails. Application
of the polyaxial screw head feature is ideal for cervical stabilisation
as it conforms readily to the variable shape of the ventral cervical
vertebral body and is relatively easy to implement with training.
Further development and optimisation of surgical techniques may
result in further reduction of short-­term post-­operative complica-
tions, ability to place the construct at C7 -­T1, and greater neurolog-
ical improvement.
I N FO R M E D C O N S E N T
Owners provided consent for enrolment of client-­owned equine pa-
tients in this clinical study.
AC K N OW L E D G E M E N T S
The authors acknowledge and thank the clinical staff of the Colorado
State University Veterinary Teaching Hospital and members of the
Preclinical Surgical Research Laboratory who provided patient care
and assisted with the surgical procedures.
C O N FL I C T O F I N T E R E S T S
J. Easley is a member of the Scientific Advisory Board for Artemedics,
LLC. The other authors declare no other competing interests related
to this report.
AU T H O R C O N T R I B U T I O N S
J. Easley, H. Seim and Y. S. Nout-­L omas contributed to study
conception and design. All authors contributed to acquisition
of data. Y. S. Nout-­L omas, J. Easley, L. Pezzanite and R. Bayless
contributed to data analysis and interpretation. L. Pezzanite, Y. S.
Nout-­L omas, R. Bayless and J. Easley contributing to drafting of
the manuscript. All authors contributed to and approved the final
manuscript.
ETHICAL ANIMAL RESEARCH
This study was approved by the Institutional Clinical Review Board
of Colorado State University.
PEER REVIEW
The peer review history for this article is available at https://publo​
ns.com/publo​n/10.1111/evj.13449.
 |

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PEZZANITE et al. 357

DATA ACC E S S I B I L I T Y S TAT E M E N T of the first World Orthopaedic Veterinary Congress. ESVOT & VOS,
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Brad B. Nelson https://orcid.org/0000-0002-0205-418X
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Yvette S. Nout-­Lomas https://orcid.org/0000-0001-6583-2308 Kümmerle J, et al Outcome of ventral fusion of two or three cer-
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