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  Discussion on Bursoscopy
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Member:
digger89

Posted on Tuesday, Sep 13, 2011 - 6:59 pm:

Has anyone out there tried a bursoscopy on their navicular horse? We have tried various shoes, pads, barefoot, stall rest, turnout, Tildren, steroid injections, balance xrays, MRI, IRAP, and shockwave over the past 13 months on my 10 year old paint with no lasting success (IRAP/shockwave worked for 1 week). We are reluctantly considering "nerving" but the vet also suggested taking a look in the navicular bursa instead, saying that this is almost as effective as the neurectomy option. I would love to hear from anyone else who has had experience with this. Sarah
Member:
lynnland

Posted on Wednesday, Sep 14, 2011 - 4:07 pm:

Hi Gang,

Here is a link to an article that discusses this procedure. I was confused as to how it was used therapeutically as opposed to diagnostically.

https://www.springerlink.com/content/a234730mk2313212/fulltext.pdf
Moderator:
DrO

Posted on Saturday, Sep 17, 2011 - 10:46 am:

Hello Sarah,
Sorry for the slow response it has been very busy this week at the practice. Bursoscopy is a diagnostic technique using a endoscope to help determine the nature and severity of the lameness problem. The procedure may lead to useful therapies like cleaning up any damaged soft tissues that are causing ongoing inflammation. At least it will rule in and out disease processes that can lead to a better prognosis.
DrO
Here is the best published data I can find on the subject:

Equine Vet J. 2011 Aug 18.
Endoscopic evaluation of the navicular bursa: Observations, treatment and outcome in 92 cases with identified pathology.
Smith MR, Wright IM.

Source
Newmarket Equine Hospital, Cambridge Road, Newmarket, Suffolk, UK.

Abstract
Reasons for performing study: Diagnostic navicular bursoscopy has been described in limited cases. Review of greater numbers is needed to define its contribution to case management and prognostic values. Objectives: To report: 1) clinical, diagnostic and endoscopic findings in a series of cases, 2) surgical techniques and case outcomes and 3) prognostic values. The authors hypothesise: 1) lameness localising to the navicular bursa is commonly associated with dorsal border deep digital flexor tendon (DDFT) lesions, 2) endoscopy allows extent of injuries to be assessed and treated, 3) case outcome relates to severity of DDFT injury and 4) the technique is safe and associated with little morbidity. Materials and methods: All horses that underwent endoscopy of a forelimb navicular bursa for investigation of lameness were identified. Case files were reviewed and those with injuries within the bursa selected for further analysis. Results: One-hundred-and-fourteen horses were identified. Ninety-two had injuries within the bursa and DDFT injuries were identified in 98% of bursae. Of those examined with magnetic resonance imaging (MRI), 56% had combination injuries involving the DDFT and navicular bone. Sixty-one percent of horses returned to work sound, 42% returned to previous performance. Horses with extensive tearing and combination injuries of the DDFT and navicular bone identified with MRI, had worse outcomes. Conclusions: Lameness localising to the navicular bursa is commonly associated with injuries to the dorsal border of the DDFT. Endoscopy permits identification and characterisation of injuries within the navicular bursa and enables lesion management. Outcome following debridement is related to severity of injury but overall is reasonable. Potential relevance: Horses with lameness localising to the navicular bursa may have tears of the DDFT. Bursoscopy is able to contribute diagnostic and prognostic information and debridement of lesions improves outcome compared to cases managed conservatively.
Member:
brandi

Posted on Saturday, Sep 17, 2011 - 6:53 pm:

Sarah,
We did this on my Paint, who is now 16, he was retired from riding about 5 years ago, though my surgeon's approach was different than that described in Lynn's link. He went through the ddf tendon sheath and through the t-ligament (as I understand things), and Tom likes this method because it leaves the nav bursa and the tendon sheath "in communication" after the surgery, so injecting the tendon sheath allows the medication to make its way into the nav bursa - also if pain is present in the nav bursa due to pressure from inflammation, this pressure is relieved because excess fluid can travel into the TS space as the horse strides. I hope this makes sense.
Anyway, Apache was more lame on his right so that was the foot we went after initially. Results were good enough that his left then was the most tender. A year later we went after the left with no appreciable improvement. Tom wanted to go in again on the left another year after that and unfortunately this time my boy had some mild reaction in the leg - internally - which ultimately ended up being a permanent thickening of the pastern area and some reduced flexibility, so we were unable to gauge the success of the 2nd try. So now I'm looking into the neurectomy as well.
This boy has had much tried on him since I've had him, every type of shoe, boot, supplement, joint injections, magic potion and these 3 surgeries - still not as much high-tech treatment as yours has had. The surgeries, and basically everything in the last 3-4 years has been just to extend his life as a pasture pet, I gave up riding him after the nav bursa injections failed. He's not a good candidate for the neurectomy because of many soft-tissue injuries to both impar ligaments and both ddfts, due to early race-training and one injury since I got him in '03. I know that the neurectomy will put him at risk of rupturing one of those scarred tendons/ligaments, but I am hoping that 5 years of significant lameness and his adult age will keep him sane on his feet. It's rather a last-ditch effort, currently he can still take a run through the pasture with his buddies, but they are much fewer and farther between and come at more of a cost to him today.
I know that my information does not provide you with any clear answers, but maybe it will help you ask some helpful questions that help lead you in a direction you feel comfortable going. Best of luck to you.
Moderator:
DrO

Posted on Tuesday, Sep 20, 2011 - 8:45 pm:

I think Brandi's post is illustrative. The case selection must be taken into account when looking at these numbers.

It is very likely that the selection of those horses was key as to the fair rate of return to work achieved. All other diagnostic routes were first explored to rule out disease of other locations (aggressive and careful use of nerve and regional anesthesia) followed by CAT scans and MRI's) to rule out diseases that were not likely to respond to endoscopic surgery. Then surgery was done.

This is not meant to minimize the importance, for many horses it is the only chance for the horse to getting going again short of a nerving. And the long term prognosis better with the surgery vs the nerving.
DrO
Member:
digger89

Posted on Tuesday, Sep 20, 2011 - 9:15 pm:

Thank you guys for the input. I have decided to take him for another MRI (he had the first one a year ago). Dakota's right front foot has just recently developed some heel pain so I think the MRI might give us enough information about both feet to decide the best way to procede. If the results indicate that a bursoscopy is appropriate we will go that route on the left. As for the right foot, I hope the MRI will point us toward some specific treatment.
Member:
digger89

Posted on Friday, Sep 30, 2011 - 4:45 pm:

Dakota had his MRI yesterday, with very bad results:
Conclusion: The left front foot has developed a severe deep digital flexor tendon lesion. The injury courses from the level of the pastern to the tendon insertion on the coffin bone. The tendon is adhered to the navicular bursa and the collateral ligament of the navicular bone and the impar ligament. The navicular bone has edema in the medullary cavity and remains remodeled on the distal border. The right navicular bone also has mild edema with a focal inflammation at the central flexor cortex. The deep digital flexor tendon has a focal inflammation in the center of the tendon adjacent to the navicular bone. This appears to be the start of a tendon injury in the right front leg and is most likely the cause of the lameness.

Recommendations: The chief reason for the renewed lameness is the tendon lesions. The navicular bone has not changed. The primary treatments for deep digital flexor tendon injuries in the foot is similar to the previous treatment for navicular disease and includes rest and supportive shoes. The lack of response to the previous suggests that a repeat of the rest and shoeing may not be sufficient to resolve the problem. The following is suggested with some options.

Corrective shoeing:

· Apply bar shoes with pads. The final hoof angle with shoes and pads in place should be at 53 degrees.

· Apply full pads under both bar shoes

· Roll or square the toes to ease pressure during hoof break over.

Medical treatment:

· Administer firocoxib 57 mg (Equioxx) orally once daily for 14 days.

· Initiate a weight reduction program

Exercise:

· One month of absolute stall rest

· Second month of walking in hand for 10 minutes twice daily

Options:

· Navicular bursoscopy to remove diseased tendon tissue and any adhesions. This would not be successful in affecting the tendon distal to the navicular bones.

· Stem cell/PRP treatment. After collection stems cells from bone marrow the cells are cultured and then injected into the navicular bursa and directly into the tendon lesion. It will be difficult to place any treatment distal in the deep digital flexor tendon. This has only been completed in a few horses so its effectiveness is still questioned.

· Palmar digital neurectomy. This desensitizes the back and bottom of the foot. This will likely be the best treatment to resolve the lameness and allow Dakota to be used. The longevity of this treatment can be questioned in this case, but this can not be predicted based on the MRI.
So now I am definitely not going to do the bursoscopy since the distal tendon lesion can not be reached by the scope. Because Dakota has already been unsuccessfully treated with the shoes and pads, stall rest, etc. and has been on the recommended dose of firocoxib for months, I really see nothing else to do other than the neurectomy on his left foot. We will have to treat the right foot too but we have not made any decisions about that yet. Sarah
Moderator:
DrO

Posted on Sunday, Oct 2, 2011 - 8:59 am:

Hello Sarah,
This report sums up your options well and laying out your goals and resources just as logically should help you determine your next step.
DrO
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