Thermography and Ultrasonography in Back Pain Diagnosis of ... · Reprint requests: Professor...

ORIGINAL RESEARCH

Volume 26, Number 11 507

ABSTRACT

The object of the current study was to evaluate the efficacyof thermography and ultrasonography in the diagnosis ofthoracolumbar lesions in Quarter Horse athletes and asso-ciate the different types of lesions found with the athleticmodality practiced. Twenty-four horses were admitted tothe Surgery Service for Large Animals of the Veterinaryand Animal Science Faculty, UNESP, Botucatu, Brazil,with complaints of back problems. All the horses weresubmitted for physical examinations to confirm the exis-tence of thoracolumbar alterations and then for thermog-raphy and ultrasonography. Thermography was used tomap the lesioned areas of this region and ultrasonographyfor lesion characterization. The lesions found weresupraspinous desmitis, interspinous desmitis, dorsal inter-vertebral osteoarthritis, and impingement of the spinousprocesses or kissing spines. The existence of a relation be-tween the type of event practiced by the horse and the typeof lesion found was determined. In horses that competedin the barrel race, a predominance of lesions in the tho-racic caudal, thoracolumbar, and cranial lumbar regionsoccurred, with intervertebral osteoarthritis and inter-spinous desmitis being the most common. In cuttinghorses, most of the lesions were observed in the caudallumbar region, whereas horses competing in reiningshowed a preferential location for lesions in the middlelumbar, with a predominance of supraspinous desmitis andmyositis. Thermography associated with ultrasonographywas shown to be efficient in the diagnosis of the thora-columbar lesions of these horses.

Keywords: back pain; lameness; loss of performance;vertebral column

From Surgery Service for Large Animals of the Veterinary and Animal ScienceFaculty of the São Paulo State University (UNESP), Botucatu Campus.Reprint requests: Professor Doutor Fonseca, Departamento de Cirurgia e anestesi-ologia Veterinária, FMVZ – UNESP – Botucatu - Distrito de Rubião Jr, s/n, CP560, 18618-000 – Botucatu/SP.0737-0806/$ - see front matter© 2006 Elsevier Inc. All rights reserved.doi:10.1016/j.jevs.2006.09.007

Thermography and Ultrasonography in Back PainDiagnosis of Equine AthletesB.P.A. Fonseca, MS, A.L.G. Alves, PhD, J.L.M. Nicoletti, PhD, A. Thomassian, PhD, C.A. Hussni, PhD, and S. Mikail, DVM

REFEREED

INTRODUCTIONThe elevated incidence of back problems, difficulty of di-agnosis, and importance of this anatomic region in loco-motion of the equine species justify investigations in thisarea, principally those directed at improved quality in di-agnosis and consequent therapeutic innovation.

Currently, a growing number of horses are purchasedand trained for participation in equestrian sports inBrazil, especially the western sports engaged in by theQuarter Horse. These horses compete in reining, cut-ting, team roping, and barrel racing events, in which de-mands for exercises at high speeds and abrupt stops orchanges in direction are observed and consideredunique in the equestrian athletic world. These demandsgenerate a constant challenge to the musculoskeletal sys-tem, often passing the physiologic limits of these horses,with consequent compromise to the health of the loco-motor system, in such a manner that the incidence ofcertain lesions for specific sports is clear, although backpain is observed in all western modalities.1 Diagnosis ofthe source of equine lameness is often difficult, princi-pally in cases in which the pain is located in the proximalhind limbs and is not related to synovial structures.2,3

Back pain is included in this category of lesions. Lumbarpain, whether of primary or secondary origin, is an im-portant cause of the loss of performance in equine ath-letes.4,5 Therefore, diagnosis of both the location of le-sions and their magnitude, in terms of pain, is difficult,because frequently the most evident clinical sign is notthe pain itself, but the loss of performance.6,7

We believe that scientific and technological advances inthe diagnosis of back problems are essential to enablehorses to express their maximum athletic potential,whether in western sports or in many other equestriansporting modalities. Increased development in thermog-raphy and ultrasonography as complementary diagnosismethods has been observed worldwide by means of thenumerous papers published in the last few years.8,9 InBrazil, notable interest in the use of thermogram and ul-trasonogram in the diagnosis of lameness has been ob-served, though controlled studies relating thermographic

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508 Journal of Equine Veterinary Science November 2006

and ultrasonographic images to clinical findings in casesof lumbar pain do not exist.

Thus, the objectives of the current study were to eval-uate the efficacy of thermogram and ultrasonogram in thediagnosis of thoracolumbar lesions in Quarter Horse ath-letes and to associate the different types of lesions foundwith the athletic modalities practiced: cutting, reining,and barrel racing.

MATERIALS AND METHODSTwenty-four Quarter Horses were used, aged between 4and 8 years, of both sexes (11 male and 13 female) and allactive athletes. The horses were admitted to the SurgeryService for Large Animals of the Veterinary and AnimalScience Faculty of the São Paulo State University(UNESP), Botucatu Campus in Brazil, with complaintsof back pain, during the period April 2004 to May 2005.These horses competed in three sporting modalitieswithin western categories: reining (4 animals), cutting (9animals), and barrel racing (11 animals).

A physical examination of the locomotor apparatus ofeach horse was performed with the horse static. The ex-amination evaluated alterations in posture, conforma-tion, and movement to characterize the type and degreeof lameness and to perform flexion tests,10 with the ob-jective of excluding horses that presented lameness unre-lated to the thoracolumbar region. The physical exami-nation of the thoracolumbar region comprisedinspection, palpation, and mobility tests in accordancewith known protocols.5,8,11

A thermography examination (DTIS 500, EmergeVision) was performed after the physical examination,with a period of 1 hour between examinations, so thatbody temperature of the horse returned to normal.Thermographic images were obtained from the followingpositions: side view of the body and neck from both sides,including the side of the hind limb, and dorsal view of theextension of the vertebral column divided into thora-columbar view and lumbosacral view.

The examinations were performed in the Equine SportsMedicine Center (Centro de Medicina Esportiva Eqüina)of the FMVZ, UNESP, Botucatu Campus, Brazil, whilemaintaining the environment as stable as possible in rela-tion to the natural temperature and humidity. Directmarking and visualization of the exact locations of alter-ations in the thermal pattern was realized through the useof adhesive tape (Fig. 1). The parameters of normal ther-mal profile at rest were based on preestablished norms.9 Atemperature difference between antimeres within a rangeof 0.5°C to 1°C was considered normal. After mappingthe thoracolumbar region using the thermography exam-ination, ultrasonography (SSD-900, Aloka, Japan) of thisarea was performed using a 7.5-MHz linear transducer.

For the ultrasonographic examination, the area underevaluation was prepared by moistening the hairs with

warm water and applying hydrosoluble contact gel(Ultra-gel, Ind. e Comércio de Produtos GelatinososLtda, São Paulo, Brazil) for the best contact with thetransducer. Median, paramedian, and transverse ap-proaches were combined for complete access to axialstructures.12

Supraspinous ligament lesions were characterized ac-cording to their echogenicity and parallelism of the fibers;lesions of the interspinous space were classified accordingto increased echogenicity, presence of hyperechoic pointsin the space, and the reduction or loss of the space.Spinous processes were characterized regarding the regu-larity of the dorsal surface. Kissing spines were consideredpresent when a continuity of the bone line between twoor more spine processes, with loss of interspinous space,was observed. This may or may not have been associatedwith supraspinous desmitis.12

Articular processes were classified with regard to theregularity of the articular surface and the reduction or lossof articular space.12 The muscles were characterized bythe echogenicity of the fibers (hypoechoic zones) andperimysium (hyperechoic lines separating the fibers).Presence of a hypoechoic or anechoic gap within the mus-cle fibers was considered a criteria for the myositis diag-nosis. In chronic cases, a fibrosis area can appear as a hy-perechoic circumscribed lesion.13

All examined and diagnosed animals were treated.Treatments used were: supraspinous and interspinousdesmitis: paravertebral infiltrations with steroids (methyl-prednisolone acetate, depo-medrol, Pfizer; 40 mg/pointof injection) and neurolytics (Sarapin, High ChemicalCompany; 2 ml/point of injection) in the lesion area;myositis: muscle relaxants (Tiocolchicosido, Coltrax,Aventis Pharma; 20 mg/animal intramuscularly) andnonsteroidal anti-inflammatories (PhenylbutazoneButazolidina, Novartis; 2.2 mg/kg intramuscularly); dor-sal intervertebral osteoarthritis: local infiltration in themultifidus muscle with steroids; kissing spines: shockwave therapy.

RESULTSIn all horses, presence of thoracolumbar pain was con-firmed by means of the physical examination performed.The degree and type of pain response and mobility alter-ations varied between horses, whereas more than one re-sponse could be found in a single horse.

Only three horses presented lameness, and in all casesthe diagnosis of back pain preceded that of lameness.Alterations were observed in movement, principally inthe circle gallop examination, where diminisheddorsoventral mobility and shortness of gait were themost commonly observed.

In the thermogram, a high number of hot spots in thethoracic region were observed (65.4%), most in the mid-line (46.1%), corresponding to the trajectory of spinous



and supraspinous ligament processes (Fig. 2). In fourhorses, hot spots were observed in the lumbar region,which suggests Longissimus dorsi myositis in the area cor-responding to the increased temperature (Fig. 3), whereasthe predominant finding in the lumbar region was coldspots (Fig. 4).

In the images obtained on ultrasound examination,both soft tissue and bone tissue lesions were identified.The lesion with the highest incidence was supraspinousdesmitis, followed by dorsal intervertebral osteoarthri-tis, interspinous desmitis, spinous processes syndrome,and Longissimus dorsi lesions, suggesting myositis (Fig.

Figure 1. Thermogram with the respective markings of thermographic findings.

Figure 2. Thermogram with hot spots (arrows) alongthe dorsal midline of a horse suggesting supraspinousand interspinous desmitis.

Figure 3. Thermogram with a hot spot (arrow) in thelumbar region of a horse suggesting Longissimus dorsimyositis.



5), although more than one lesion type could be foundon the same horse.

The ultrasound examination showed that supra-spinous and interspinous ligament lesions and spinousprocesses were best observed in the longitudinal scans;in the case of supraspinous ligament, by the reduceddiameter and by the fact that most of the lesions ob-served were located at the insertion of this ligament inspinous processes, best seen in the longitudinal view.For dorsal intervertebral articulations and epaxial mus-cle, the transverse images were more elucidative (Figs.6, 7, 8, and 9).

Dorsal intervertebral osteoarthritis was observed in thecaudal thoracic and lumbar region of the horses examined(Fig. 5) and occurred either unilaterally (15 vertebrae) orbilaterally (17 vertebrae) in any particular vertebra. Inthree horses, only one lesioned articulation was found,whereas in the remaining horses (n � 9), at least two ar-ticulations were affected.

After performance of both examinations, it was possibleto ascertain a relationship between the images obtainedby thermography and those obtained by ultrasonography.In the case of hot spots, in all locations indicated by thethermography, a corresponding lesion was found; how-ever, in some horses, not all of the lesions that were po-tential causes of local temperature increase observed usingultrasonography were detected by thermography (Fig.10, Table 1).

In contrast, in the images of cold spots, a relation be-tween the thermographic and ultrasonographic imageswas seen in all horses. In the case of cold spots, their ex-tension, rather than their number, was computed.

Separating the horses submitted to the thermographyand ultrasonography examinations according to the ath-letic modality practiced (cutting, reining, and barrel rac-ing), a relationship between these events and the types oflesions found was observed.

According to sporting modality, horses competing incutting events showed a predominance for supraspinousdesmitis (89%), followed by dorsal intervertebral os-teoarthritis (44.4%); in barrel racing horses, osteoarthritiswas the lesion of highest incidence (63.6%), followed byinterspinous desmitis (45.5%), whereas in horses practic-ing reining, supraspinous desmitis was the lesion foundmost frequently (100%), followed by Longissimus dorsi le-sions (50%).

Among barrel race horses with osteoarthritis, 87.5% ofthe lesions observed were unilateral, and of these, 62.5%occurred on the right side, a fact probably due to thehorse turning twice at the barrel on the right side andonly once at the barrel on the left.

Among the cutting horses with dorsal intervertebral os-teoarthritis, 62% presented this lesion in the caudal lum-bar region, located in the articulation between L3 and L4up to articulation L5 and L6; whereas in barrel-racinghorses, 65% of the affected articulations were found in thecranial lumbar region, from the thoracolumbar articula-tion up to the articulation between L2 and L3. The onlyaffected reining horse presented lesions between L2 andL3, bilaterally.

After treatment, only one animal did not present im-provement in the clinic board after treatment, failing toreturn to athletic performance. This animal was diag-nosed with dorsal intervertebral osteoarthritis. All other

Figure 4. Thermogram with cold spots (arrows) inthe lumbar region of a horse, suggesting dorsal inter-vertebral osteoarthritis.

Figure 5. Alterations found in the ultrasonographyexamination of the horses examined: (DIOA) dorsalintervertebral osteoarthritis; (SSD) supraspinousdesmitis; (ISD) interspinous desmitis; (KS) kissingspines; (MS) myositis.



Figure 6. Ultrasonographic image of supraspinous desmitis, showing the irregularity of the associated spinous pro-cess, with an anechoic focus in the ligament. Longitudinal view. CR—cranial; CA—caudal.

horses returned to athletic performance, without present-ing clinical signs of back pain.

DISCUSSIONDetermining the exact location of the lesion and thecause of pain using physical examination only was notpossible, although the pain could be determined as origi-nating from the thoracic or lumbar region,2,11 using as abase the horse’s response to epaxial structure palpation,the mobilization examinations, and inspection at work.

The best gait for examining the movement of the ver-tebral column was the gallop, where the horse’s neck as-sumes different positions.11,14 Among these antalgic gaits,the cervical position during movement of the horsesstood out, because the neck has a direct influence on thebiomechanics of the vertebral spine, especially by meansof the nuchal connection that continues into the thora-columbar spine as a supraspinous connection.15 When theanimal bends its neck, that is, puts it down, a flexion of

the entire thoracic spine occurs, by the augmentation ofthe tension of the nuchal connection, increasing theamount of movement, especially between T6 and T10.Horses with thoracic pain have a tendency to lower theneck during work. In the lumbar region, cervical flexionreduces the amount of lateral bending and rotation al-lowed, especially between T18 and L5. Because of this,horses with lumbar pain tend to raise the neck to increasemobility and reduce stress in this region.15

Regarding thermography in the examined horses in thisstudy, the predominant findings were hot spots; the casesof supraspinous and interspinous desmitis and muscularlesion depicted inflammatory lesions that led to increasedlocal surface temperatures.9,16 The thermographic findingassociated with possibility of myositis is an increase oftemperature in the region of the Longissimus dorsi.Increase in temperature in this region can be from themuscle or from the skin and subcutaneous tissue.17

Animals were examined for dermatological health before

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the thermographic examination, so that only animalswithout cutis lesions in the thoracic and lumbar regionswere submitted to this examination. Therefore, the onlypossible structure capable of creating heat in an abnormalmanner at the time of examination was the thoracolum-bar muscle.

Cold spots occurred in cases of dorsal intervertebral os-teoarthritis, which causes local pain without causing aninflammatory reaction at the lesion location.9 Some au-thors9,18 contradict this statement, classifying only hotspots as active, that is, as causes of pain. In view of the factthat lesions of these articulations were only found in thelumbar region, clearly a predominance of cold spots oc-curs in this location.

For the exact location of hot and cold spots, adhesivetape was used. No reports of similar lesion marking meth-ods were found in the literature, with no description ofany such technique. Thus, thermography presented a greatpotential as an auxiliary in back pain diagnosis, because it

quickly reveals the presence or absence of alterations inthis region, whether inflammatory or degenerative.

Desmitis of the supraspinous ligament was visualizedas areas of diminished echogenicity and loss of fiber par-allelism in this ligament.12 Another finding related tosupraspinous desmitis in some cases was the presence ofpoints of increased echogenicity in the ligament, indi-cating the presence of tissue fibrosis in certain areas; aspresented in the suspensory ligament of the fetlockjoint,18 an occurrence that was not described by someauthors.8,12

In the case of the interspinous ligament, images wereobtained in longitudinal scans. The lesions found in thisligament were especially characterized by increasedechogenicity and the presence of hyperechoic points. Insome cases, visualizing diminished interspinous space andeven the loss of this space was possible.12

In the case of articular processes, use of a sectorialtransducer of 3.5 MHz or 5.0 MHz to obtain images of

Figure 7. Ultrasonographic image of interspinous desmitis, showing increased dorsal echogenicity and hyperechoicfoci in the ligament. Arrows indicate the lesion location. Longitudinal view. CR—cranial; CA—caudal.



This finding reaffirms the fact that kissing spines is oftena subclinical condition found in asymptomatic horses.14,20

Considering the cold spots, a correlation between thethermographic and ultrasonographic findings occurred.All horses that exhibited diminished surface temperaturehave associated lesions found by ultrasonography.

Dorsal intervertebral osteoarthritis was the lesionfound and considered as the cause of this type of alter-ation in the thermal pattern, which led indirectly to di-minished surface temperature by action on the vasomotortonus, causing a local vasoconstriction.9,17 Haussler etal,20 Leclaire et al,7 and Denoix12 stated that interverte-bral osteoarthritis is the greatest cause of back pain inhorses. Taken as stated, this declaration suggests that thegreater part of the lesions found in this articulation wereactive, thus causing pain to the horse. In contrast, in thecurrent study, all horses that showed ultrasonographic al-terations in this articulation also presented cold spots in

this structure is recommended by authors.11,12 However,performing a complete examination of this articulationwith a 7.5-MHz linear transducer was possible.

The findings obtained by thermography could be cor-related to those obtained by ultrasonography, as previ-ously described for cases of tendonitis.19 In the case of hotspots, all of them possessed an associated lesion identifiedwith ultrasonography, but not all the lesions that couldlead to diagnosable increased surface temperature, such assupraspinous and interspinous desmitis, were detectedwith thermography. This was probably because the non-indicated lesions showed images compatible with chronicinactive processes, as also described in studies withThoroughbred racing horses.8

Another case in which thermography did not reveal thepresence of a lesion was in the kissing spines, found infour horses examined here. In these cases, the lesionedarea presented no thermographic alteration whatsoever.

Figure 8. Ultrasonographic image of kissing spines, where the continuity between the bone line of two adjacentspinous processes can be observed, indicated by the arrow. Longitudinal view. CR—cranial; CA—caudal.



Figure 9. Ultrasonographic image of dorsal intervertebral osteoarthritis, showing the irregularity of the cranial andcaudal articular process, with loss of articular space. (R) right; (L) left; (white arrow) articular space; (red arrow) le-sion. Transverse view.

Figure 10. Relationship between the number of hot spots found in the thermography examination and the numberof lesions found in the ultrasonography examination.



their thermal maps, demonstrating that all the lesionswere active.12

Regarding athletic activity, in the current study a rela-tionship could be established between the sportingmodality practiced by the horse and the lesions found. Inhorses that competed in cutting, the lesion showing high-est incidence was supraspinous desmitis, followed by dor-sal intervertebral osteoarthritis. The prevalence of theselesions can be explained by the type of movement per-formed by the horse and in the way this movement al-tered the vertebral column biomechanics in thesehorses.21 In this sport, the horse adopts a position offorced ventriflexion throughout almost the entire periodof competition. This position increases tension in thesupraspinous ligament and on the dorsal intervertebral ar-ticulations of the lumbar region, principally from L4 on-ward. This would explain the findings from this studyshowing a majority of the osteoarthritis lesions in articu-lations of the caudal lumbar region.

In horses competing in three-barrel racing, the infirmi-ties of greatest incidence were dorsal intervertebral os-teoarthritis and interspinous desmitis. In this modality,

lateroflexion and rotation movements are more fre-quently realized by the horse. These movements act di-rectly on the dorsal intervertebral articulations, princi-pally in the lumbar region because of its characteristicconfiguration in this region, and on the interspinous lig-aments, which, during the axial rotation movement, suf-fer increased tension force.15 The articulations affected byosteoarthritis are predominantly located in the lumbar re-gion between L1 and L3, because rotation and lateroflex-ion movements act principally on the cranial lumbar ver-tebrae, whereas from L4 or L5 the vertebrae are stabilizedby intertransverse articulations.15

For horses competing in reining, it was difficult to drawa concise relationship between the alterations in thebiomechanics of the horse caused by the movement dur-ing competition and the lesions found, because only fourhorses were examined, but these animals show a tendencyto present supraspinous desmitis and Longissimus dorsimuscle lesions. This prevalence can be associated withmovements made during competition, where the horsesrepeatedly perform dorsoventriflexion (slide) and lat-eroflexion (spin). These movements increase tension on

Number ofBunning Cervical Cervical Number of Lesions in the

Animal Hoppe Bending 10 Extension Hot Spots Ultrasound

1 - � - 3 32 � - - 5 63 � � - 6 64 � - - 2 25 - � - 4 46 � - - 3 37 �� - - 4 78 - - �� 5 69 - - - 5 510 � - �� 6 611 - � - 2 712 - �� 6 1013 �� - - 4 414 - �� 5 715 � � - 4 416 � - - 2 217 � � - 6 718 � - - 5 519 � �� - 2 420 �� - - 1 121 �� - 5 522 - � - 4 423 �� - - 4 424 �� - - 3 4

(-) normal; (�) mild; (��) moderate; (��) severe.

Table 1. Relationship between the physical examination (at work), number of hot spots found in the thermographicexamination, and the number of lesions found in the ultrasonographic examination



the supraspinous ligament and dorsal intervertebral artic-ulations, respectively, based on thoracolumbar biome-chanics,15,22 which could explain the incidence of thesetwo lesions in these horses. Occurrence of muscular le-sions can be associated with the fact that the competingtime for reining is relatively long with repeated move-ments, as previously noted, which leads to an overloadingof the thoracolumbar musculature, principally the epaxialmuscles, which provide stability to the vertebral columnduring ventriflexion movement.1,15

In conclusion, when analyzing the results obtainedunder the conditions of this study, thermography and ul-trasonography associated with a physical examinationproved to be a rapid and efficient method for diagnosis ofexisting lesions in the thoracolumbar region. In addition,it was found that the sporting event practiced by a horseand the type of lesion present in the thoracolumbar re-gion are related.

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