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  Discussion on Steriod (cortizone) use to treat sacro-iliac subluxation
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New Member:
Ejaco

Posted on Monday, Jul 24, 2006 - 12:10 am:

Dear Dr O

My vet injected the sacro-iliac joint of my thoroughbred gelding with cortizone (I am told this was Kenacourte A10) to treat his sacro-iliac subluxation. I note that in your article on treating sacro-iliac injury you recommend non-steriodal anti-inflamatories. I would like to know your opinion of the use of cortizone in treating this injury.

As background, my horse went through a fence 18 months ago and badly hurt his left hind end. He was diagnosed with a fractured tuber coxae and stall rested for 9 weeks, followed by paddock rest for 2 months. After about 10 weeks a hunter's bump on the left side became obvious, however no special treatment was given. He was slowly brought back into work and improved consistently. He was sound for flatwork and trail riding and had recovered even muscle development. However he continued to show signs of having discomfort - he would hold his left hind up occasionally in the stall and on long trail rides would become crooked and turn his head to the right to find relief(he is always a little crooked due to the misalignment of his pelvis.)

Recently, after a short holiday in the middle of medium level of work including jumping over low jumps, his condition deteriorated in that he became short in the right hind after any exercise, even leading him at a walk. A different vet indicated it was a flare-up of his sacro-iliac injury (despite the problem showing in the opposite hind leg) and prescribed 10 days bute and exercise. After the bute finished he became lame again after any exercise, so I put him back on bute and tried paddock resting him for 2 weeks. A massage therapist ruled out hamstring problems and agreed the discomfort remained in the old areas of the left side of the sacrum and along the upper back muscles. She recommended I try to find out more about what is amiss in the area, possibly with an ultra-sound.

This prompted me to return to the original vet, who confirmed the other vet's diagnosis of sacro-iliac subluxation. Ultra-sound showed the fracture had healed fine (which I never doubted). The vet then told me about the use of cortizone to reduce the pain of this type of injury, so I went ahead with that treatment straight after the bute was finished - 4 days ago. So far I have not tested the treatment, apart from leading him 2 kilometres, after which he was fine. My fingers are crossed that he will be more comfortable but I would like to know whether the treatment used is generally accepted, and your views on it. The vet is recommending that the treatment be repeated at intervals, presumably for as long as my horse is in work. I note this is much longer than your article on steroids discusses and wonder if there have been any studies on the long-term use of cortizone injections.

The vet also recommended shock wave therapy, but it sounds drastic. I would also appreciate your views on this in my case.

Lastly, I also give my horse the maintenance dose of Cosequin (brand name for a mixture of glucosomine and conDrOitin sulphate). Will this remain useful now that he has the cortizone, or am I going to a needless expense by continuing it?

Thanks, Elizabeth
Moderator:
DrO

Posted on Tuesday, Jul 25, 2006 - 11:57 am:

Hello Elizabeth,
Sorry for the slow response but wanted to research this question and really there seems to be no epidemiological research where a number of cases are looked at for results. One of the real problems is that this area is practically unreachable for careful examination making an exact diagnosis tough.

A few comments, first ultrasound is not a good tool for evaluating fractures as it does not penetrate bone. You may able to access a separation at the surface for there will be large amounts of the fracture not viewable on US. Also joint therapies that work by modifying the joint fluid environment are not effective here because there is no synovial membrane of fluid with this joint. It is a fused joint.

Since this is a reinjury of the si joint I think several months stall rest with little more than hand walking might be indicated then a slow return to light work, which often is all a horse with this type injury may be able to do.

Will steroids help? If there is unresolved inflammation of the ligament that binds these two bones together but a stable connection exists, I believe you can expect much improvement in the pain however your history suggests this horse should only be used for flat work and light trail riding. I am uncertain that shock wave can effectively reach this deep into the horses pelvis.
DrO
New Member:
Ejaco

Posted on Sunday, Aug 20, 2006 - 10:05 pm:

Thank you Dr O. The cortizone injection was given one month ago and I have not found a significant improvement in my horse's condition. Presumably this means that there was no inflammation. I suspect a trapped nerve, but there are no specialists available here for me to ask.

I intend to contact my vet and ask him if he can suggest anything else, but would appreciate whether you can suggest what options I might discuss with him. In particular I am interested in your report about the long-term use of Bute at a very low level, which you found to be of benefit without producing any known side effects. It would be appreciated if you could you confirm the quantity, which I believe was stated to be 1 gram, which I understand is about a tenth of the normal dosage. Or did I read this wrong?

My last option is complete rest, as you recommend. I have not tried this to date as both vets I have been to have recommended ongoing exercise.

Elizabeth
Moderator:
DrO

Posted on Monday, Aug 21, 2006 - 12:18 pm:

Or possibly there is instability that ongoing exercise exacerbates or possibly the location of the lameness is somewhere else?

It is not true that there might not be side effects from the use of bute even at low doses because there always is the possibility of unusual reactions and when used over time the chances go up. In spite of this we have seen horses tolerate bute at lower doses for long periods. I have edited the NSAID article to make recommended dosages for long term treatment easier to read but the actual dosage for your horse should be discussed with your veterinarian.
DrO
New Member:
Ejaco

Posted on Wednesday, Sep 13, 2006 - 1:10 am:

Thank you Dr O. I am continuing to discuss treatment options for my horse with my vet. He does not rate the likelihood of improvement from shock wave therapy as being very high. Regarding bute, he has suggested it be used only when I work the horse. The dose he recommends is 5ml bute paste half an hour before work, on an empty stomach.

However the other vet I have consulted does not believe that there would be any benefit from giving bute just before work, because he says it needs to build up in the blood stream for 2 days beforehand, to gain the benefit of the anti-inflammatory action.

I note the scientific reports following your article on bute indicate that bute is available in the bloodstream within an hour, but I am not sure what this means. Are you able to clarify when bute should be administered and whether it will provide any benefit (ie pain relief) if only used periodically, without having the chance to really build up in the bloodstream?

(I am also pursuing the possibility of getting a human acupuncturist to do acupuncture, since there are no equine acupuncturists around.)

Thanks!
Elizabeth
Moderator:
DrO

Posted on Wednesday, Sep 13, 2006 - 7:43 am:

I do not know of any support for the 2 days statement Elizabeth and is not consistent with studies that find therapeutic levels by at most 8 hours following administration. Maybe he is confusing maximal concentrations within synovial structures following beginning dosing with therapeutic dosage? I have not seen this work but is the only thing I can think of. However this is not relevant as there is no synovial structure involved with this joint to slow down exposure.

We regularly recommend the episodic use of bute in chronic lameness conditions and try to get it in about 8 to 12 hours before and after work.
DrO
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