Liam's Final Chapter

Today, I had my sweet, bright, alert and enthusiastic 2 year old euthanized.

The cute snoot

OSU diagnosed Liam with wobblers. They rated him a 4/5 on the neurological scale, which also made him ineligible for the ultra expensive basket surgery that attempts to correct wobblers. Surgery will generally downgrade horses by one grade, two grades if they're lucky. Surgery is therefore only done on horses who are grade 1 or 2, SOMETIMES 3. At 4, Liam was a non-surgical candidate. Grade 1 is sometimes rideable, grade 2 is sometimes pasture sound.

After a baseline neuro test that showed he struggled to control his hind end and triggered some struggle with his front, we moved on to neck radiographs.

From https://veteriankey.com/the-neck-and-back/

The radiographs painted a very bleak picture. Liam's neck was still growing since the growth plates are still open in the vertebrae (and at 2, they should be). The C1 to C3 looked good, with normal joint spaces and what appears to be plenty of room for the spinal column to pass through. The joint space between C4/C5 was a little cloudy and ill-defined, indicating some arthritis. The joint space between C5/C6 and C6/C7 were both very cloudy and barely defined, indicating severe arthritis.

Normal growth plate, MSD, SD, and the unlabeled green ovals are joint spaces.

The C4/C5 space is a little cloudy. C5/C6 is pretty cloudy, and the C6/C7 has a very occluded edges.
Not pictured, C7/T1. Rood and Riddle also suspected severe arthritis in that joint as it was just as occluded as C6/C7.

A secondary problem in the C7 vertebrae was a narrowing of the spinal column space (minimal sagittal diameter-MSD below) in relation to the sagittal diameter (SD below). The C7 should be the widest channel of all the cervical vertebrae. The ratio of MSD:SD should be 50% for C2-C6, and closer to 60% for C7. Not only does his C7 narrow, it was the lowest percentage of the 6 at 51%.

From https://dspace.library.uu.nl/bitstream/handle/1874/289531/Scriptie.pdf

The neck presented solid enough evidence, that when combined with his in hand neuro tests, the vets were confident that his spinal cord was being compressed somewhere in the neck, most likely near the base, but it cannot be determined from only x-rays. X-rays only paint a single cross section of the horse, meaning, while it appears the C7 spinal cord channel has gotten shorter in height, it could also be wider than the other vertebrae, which would not cause compression. Sadly, x-rays cannot be shot from above. I could opt to take him to Rood and Riddle, who would do a CT scan of majority of his neck. It would go up to the shoulders, which are simply too big to fit in the machine, so we may not even see the C7 in the scan. The other option was a myelogram.

Myelograms are highly invasive procedures where the horse is put under general anesthesia and a spinal tap is done at the cranium. Special dye is injected into the spinal column and the horse's neck is extended and flexed, and x-rays are taken as it progresses down the spinal column to see where the dye stops (which indicates compression). It is a relatively traumatic procedure for the spinal column and can result in seizures and a temporary increase in neurological issues after the horse wakes up.

Here is a great link to the myelogram procedure.

The day I officially signed papers and paid for him 

Reasons to do a myelogram: confirm exact locations of compression for surgery, confirm compression for insurance purposes, confirm for a personal need to know.

None of those reasons apply to Liam. He's not a surgical candidate even if we could find it. I didn't get insurance set up on him yet so they have no say (I'm sure that would be audited and questioned, oh geez... 2 months in and a major claim on a fairly clear PPE? FRAUD). Finally, I personally do not need to know more beyond 'in the neck somewhere'. My need to know does not out weigh the suffering he would go through waking up. The vets warned me he would probably be grade 5/5 coming out of a myelogram and would probably need a sling to stand up and stay standing.

Beefcake! His shoulders really grew at the end of May- his topline was much more level in June than in this pic from April.

The vets did put out another offer: they can do the myelogram and just not wake him up... euthanize him on the table so to speak.

I didn't think the cost of doing a myelogram justified my need to know. I spoke with event trainer, who whole heartedly agreed we don't need to know.

Liam wasn't sure he needed to know about this ball.

So instead, Liam spent several more days at OSU with several gallon size bags of horse cookies (no lie, I left 4 gallon bags of treats and 2lb of carrots), and a note that said "Please feed me LOTS of treats. I also enjoy neck scratches."  I had to go home and work several days, but then I went back Wednesday to spend time with him, and today followed the shipper back to event trainer's farm. The vets gave him a bunch of anti-inflammatories to help him be more stable for the trip home, and he arrived without a scratch. The vet met us there, and he was humanely euthanized this afternoon, happy in the sun and eating grass.

Handsome boy

Sometimes you can try "stunting" the growth of a young horse with mild wobblers and pristine neck rads, and try to get them to grow out of it. The advanced level of his neck arthritis made this option a non-option.

Sometimes high doses of vitamin e also alleviate the inflammation in the spinal column. Natural Vitamin E (d-alpha, not dl-alpha) crosses the blood/brain barrier quite easily making it an excellent anti-inflammatory for the spinal cord. Therapeutic doses for this are 10,000 IU a day. We were already doing that.

The vet said we could reasonably give him anti-inflammatories for the next 3 weeks and keep him on stall rest to see if he got better and by how much. This didn't have a good feel for me, he could hurt himself at any time. This option just prolonged the inevitable with possibility of disaster.

He took his napping VERY seriously. He would lay flat out for an hour at least once a day.
He scared his vet tech the day before he came home- he was down flat out in the stall and twitching all over. I told his vet upon his arrival that he does do this daily, and it's perfectly normal for him to be down for more than an hour.The tech called her thinking Liam was having a seizure. Better safe than sorry!

We don't know why he suddenly went downhill very fast. None of his genetic line have reported cases of wobblers in the foals. His dam was carefully matched to a stallion. He was carefully fed by a wonderful woman with 40+ years of growing baby horses experience. He was turned out as a baby and yearling. All of the right boxes were checked. He also checked off the big ticket at risk checklist: big, fast growing, male, baby warmblood. What made the arthritis happen? Who knows. OSU ruled out injury since the issue is in more than one joint space. He has been brewing this for a while, it didn't just happen in the last two months. I do not think anyone knew about it, I want that clear. I do not think I was misled or lied to. The prevailing thought is he was brewing the arthritis and he might have slipped in the field playing with his new friends and tweaked it in a chain reaction. He also grew again at the end of May, where his chest widened a little so he wasn't so base narrow and he got taller. All of the above? None of the above? Wobblers is poorly understood and unfortunately is put in the "shit happens" category.

I do not think his PPE failed either. We had no reason to suspect neck issues and it doesn't make sense to do a PPE that costs 40% of the cost of the horse.

So itchy! He was always up for a grooming session with lots of currying.
Link to YouTube

I am going to try to rejoice and treasure the time I got to spend with him. Working on his confidence in the world around him, standing and leading skills, and marveling at his think first personality that lead to an incredibly brave, curious, and sensible baby horse with an old soul. I'll remember the head hugs he gave me when I cried into his neck the weekend he spent at OSU waiting to come home. How he groomed my leg with his nose when I scratched just the right spot on his neck. How quickly he came to trust me when I would tell him "step" from the halt when he was scared, and he'd pick up a front leg and put it on a mat or different color pavement or whatever was frightening him at the time. He was the horse I wanted, for sure. I was thrilled to make him a long term partner to do all the things with. I even considered a return to low level eventing because he was so sensible and had a great sense of self-preservation. I am heartbroken that it ended like this.

I taught him to step confidently onto a mat to prep him to be confident stepping into a trailer.

I feel like I failed him, even though I know we did everything that was reasonable. Putting him down was so difficult when he was bright, alert, hungry, and interested in life. He was perfectly aware he couldn't do things and was happy to walk slowly and didn't get riled up about being left behind. His mind was still perfectly intact while his body failed. In reality, I know he was dangerous. He could have wiped out at any time, injuring himself, another horse, or a person. He could have spooked and fallen and broken his neck or suffered some other traumatic event requiring an emergency vet to rush out to euthanize him... and he'd have to wait for that vet in pain. All of that logic still doesn't make it any better to have to euthanize a 2 year old who is still mentally vibrant.

Oh curiosity! He finally got over his fear of water, decided this puddle was fun, decided to roll in it, and then changed his mind half way down and kneeled for a while.

I had finally picked a registered name for him and sent it in with his DNA sample: Legato. "In music performance and notation, legato indicates that musical notes are played or sung smoothly and connected." It was a hope for connection and flow in the future. Maybe I should have kept it as Lawless, since he broke all the foaling rules and all the growing rules it seems.

At this point, I am not very upset at the further loss of my dreams. Those have been dead for a while. I have not been hungry in a while. I'm more upset at the loss of a budding relationship that should have had years to bloom and grow. But I am most upset about the life Liam never got to live. At least in his brief time here, he only knew grass and love, and never unkindness.

Legato "Liam"
April 30, 2017 - June 27, 2019

Liam's Pre-OSU Story

Before I get into OSU's findings, I want to go through what took us there.

I called the emergency vet many Fridays (5/31) ago when a hind end lameness turned full blown neurological. I already had an appointment for a vet to come out for a lameness exam to see if he pulled something stomping at flies, but swaying and staggering changed things... it wasn't a pulled muscle anymore, he was sick.

The emergency vet came out and took his temp (101.2, a very slight fever), did a run over of all his joints and general condition. She had him walk away from her, and turn small circles. She didn't even try pulling on his tail or stacking his hind feet- he was so unstable on his own feet that she didn't think it was fair. She didn't feel anything in the joints, but the elevated temperature and neurological problems bothered her.

Forgive my lack of polo, as I was packing for the barn before work, I realized I was out of barn shirts!

She pulled a ton of blood for various diseases, and Liam got a hefty dose of DMSO tubed into his stomach, a shot of dex, a shot of banamine, and oral vitamin e.

By Saturday morning, Liam's temp was back under 100 and he was much more stable on his feet. He'd been on stall rest for 4 days at this point.

*Gets on soapbox*

HAVE YOUR VET VACCINATE YOUR HORSE. I know it's annoying and more expensive, but let me tell you, having my vet vaccinate Liam at his PPE was a great decision. We knew exactly what he'd been vaccinated for and what manufacturer and what batch, etc. This whole incident was/is stupid expensive, but the vaccine manufacturer paid for one of the very expensive tests (a blood and nasal swab).

*Gets off soapbox*

I hesitate to share all that was tested for, because I don't want to scare people or put rumors out there. But I also want to take care of some rumors I've heard: we tested him for EHV (blood and nasal swab), west nile virus, EPM (blood only, no spinal tap since that has to be done at the clinic), lyme, strangles/rhino/upper respiratory diseases (guttural pouch culture). EHV was the big name disease of course, and the vet had to notify the USDA of a possible case. The USDA took it very seriously, and they visited the farm the next business day to check our bio-security and isolation. They made suggestions on keeping Liam properly isolated to keep the other horses as unexposed as possible, but also safely isolated so he didn't hurt himself. They discussed quarantine procedures if Liam was positive.

The geldings on the farm were redistributed to new fields, and Liam was put in 24/7 isolation with a tribute friend (literally, the barn owner turned him out with Liam and told him, 'may the odds be ever in your favor') in a field that didn't share a fence line with any other field, and both horses were banned from the barn. The virus doesn't live well outside the horse out in the sun, so this was actually ideal. Liam's stall was stripped and the barn and his stall were bleached.

Liam shredded his fly sheet in less than 24 hours... and didn't like Jaxon's clothes either. He did keep his shoofly leggins on though!

Luckily, all of this effort was for nothing. Most of the tests came back negative, including the big one, EHV. Yay! We did twice a day temperature monitoring, and his temperature was in normal range every time. As he started feeling better, he started fighting barn owner on having his temp taken, and taking his meds (liquid vitamin e syringed and marquis).

The one positive was one parasite for EPM. I'm not exactly sure what the test was looking for, but I am fairly sure it was the ELISA test. His ratio was 1:1000, and the "exposed" range is 1:250-1:4000.

From the ELISA tests detailed on this website:

Although a wide range of serum titers was observed for necropsy positive EPM cases, there was a trend for higher serum titers (≥ 1:4000) to correlate better with EPM.

Without the spinal tap to compare to, we could only make a guess that EPM was causing his issues. We started treating for EPM the day after his emergency visit without the results yet, deciding that treating him won't hurt him, but waiting could. The vet decided we should keep treating him, even though his blood serum value isn't greater than 1:4000, because his value is elevated and he's experiencing neurological problems.

Liam seemed like he was responding to the marquis and vitamin e when the vet came back to do a guttural pouch culture (because of the bacteria findings on the PCR nasal swab) on 6/6. His throat looked fantastic and healthy, so we expected the culture to come back clean (which it did). He was super alert, mildly fighting the vet, and in general being dramatic.

He took a downhill turn on 6/11. He came in from the field with swollen hind legs and a fever again (101.3). A video from the morning showed him looking very subdued, slow, and more neurological than he had looked in a while. The vet was called to make sure the hind leg swelling was *just* cellulitis and not something more sinister. He had some rubs on his hind legs, so we agreed the cellulitis was not directly related to the original ailment, but related in that he probably interfered because he's neurological.

By the time she got there, he was more neurological than the morning, but his fever had gone. She pulled blood to do a CBC, which they test in house. He got a shot of exceed as well. He might be more neurological as the parasites die off and increase inflammation in his body, or it might be the inflammation returning because it's not actually EPM that's causing the issue. EPM doesn't cause fevers though, but cellulitis can, but he didn't have cellulitis the first time around. The vet asked us to monitor his temperature twice a day to see if there's any kind of pattern and to see what kind of variation there is. He proceeded to spike fevers of 101.3 to 101.8 in the morning after cool nights turned out and return to 99.6 to 100.8 by the evening. It was a bit baffling. It did clear up as the cellulitis cleared up.

A visiting clinician had her boyfriend (a vet) do a look over of Liam at the end of her first day teaching at the farm, who thought he had wobblers. A third opinion was requested, and I sent her all the videos and information I could. She thought he might have broken his pelvic floor along with EPM, and encouraged me to take him to OSU immediately and not wait the 3 weeks until she was going to be traveling to my area.

So there's some back story.

Power of Thought

I feel like a broken record here, but think some good thoughts for Liam, he's feeling under the weather.

The emergency vet was called Friday, she pulled a bunch of blood to send out Monday, and loaded him up with drugs to cover most of our bases while we wait.

He's feeling a lot better after all of his drugs Friday, but he's still on a big cocktail and not symptom free.

Feeling a good deal better Saturday morning. 

Good thoughts y'all, because most of the diseases in this first round of testing aren't good.

11/21/2018 - Diagnosing Penn, Part 5 (Treatment)

This took an extra day to get out because of the massive ups and downs my own emotions are taking on an almost daily basis since Thanksgiving. I had settled into a generic dead feeling about all things horses, but all the emotions were stirred up getting the last post together.

Collateral Ligament Badness

So where we left off, the collateral ligaments were #1 on the vet's list, with the coffin effusion and navicular issues neck and neck for #2.

Without treatment on the collateral ligaments, Dr Allen gave him at best, a 30% chance of being sound again. He suggested PRP injections into each CL, with shockwave following each injection. He gave a 40-60% chance of soundness if we did that. He also recommended some shoeing changes to help support the ligaments while they heal.

The shoe on the right is the one they took off Penn. It's his right front shoe, you can see the medial branch is wider and the whole thing is rolled. The shoe on the left is what the vet wants on him instead, but Penn's shoes need the other branch widened. It's basically a regular shoe with a cut of a second shoe welded to the inside. The vet thought steel shoes would eventually get too cumbersome and recommended an aluminum pre-made shoe eventually. And no more pad since that nullifies the effect we're going for.

He said we can also do PRP injections into both coffin joints for the effusion. He said that the injections he got back in August seem to have done their job, but he thought the effusion was coming back and we could readdress it.

The last thing he wanted to address were the navicular issues- he suggested another round of Osphos. He said it lasts between 3 and 6 months, so people generally do Tildren because it lasts about double the time. They end up costing about the same though in the long run.

Doing my due diligence, I asked how much all of these options cost. I already knew the cost of shockwave and Osphos, but not the PRP. Umm... let's call it "cost prohibitive" to do 4 PRP injections, plus 2 shockwave treatments. The cost for 2 PRPs was probably among the more expensive things we've done for Penn, aside from the 5 shockwave treatments that his insurance already covered.

Keeping in mind the reasonable vs unreasonable vs cost, we opted to go short term. Coffin injections and Tildren mean nothing if the collateral ligaments don't heal. We felt, while expensive, the PRP injections for the collateral ligaments were Penn's only real shot at soundness. We also opted for Osphos since while expensive, it's almost reasonable compared to everything else. Lastly, we decided to take new hoof balance x-rays. I didn't realize the ones from August would be considered old by now!

Part of the decision for no PRP injections for the coffin joints is I wasn't sold that Penn's coffins are actually hurting him, which sounds awful. Sure, his coffin joint in both fronts has some funny bone growth, but I'm betting it's always been there and isn't brand new. He was sound at one point in time. He felt a lot better after the steroid coffin injections in August, but about 2 weeks later he started to revert back, so I don't think they did much, and even Dr Cricket said they didn't appear to have worked for him.

We made all these decisions late Tuesday. Penn slept over at VEI so he'd be available when they were ready for him.

_________________________________________

Before I got to the vet office Wednesday morning, they had taken him to the back for his hoof balance x-rays.

11/21/2018
Did you know that horses who 'toe out' generally have P1s that are different lengths on the medial and lateral sides? The medial (inside) side of both of Penn's fronts are drastically different lengths than the lateral (outside). I mean, it wasn't as obvious to me in the previous x-rays, but the first thing I asked was, "I'm guessing it's not normal for the P1 to look like that?" Dr Allen was happy I noticed, and basically said there's nothing we can do about that.

8/16/2018

11/21/2018

8/16/2018

Will his legs ever be perfect? No. Are they better? I'd like to think so. He's still flat footed, but he's less crooked. It looks like he somehow has even less sole in those 3 months... though I will say he had an uneven amount of sole and we did fix that. His toe can still be brought back a bit. After Dr Allen looked at the new x-rays, he did hem and haw over pads- he immediately said, "I can see why Cricket put him in pads." and then had a good think over what he wanted to do, but eventually decided on no pad. The ligament support is more important than the sole coverage right now, and the pad interferes with the ligament support since it goes across the foot.

What I'm curious about, and I didn't talk to Dr Allen about it, but the vet who did Penn's PPE noticed he was crooked and said they could have addressed it as a baby (but then of course she's like, no matter, it's fine!). I'm wondering if he received different nutrition or care (ahem, better... I have many reasons to believe his VET breeder was much closer to a backyard breeder than thoughtful vet breeder), if his legs could have been straighter. Would leg braces have encouraged the bone to grow more on the deficient side?

Dr Allen also said something curious, he thought Penn had a sheared heel on the right front. He pointed out how the inside heel was taller than the outside. Not really knowing what that meant, I said OK and logged it down. He asked for the medial side of the right foot to be trimmed down over time. I had to look it up after I got home, then I immediately went out and looked at Penn's feet.

Top hoof is the right, bottom is the left. Apparently the right foot is sheared. I mean, I see it, but it's very very slight. The right hand side of the picture is the inside of the foot.

I came in while they were finishing up his x rays and putting his neck catheter in to pull blood for his PRP. They shaved his coronary bands at that time too. I did get a chuckle out of that- they always say how good he is and I told them he might be funny about the clippers, and they were like, "Really?" They flicked them on and he immediately became agitated and spooky. I asked that they touch his shoulder with them running and then he'll stand for it. They looked at me like I had 12 heads, but did it, and sure enough he stood like a gentleman and let them shave him... though, he did watch them very suspiciously!

Penn got some time to just be a horse after that. I took him out to hand graze while the team was prepping for his injections and the PRPs were spinning in the centrifuge. 

I got to be there for the PRP injections, and it was absolutely fascinating. I had a real job to do while they were doing that, so I couldn't take pictures of anything, but basically a team of 5 people is what it takes to get this done (vet doing injections with sterile hands, vet working the ultrasound with sterile hands, tech taking x-rays, tech handing everyone else things, and someone to hold the horse).

The method Dr Allen developed to inject PRP into the coffin collateral ligaments is ultrasound guided, x-ray confirmed, and pulling the needle out slowly as he injects. I'll bullet out how everything worked:

• One of the vets did nerve blocks to the entire foot in both front feet to help prevent any pain from bothering Penn while they were injecting.
• Scrub the lateral side of the left front and the medial side of the right front coronary band area thoroughly since the injections will be quite deep.
• Sedate Penn.
• Set Penn's front hooves up on two wooden blocks, since they needed to take x-rays during the procedure.
• They started with the right front. Dr Allen placed the needle while being guided by ultrasound by the other vet, with the extra tech turning knobs and pressing buttons on the ultrasound machine.
• The x-ray tech would place the x-ray plate and aim the hand held unit and take front and side images to make sure the end of the needle was placed in the wing of the coffin bone.
• Dr Allen confirmed placement, then proceeded to 'push the plunger' and slowly draw out the needle, thereby injecting PRP solution up the length of the ligament.
• Repeat for the left front. The right front was placed correctly the first time, but the left front was much more difficult to place. He got it though.
• Pressure is placed over the injection site, especially over the left front because it well hell bent on spewing lots of blood. Ok well maybe it wasn't lots, but blood runs really easily in short alcohol soaked hair, haha!
• Shockwave was done immediately following each injection, and then both of Penn's fronts were wrapped up.

And because I may as well share all the cool shit from this shitshow of a week, I have the placement x-rays too! 

Penn was a champ for his injections, everyone said what a good boy he was. In my head I was like, "How could he not be? You nerve blocked him and sedated him. He should be an angel." Apparently that isn't always enough. He didn't even need to be twitched. That's cool, I'm happy if everyone loves Penn, that means I've done my job in teaching him to behave, even if it majorly sucks. After he woke up a bit (and even at his Friday visit), all of the staff were stuffing him full of treats because they just liked working with him.

Dr Allen was happy with how the injections went. As he was doing the actual injection, I was sitting there thinking, "OMG why isn't it going in? Do they have a bad syringe that's sticking and broken?" He was shaking with effort to get the fluid out of the syringe. Apparently this is a very good sign. It means the tissues are still healthy. He said the horses who he can just squeeze the fluid into easily are generally shredded inside.

So Penn's final notes included:

• Changes to his shoeing with extra wide medial branch of the RF and lateral branch of the LF shoes. Slowly take away from the medial side of the RF to help fix the sheared heel.
• Two more rounds of shockwave to each collateral ligament, for a total of three rounds. He got the first round on 11/21, he got the second on 12/12, and he'll get the third on 1/2.
• Hand walk for a week after he gets home (this is already completed).
• A follow up appointment should be scheduled for 90 days after his 3rd round of shockwave.
• Limited turnout in generally pristine conditions, tranquilize as needed. Keep him as quiet as possible.
• Tack walk 3-5 days a week for 20-30 minutes until his recheck in spring.

They sent me home with a bottle of ace because the "minimal" bouncing he's been doing in turnout is unacceptable- he must only walk and stand. No trotting, bucking, playing, etc. I don't want to use reserpine because of the diarrhea risk, and because those COTH threads were scary. I did talk to a friend who used it on her horse, not knowing about the more rare side effects... and while he was generally fine, he hasn't been the same mentally since).

I've been a bit of an emotional train wreck since this vet visit. First was the, "We have a plan and we'll see how it goes", then the "OMG HE'S NEVER GOING TO BE OK AGAIN", then there was a strange "He's going to be just fine!" period, followed by a more mellow "he's not going to be ok" period. There's a bunch of stuff up in the air, and it won't settle back down until his recheck, which is kind of what I think it killing me a bit. I'm having trouble making it out to the barn to do his walks. I get out there 3-4 days a week now instead of 4-5 that I used to. I'm burned out on horses in general on top of being sad for Penn.

Dr Allen was hopeful I'd be able to start trotting him after his spring recheck, so I think that's keeping me running a bit. Do the rehab properly. Penn deserves it.

11/20/2018 - Diagnosing Penn, Part 4 (Diagnosis)

**First, I want to thank everyone for their kind words and support. It really means a lot. I wish I had better news for how it all turns out, but I don't. Everything is detailed in this post. Part of why this series of posts was so drawn out is because I needed time to go through the almost 700 images from the MRI.**

Despite the bad circumstances, I am completely fascinated with the imaging from the MRI.

MRI day had finally arrived! Everything was going well until Penn absolutely refused to get on the trailer at o'dark hundred. My truck and trailer talk nicely to each other, but the borrowed truck was not speaking to my interior trailer lights. I parked the back of the trailer in a flood light hoping that would provide enough light, but Penn still tripped on the ramp, almost fell down, and then absolutely refused to get in. Mom ended up using her cell phone flashlight to light up the inside of the trailer, and then Penn happily walked on. Unfortunately, that blew the 15 min buffer window I had allowed for slow driving and we ended up leaving at 6 instead of 5:45.

Everything was smooth sailing for our drive to Morven Park, and we even arrived 10 min early! It took me all of those minutes to find someone who could direct us where to go. One of the vets from VEI met us there and helped me get Penn inside and unblanketed. She pulled his shoes (which was an oddly traumatizing event for me, the same sick sad feeling as when we pulled Mikey’s hind shoes when he was recovering in 2015), and then she put his neck catheter in.

I love that VEI’s vets are happy to talk to me and include me in what they’re doing. Doing something as simple as holding the horse so he doesn’t roll in fresh shavings with a neck catheter in was really nice and made me feel useful instead of banished. I was able to tag along for the whole pre-MRI work (but not the MRI itself, which is apparently super boring after the first 5 min, and it takes about 2.5 hours if the horse is good).

A system similar to what scanned Penn.
Check out the website (Hallmarq) that I found this image on for more info!

The standing MRI that Penn had done isn’t like a human MRI. He didn’t need to be knocked out, just heavily sedated so he didn’t move at all. It’s also not nearly as powerful- metal won’t go flying across the room. The only metal you need to remove is anything that will end up in the MRI’s field of view. We had to pull his shoes, and then the vet used x-rays to ensure we got all of the metal from the nails. Slivers won’t get pulled through the hoof, but they will create black spots that the machine can’t see through. It took about a half hour to get the slivers out of his hoof wall- only because the x-ray software wasn’t playing nice and the vet had to keep rebooting the computer between test images. Penn stood like a champ on the Plexiglas foot rest and didn’t move at all. He was just happy to get face rubs and attention.

After getting the metal out of his hooves, we took him back to the room where the equipment is located and they gave him some sedatives and said goodbye to me. They led him to the room with the MRI in it, and I went out to meet my mom and go find some breakfast!

We ended up touring Morven Park's grounds on our way to breakfast. I had only seen the barns and dressage rings, and I couldn't place where they built their new rings. We drove past the mansion, cross country course, soccer fields, before eventually ending up at the part I'm familiar with.

Uh, drool. I hope one day I get to go ride there! There's another area behind that mound that seems to be the same size.

We left Penn around 8:30 or 9 am I think, and the vet called me around 12:45 pm to say he was back in his stall and things had gone well. Penn had been very good for the left foot and left pastern, but had to pee during the right pastern. There was some clean up and they had to redo the right pastern before moving back down to the right foot. Basically, he had been a model patient and could go back to the vet office as soon as he was awake enough to travel.

So drugged, plus a muzzle. Diapers on both fronts since he doesn't have shoes.

It's a good thing we didn't plan on leaving the day of the MRI, Penn wasn't ready to go until almost 1:30 pm, and I was already tired by that point. We took Penn back to the vet office and settled in to wait for practice owner, Dr A Kent Allen, to be done with his clients and to read Penn's MRI.

One of his afternoon clients was GP Trainer with 3 of the horses from her barn, so I got to talk to her for a little bit. She was the voice of reason that I did not want to hear, but I needed to hear. She said that maybe my time with him is up- he is a wonderful creature but served his purpose for me (my bronze) and it's time to find him another job. She told me to do what's best for him, but do not go overboard and do everything both reasonable and unreasonable. Basically, weigh the treatment against how well it works and how much it costs. Come up with a limit of what we'll spend to fix him, and stick to it. She said every now and then she gets emails from clients about older schoolmaster type horses that their owners want to free lease to keep them exercised or to get them off their checkbooks. She could help me get set up with one of those to continue my education. She did apologize for "being an emotionless bitch about it" (her words, haha), but she's absolutely right and that is the voice I need to have on my side. I didn't have it when I bought him. I don't regret buying him, but I believe some of his issues were glossed over or ignored because Mikey had just died and the thinking was "Oh, Jan found a horse she likes, just approve him!"

Anyway...

It took quite a while to get the results back, but that's fine. Dr Allen was very thorough and there's no rushing it. It was well after their closing hours by the time he came to talk about it, but he spent the time with me to make sure I understood what was wrong and pointed everything out on the MRI images, which I've shared below. (I may have gotten the images wrong, or pointed to the wrong place, sorry! I had to find them myself after the fact and it took me a very long time. I am 95% sure of everything though.)

Penn has moderate tears in two collateral ligaments- one in each front hoof, both next to the coffin bone. The medial on the RF and the lateral on the LF, so the left side of each front foot.

PC: http://www.backpunch.com/the-navicular-apparatus/
The arrows are a bit difficult to see, but it's the forward-most green ligament.

To understand all that's wrong with his feet, you need this too. I pulled this image from Google, then added the P1, P2, P3 to it. I didn't know the names of these or the order or anything before any of Penn's issues this year, so I'll list a couple things for anyone who is unsure:
P1: Long pastern bone
P2: Short pastern bone
P3: Coffin bone, pedal bone

In addition to the torn collateral ligaments, his navicular area is a bit messy in both fronts, enough that it bothered the vet quite a bit. He was also concerned about the coffin joint in both fronts. It's just easier to do a screenshot of the MRI findings and diagnosis that Dr Allen gave me:

From my very non-vet perspective, it sounds like Penn should be a cripple for life.
I wonder how many 'sound' horses have some of these issues?

For help reading the following MRI images, look in these places:
     http://www.hallmarq.net/equine/veterinarians
     http://casemed.case.edu/clerkships/neurology/web%20neurorad/mri%20basics.htm
     https://www.chirogeek.com/MRI%20READING/mriReading.html#Axial_Images

I found it helpful to know how each type of sequencing displays the different tissues, and some other basics. Austen found the bottom two articles, the second of which was quick to point out that the label L in the MRI images does not mean lateral, it means left. The images are flipped- what's on the right is actually on the left side of the scanned area. I'm not sure what the F, FP, FA, P, PF and all the other orientation letters mean, but knowing what foot and which side is left makes all the difference. Basically, throw out your medial and lateral references that we've been using! We're looking at the left side of each foot, not lateral (outside) of the foot.

I was able to find most of the issues in the vet notes, so let's go through everything one by one. There were 684 images in 40 different MRI series. Every image is a cross section of the hoof using different highlighting techniques. Series names start with T1, T2, and STIR, which are some scientific way of describing the way the machine scans (for a better description, see those links above!). Each of these highlight the structures in different ways to better see what's going on in there

Some basic structure in the T1W 3D FRO pass from wherever FA is, in Penn's front left hoof. As you progress through the immediate images in this sequence, the P2 comes more into view. Remember, this is a cross section. This happens to be a mostly vertical cross section that is square with the front/back of the hoof.

Of course the first image series called "T2 W FSE SAG" (coffin joint effusion, scar tissue in navicular bursa, navicular bursa effusion) that the vet saw something is the one series I couldn't pinpoint exactly.

The next is the big one. The tears to the collateral ligaments in series "T2 W FSE TRA". There were 3 series done like this, each from different angles: P, PF, and FP. I'm 99% sure that P is "flat", aka completely horizontal. The other two have some upward angle to them, which is why the top pair of images below look funny. The bottom of the image is the frog, cut on a forward angle.

The red arrows point to the torn ligaments. They're cloudy. The right ones are more pronounced and therefore more severe.
The green arrows point to the good ligaments, they show as black empty space.
The last thing these images show is the laminar thickening of the lateral wall in the right hoof (the right side of the right hoof). It took me a long time to identify this one, and I think I've got it right. I was only able to somewhat identify it because I put the right and left images side by side.

To help everyone figure out what they're looking at, here are two image series in GIF format. I put those anatomy pictures up above because you can see the coffin and short pastern bones from a variety of angles, as well as the "pedal" look of the coffin in the P series.

T2W FSE TRA series, PF
As you get closer to the toe, you can see the holes in the coffin bone. I assume those are for blood supply.

T2W FSE TRA series, P
Think of this series as dropping down the leg in horizontal cross sections.
I think this series is fascinating because of image 9, the coffin bone looking like the winged pedal bone, and images 10 and 11, the sole and frog.

Next is the navicular bone edema, in series "STIR FSE SAG". This is a series where water shows up as bright white.

The red circle shows the excess fluid around the navicular bone.

These two series also have a completely fascinating shot of the blood vessels in the bursa on the edges of this cross section of the foot:

The last series that had notable issues was the T1 W 3D ISO series of the left hoof. It showed marginal fractures of the navicular bone on the lateral side (the outside, which is the left side in this case).

It is very hard to see. I had to compare this series in the right foot to make sure I was seeing the correct thing. The arrow points to a thin black line in the lateral part of the navicular bone. That is a fracture.

Because MRIs are fascinating, I took the time to assemble these images and put them into short videos. The following two videos are 112 cross sections of each front hoof, the T1W 3D ISO series, shot from the FA direction.

I do wonder how many "sound" horses are running around with the same hoof issues as Penn (not including the torn collateral ligaments), and whether they actively bother the horse. I know navicular bone damage is kind of common, but what about the laminar thickening? I know we'll never have a good idea, MRIs are not cheap and you don't do them just for funsies.

As fun as it is to look through the images and delve into finding the problem areas, it all comes down to what does it all mean?

Well, it most likely means Penn's competitive career is over, as well as any secondary career he might have had being a schoolmaster. At best, he'll probably be able to W/T/C both directions, with no lateral movements.

The navicular area issues are secondary to the collateral ligament injuries. If left to their own devices, Dr Allen gave the collateral ligaments up to a 30% chance of healing to a point where Penn is sound again. He said this is the kind of injury where you can turn the horse out in a field for 12 months, and the horse will come back in just as lame as it was turned out. Poor blood supply to the hoof means collateral ligament tears as deep as the coffin don't heal well, if they heal at all.

There are things we can do to help, which we did elect to do, that increase his odds of soundness to 40-60%. I'm not sure whether those odds are for return to full work soundness, or return to WTC soundness. I have a feeling they're WTC soundness and the full work soundness is much lower. Lateral movements are most likely out of the question, as well as most hills or other uneven terrain. The collateral ligaments are fairly inflexible and stabilize the lateral flexion of the joints. Penn flails quite a bit as he moves, stressing the inside of the leg the most (note the RF, where the CL is torn on the inside, is the worse of the two tears). He could re-injure them just moving around because of how he moves; there's no need to add lateral movements and more lateral stress to the mix.

So how did this happen? And when? The vets agree that the collateral ligament tears are relatively new (probably in the last few months). The way the nerve blocks went at his visits throughout the summer, he didn't have these issues at the start, middle or end of summer. They most likely happened sometime in September or October. We didn't do nerve blocks at our appointment at the start of October, but his soundness at that appointment was very similar to his soundness at the November recheck.

He could have bounced the wrong way in turnout. He started being more active as he felt better. Our footing changed from dry yet very rainy summer to mucky, muddy fall. Maybe he slipped. I'm an extremely cautious driver when I have the trailer, but it could have happened in there if Penn compensated too hard or the wrong way, or I did something wrong driving and tossed him around. It isn't due to his poor conformation- he tore the left side of both fronts. Something actively happened to him to make that happen. I'm sure his conformation didn't help matters- the whole of his foot is a mess so it was probably already compromised and ripe for injury. I'll never know what happened exactly to end my horse's career, and that's quite sad.

Who knew this tiny amount of lameness, that could be reasoned away as muscle weakness or just simply being unbalanced, is actually two torn collateral ligaments in the front hooves? I certainly won't look at slight off moments the same again.

Link to YouTube

I'll go over the treatments offered and the treatments we did in my next post, as well as his rehab plan. This post has gone on for long enough I think.

11/19/2018 - Diagnosing Penn, Part 3

I am blessed with a wonderful Barn Owner who lets me do things like borrow her truck and drive it to another state and put 600-700 miles on it in one go. TWICE. The first time was after my oil pump failed in 2017. After my truck’s brakes died on our way home from VA, the first call I made was to emergency services, the second was to her to start to arrange transport for Penn to get to his MRI and to get home.

While mom and I were driving back to VA on Monday, Husband called. We had dropped the truck off at our favorite local shop without telling them it was coming, and left it with a big to-do list. The shop had finally called him back. They were concerned because we left them quite a list, and they basically said that with Thanksgiving coming up, them already being 2 weeks deep in existing work, and the amount of parts and labor and comprehensive look over that the truck needed, it could be 3 to 4 weeks before we got it back, and then we're getting into Christmas holiday time. Maybe they were concerned about the amount of time it would take to finish... but really, like we’d say no and have it towed somewhere else? Nah. But that did change things for Penn.

The best shot... has moisture on the lens. Facepalm

We had planned on going to the MRI Tuesday and taking him directly home to PA, with the understanding we’d probably be home before the MRI was fully reviewed and a treatment plan conceived. We were planning on bringing him back a week or so later… whups, not anymore. I’d have to borrow a truck for another 2 days on someone else’s M-F schedule, which I didn’t want to do because I only have 1.5 vacation days left for the year. I made a bunch of calls: VEI agreed to take Penn overnight and squeeze him into someone’s schedule for whatever treatment was decided on (easy to do because he’d be there already), and Barn Owner agreed to let me keep the truck for an additional day.

We got to GP Trainer’s by late afternoon after a nice drive that only had a few driving shenanigans from other drivers. GP Trainer's barn is technically closed on Mondays- no boarders, lessons or riding, just staff taking care of the horses and doing projects that can’t be done with clients around. GP Trainer’s assistant made an exception for me- I needed to drop off grain no matter what, but she said I was allowed to ride if I’d like. So ride I did!

"Hey I'm walking in a field, neato!"

I had planned on schooling in the indoor. When I got there, some of the maintenance staff were working in it and I turned around to go to the outdoor, which also has glorious safe footing and it was a beautiful day out. When I got to the outdoor, I found it had been freshly dragged. Not wanting to disturb it either, I got on and decided a walk through her fields on a pseudo trail ride was just the right thing to do. Penn hasn’t been on a trail ride since May, and she has tons of level field to stroll through.

Just a pretty pic of her indoor and the sunset.

I went for a quick 15 min walk, tucked him back in his stall, packed the trailer with all the non-essentials I needed in the morning, and high tailed it out of there. We were in and out in an hour and 15 min!

I did look over his grain situation while we were there. GP Trainer feeds breakfast, lunch, and dinner, and lunch is fed outside in the turnouts in winter. I found an overturned feed pan of alfalfa pellets out in Penn's dry lot, hahaha! They didn't go over so well then. I figure he ate about half of what they gave him, and I bagged the leftovers and put the rest of the bag in my trailer while he was eating a much more satisfying grain dinner with some of his regular supplements.

Cute face that says, "I do not like alfalfa pellets, Mom!"

The evening was fairly boring, mom and I had dinner and turned in early because a 7:30a MRI appointment meant leaving GP Trainer’s barn by 5:45a, which meant arriving there by 5a, which meant a 4am wake up!

11/16/2018 - Diagnosing Penn, Part 1

Winter decided to rear its ugly head right before we were supposed to travel down to VA for Penn’s recheck. We only got a little ice and snow, but the vet office got a good deal more. They called to say they might have to push appointments back a bit because of a delayed start, which I said was fine because I had already pushed my own appointment back an hour to 2 pm because I was concerned I wouldn’t be able to get out of the barn’s valley.

Not much snow, but it has ice under it.

However, all things lucked out! The snow plow came through as I was hooking up the trailer and salted the steepest part of the road, Penn loaded right up, and off we went! We had a nice drive down to VA, and arrived early despite leaving 45 min later than I originally planned. I ended up hanging around for a bit waiting for the vet to be done with her prior appointment (that's where most of the stall pictures happened- I don't have other media from Friday)

Enter: One feed tub of alfalox.

The vet ran her hands all over Penn first to check pain points and body condition, and found an unreasonable amount of hind end pain. We did the usual tests first- walking on a straight line, trotting on a straight line, trotting both directions on a circle on a hard surface.

He was pretty much the same as last time- 1/5 bilaterally lame on the hard surface on the inside front when trotting. We went over how hit or miss he’s been feeling at trot under saddle. She decided to put the surcingle with 60lbs of deadweight back on since I said it’s worse under saddle and he had quite a bit of hind end pain.

This is where things turned a bit: he became sound with added weight. He wasn’t happy at all, he tossed his head frequently but remained sound. She jokingly called it “the dressage horse response”, aka lift your back and use yourself. She did call it positive for back pain since he was tossing his head.

Penn had enough of gray horse's anger issues and decided to attack, but was not prepared for the gray horse to "fight back".

We went back to the barn and did straight line trots after flexions. The flexions were better than last time: the RF was unremarkable (for the first time ever) and the LF was mild. The hinds saw an increase in pain though- the lower and upper flexions were mild + on the left hind, and moderate on the right.

That left us at an interesting place: his hind end pain concerned the vet especially since I said we’ve battled hind end pain for as long as I’ve owned him, but the front end hadn’t gotten better. She gave me a choice about where best to spend my money: we can redo the nerve blocks on the front end, or we can do a CURO test on the hind end suspensory tendons. She was concerned about the health of the suspensory tendons, citing there is a disease that attacks them and causes irreparable damage, but we often don’t know about it until too late. She said it also could be that he’d benefit greatly from hock injections. Doing the CURO test would make her sleep better about just doing hock injections.

I hemmed and hawed over it, but settled on the front end issues. Those are the one preventing him from being a ‘useful’ horse- he can’t show or go to lessons as he is now. I never know if I’m going to have a sound horse or a lame horse until we’re trotting. As they were scrubbing him up to do nerve blocks in the front heels, I asked how much the CURO test was to do. She said $150. I was like, “Oh, that’s nothing. Let’s do that too if the nerve blocks won’t affect the results.” She was very pleased and we got the CURO test set up after the blocks had been injected.

Penn, I think this is why other horses beat you up so easily. You don't take a hint!

So CURO is kind of interesting- it’s sensors placed on the hind end suspensory below the hock, which are hooked up to a pack on a surcingle. The horse walks back and forth, then trots back and forth, then walks again. Normal output is 5 or above. I could barely find anything out about it online, but here’s a link to their website.

His results were as follows:
LH:
       Overall – 5
       First walk: 4.8
       Final walk: 5.3
RH:
       Overall – 6
       First walk: 6.5
       Final walk: 5.7

Both seemed within normal tolerances, but to me, the left seems worse off… which actually tallies with how he’s felt under saddle. He wants to pitch his hind end left and not use his left hind. The right hind is the more sore hind, so he might be compensating for the left hind. Both results were within normal tolerance, so she thought we would be safe to do the hock injections at some point.

"MAHM HALP"

The first nerve block didn’t produce a change, which was both good and bad. His heels don’t appear to be hurting anymore, which means the shoeing changes we’ve made are working for him. The bad news is that something else hurts.

The next set of nerve blocks blocked the entire foot, and he became much sounder. Well fuck it all. She said that basically puts us firmly in MRI land to further diagnose the problem. We could do that, or continue as we were and see if he gets better or worse. I had prepared to do an MRI on this visit, so we opted for the MRI.

I didn’t realize that VEI doesn’t have an MRI, they use the one at Virginia Tech’s Morven Park medical facility. It has to be booked ahead of time, so we booked it for the first day we could- the next Tuesday morning at 7:30a. Unfortunately that left us in a bit of a lurch for what to do with Penn. I had planned on going over to GP Trainer’s barn that evening and having a simple walk trot rehab lesson with one of her assistants Saturday morning. The vet approved having a lesson- GP Trainer’s footing is practically perfect and extremely safe so she had no issue with walking and doing some limited trot on it.

The problem is the amount of traveling Penn would have to do in the following days: The original plan was to bring him down for his vet visit Friday morning, take him to spend the night at GP Trainer’s, have a lesson Saturday morning, load him up and go home. Well, if we adhered to that schedule, we’d have to pack him back up in the trailer Monday, bring him to either GP Trainer’s or VEI to spend Monday night, then load him up at the buttcrack of dawn to take to Morven on Tuesday, then bring him home again on Tuesday (we would come back for any treatment based on the MRI results since they wouldn’t be available until Tuesday evening anyway). He’d spend 6 hours in a trailer for 4 of 5 days in a row.

Friends?

Luckily, GP Trainer quickly agreed to just house Penn and my trailer until Tuesday. That left me scrambling for feed and blankets for Penn- this was the one visit where I hadn’t brought a bunch of extra feed, nor had I brought any of his turnout blankets! She said they could find something for him to wear if he needed it (he had a BOT mesh sheet and mid weight stable blanket), so that just left the feed problem to be dealt with on Saturday.

To be continued!