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An equine cadaver study investigating the relationship between cervical

flexion, nuchal ligament elongation and pressure at the first and second
cervical vertebra

M. Dippel, R.R. Zsoldos, T.F. Licka

PII: S1090-0233(19)30092-9
DOI: https://doi.org/10.1016/j.tvjl.2019.105353
Article Number: 105353
Reference: YTVJL 105353

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Accepted Date: 5 August 2019

Please cite this article as: Dippel M, Zsoldos RR, Licka TF, An equine cadaver study
investigating the relationship between cervical flexion, nuchal ligament elongation and
pressure at the first and second cervical vertebra, The Veterinary Journal (2019),
doi: https://doi.org/10.1016/j.tvjl.2019.105353

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Original Article
An equine cadaver study investigating the relationship between cervical flexion, nuchal
ligament elongation and pressure at the first and second cervical vertebra
M. Dippel a, *, R. R. Zsoldos b, c, T. F. Licka a, d
a
Equine University Clinic, Department/Clinic for Companion Animals and Horses, University of
Veterinary Medicine Vienna, Veterinärplatz 1, 1210 Vienna, Austria
b
School of Agriculture and Food Sciences, The University of Queensland, Hartley Teakle Building,
Room S325, Level 3, South Wing, Keyhole Rd, St Lucia QLD 4067, Australia
c
Working Group Animal Breeding, Department of Sustainable Agricultural Systems, University of
Natural Resources, Wilhelm Exner Haus, Peter-Jordan-Straße 82. 1190 Vienna, Austria
d
Royal (Dick) School of Veterinary Studies, University of Edinburgh, Easter Bush Campus, Midlothian,
EH25 9RG, Scotland, UK

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* Corresponding author. Tel.: +43 1 250 775 229.
E-Mail address: maximiliane.dippel@vetmeduni.ac.at (M. Dippel).
Highlights

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 Study on nuchal ligament length and pressure at the site of the nuchal bursae in equine head and
neck specimens


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Specimens were evaluated in neutral, mildly flexed and hyperflexed position
Hyperflexion was associated with the highest pressure at the site of the nuchal bursa over the
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atlas and over the axis.
 Neck flexion angles were highly significantly correlated with pressure values and with nuchal
ligament length.
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 The results supports the recommendation not to perform hyperflexion in horses with nuchal
bursitis
Abstract
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Pressure in the atlanto-axial region due to hyperflexion (‘rollkur’) may influence the

development of a nuchal bursa, as adventitious bursae may be caused by pressure. Investigating

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the pressure between the nuchal ligament and atlas/axis in a flexed position may provide
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information on the pathogenesis of nuchal bursitis. In this study, ten equine head and neck

specimens with one side of the soft tissues over the cervical vertebral spine removed were

placed in lateral recumbency on a table in neutral, mildly flexed, and hyperflexed head and neck

positions. Angulations of the neck were measured using markers placed on the nuchal ligament
and drilled into the skull, vertebrae and withers. In six specimens, the pressure between the

nuchal ligament and the atlas and the axis was measured using an inflatable air pouch.

Hyperflexion was associated with the highest nuchal ligament length and with the

highest pressure values at the site of the nuchal bursa over the atlas (99 ± 24 mmHg, more than

four times the pressure in the neutral position) and over the axis (77 ± 30 mmHg, more than

twice the pressure values of the neutral position). Also, over the three head and neck positions,

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neck flexion angles were highly correlated with pressure values and with nuchal ligament

length. This marked increase in pressure at the level of atlas and axis caused by head and neck

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hyperflexion should be considered during training of horses at risk of, or diagnosed with, nuchal

bursitis.
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Keywords: Bursitis; Equine nuchal ligament; Head and neck position; Nuchal bursa; Rollkur
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Introduction
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Adventitious or facultative bursae are synovial structures that are found in some but not

all individuals; they may develop after birth if soft tissues, such as subcutaneous tissue, are

subjected to pressure and friction, commonly over bony prominences (Dyson, 2011a; Singh,
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2017a). In the horse, a number of bursae which are inconsistently present have been described,

such as the subcutaneous calcanean bursa and the olecranon bursa (Budras et al., 2013a, b).
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Three bursae are associated with the equine nuchal ligament, the cranial nuchal bursa (bursa
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subligamentosa nuchalis cranialis), the caudal nuchal bursa (bursa subligamentosa nuchalis

caudalis) and the supraspinous bursa (bursa subligamentosa supraspinalis; Dyson, 2011b;

Abuja et al., 2014). In the neck, the two nuchal bursae are located between the funicular part of

nuchal ligament and the dorsal arch of the atlas (cranial nuchal bursa) and the spine of the axis
(caudal nuchal bursa), respectively (Sisson, 1975). The caudal nuchal bursa is described to be

inconsistently present (Sisson, 1975; Wagner and Gerhards, 2010; Dyson, 2011b; Abuja et al.,

2014) while the cranial nuchal bursa is described to be either consistently (Budras et al., 2013c;

Singh, 2017b) or inconsistently present (Sisson, 1975; Wagner and Gerhards, 2010; Dyson,

2011b; Abuja et al., 2014). Nuchal bursitis is occasionally seen in horses (Hawkins and Fessler,

2000; García-López et al., 2010; Abuja et al., 2014). Clinically relevant bursitis is more

common in the cranial than in the caudal nuchal bursa (Abuja et al., 2014). Furthermore,

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pathology of the nuchal bursae is sometimes associated with nuchal ligament desmitis (García-

López et al., 2010). Biomechanically, bursae act as a cushion at the interface of bones and soft

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tissue structures where pressure is concentrated (Durham and Dyson, 2011); based on this, it
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can be assumed that nuchal bursae serve to reduce the mechanical forces between the first two

cervical vertebrae (C1 and C2) and the nuchal ligament, which connects the occiput with the
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withers. Furthermore, the nuchal ligament is essential for balancing the horse by elastically
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connecting the head and neck with the trunk (Clayton et al., 2010). During locomotion,

lengthening and shortening of the nuchal ligament play an important role in cycling strain

energy while receiving the mechanical work propagated from the cervicothoracic junction
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(Gellman and Bertram, 2002a, b).

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The influence of the head and neck position on equine welfare and performance has
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been discussed, especially the potential negative effects of hyperflexion (Rollkur; Rhodin et al.,

2005; van Breda, 2006; van Oldruitenborgh-Oosterban et al., 2006; Rhodin et al.,; von Borstel

et al., 2009; van Weeren, 2013; Christensen et al., 2014; Smiet et al., 2014). Irrespective of the

discourse on potentially detrimental effects of repeated hyperflexion or hyperflexion of long

duration, hyperflexion exercises are common physiotherapeutic training methods to keep

horses flexible in the head and neck region (Clayton et al., 2010), aiming to facilitate muscle

activation and improve strength and flexibility as well as restore functional movement

following immobilisation (Goff and Stubbs, 2007).

The aims of the present study were: 1) To evaluate the pressure underneath the nuchal

ligament at the sites of the cranial and caudal nuchal bursa created by flexion of the head and

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neck in cadaver specimens; and 2) To compare the pressure at this site with the head and neck

in a flexed versus neutral position. The hypothesis was investigated that hyperflexion of the

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head and neck segment creates significantly higher pressure at the site of the cranial and caudal
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nuchal bursa compared to the neutral or to the mildly flexed head and neck position.
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Materials and methods
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Specimens of the head and neck of ten horses, of various breeds, were collected (Table

1). All specimens were collected from horses euthanased at the University Clinic for Horses,

Vetmeduni Vienna, Austria, due to various conditions unrelated to the head, neck or withers.
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On the day of euthanasia, specimens were isolated at the level of the sixth thoracic vertebra to

preserve the entire nuchal ligament, leaving the overlying tissues and skin intact. Specimens
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were stored at -20 °C, removed from the freezer 48-72 h before dissection and thawed at room
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temperature prior to use. Specimens were used in the chronological order in which they became

available. Neck circumference was measured using a measuring tape just caudal to the occiput

and at the midpoint between the withers and the occiput in order to document neck

conformation. When not in use, specimens were wrapped in water-soaked towels covered by
plastic sheets and kept in a refrigerated room at 4-6 °C to reduce the rate of post mortem changes.

All ten specimens were used for the anatomical study, as well as the measurements of angles

and nuchal ligament elongation, and from the fifth specimen onwards, additional pressure

measurements were carried out.

Anatomical study

Each specimen was placed on a table in lateral recumbency (six right-lateral, four left-

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lateral). The side of the recumbency was intended to be alternating; however, as the skin and

superficial muscle of the left side of one specimen was damaged during post-mortem separation

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from the trunk, it also had to be positioned on its left side. Dissection started with a 20 cm long
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lateral skin incision on the side facing upward, about 3 cm lateral and parallel to the dorsal

midline over the first two cervical vertebrae. Carefully dissecting the tissue at the site of the
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cranial and caudal nuchal bursa, any presence of bursal structures was noted. Subsequently,
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skin and musculature overlying both the cervical spine and the nuchal ligament were removed

including the Mm. multifidi, to expose one side of the seven cervical vertebrae and the entire

nuchal ligament. Care was taken to keep all articular features of the cervical vertebrae
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(ligaments, joint capsules, intervertebral discs) intact.

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Specimen preparation
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For positional data collection, retro-reflective markers were used. Three screws were

drilled into the skull bones of the specimens, one each into frontal bone (head1), nasal bone

(head2) and crista facialis (CF) with one retro-reflective marker (14 mm diameter) attached to

each screw with double-sided adhesive tape. Similarly, three tripods, each with three retro-
reflective markers (6 mm diameter) were attached to C1, C2 and the seventh cervical vertebra

(C7). Five single retro-reflective markers (14 mm diameter) were evenly distributed along the

funicular part of the nuchal ligament (NL1, NL2, NL3, NL4, NL5), between the occiput and

the fourth thoracic vertebra, with double-sided adhesive tape (Fig. 1). Each specimen was

secured in position on the table with two screws drilled through two of the vertebral bodies of

the thoracic spine (T3-T5) into the wooden table top and the cranial part of the thorax was

additionally tied to the table using a tension belt. A rope (2 m) was tied around the nose of each

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specimen to allow positioning the specimen into the three different head and neck positions

evaluated in this study.

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Head and neck position
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Positional data was collected for each specimen in three different head and neck
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positions frequently described (Gómez Álvarez et al., 2006; Weishaupt et al., 2006; Elgersma
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et al., 2010), with the head and neck angle defined as the angle between the long axis of the

mandible and the ventral midline of the neck. The neutral, relaxed position was defined as

HNP1, equivalent to HNP1 of Nestadt et al. (2015) with an angle of approximately 90°. A
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mildly flexed position with an angle of approximately 60° was defined as HNP2, equivalent to

HNP2 of Nestadt et al. (2015). A hyperflexed position (commonly known as ‘rollkur’) with an
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angle of approximately 45° was defined as HNP3, equivalent to HNP4 of Nestadt et al. (2015).
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Head and neck positions were achieved by pulling on the rope attached to the nose and securing

the rope.

Positional data collection

 Ten high-speed cameras (Eagle Digital Real Time System, Motion Analysis

Corporation) were used to record the three-dimensional position of the retro-reflective markers.

Prior to recording, the cameras were calibrated using an L-shaped calibration frame and a

calibration wand. The coordinate system was defined as follows: The x-axis was parallel to the

sagittal axis of the specimen, the z-axis was orientated dorsoventrally in the specimen and the

y-axis was perpendicular to the plane formed by the x- and z-axes (Fig. 1). Data were collected

in each specimen in each head and neck position (HNP1, HNP2 and HNP3) three times for 10

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s at 120 Hz.

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Pressure measurements
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After positional data collection in all three head and neck positions, a pressure

measurement device (Tiga-Med) was used in six specimens to document the pressure between
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the nuchal ligament and C1 (C1HNP1, C1HNP2, C1HNP3) and between the nuchal ligament
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and C2 (C2HNP1, C2HNP2, C2HNP3) in the three head and neck positions. The pressure

measurement device consisted of a conventional blood pressure cuff, folded and wrapped in

duct tape to the size of 10 x 5 x 2 cm (Fig. 2). The cuff was inflated to 20 mmHg and placed
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between the nuchal ligament and C1 and C2 respectively. The cuff remained in either position

for the measurements.

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Data processing and statistical analysis

Three-dimensional coordinates of each marker were computed using kinematic software

(Cortex-64 5.3.1, Motion Analysis Corporation). Data series were smoothed using a

Butterworth low pass filter with a cut-off frequency at 6 Hz. Further calculations were carried
out in Excel (Microsoft Office 2016, Microsoft Corporation). Measurements were carried out

in ten specimens in HNP1, HNP2 and HNP3; in six of these specimens, data were also collected

with the pressure measurement device at C1 (C1HNP1, C1HNP2, C1HNP3) and at C2

(C2HNP1, C2HNP2, C2HNP3). For each measurement condition, the flexion-extension (FE)

angles of the x and y coordinates were calculated between markers along the head and neck and

expressed in degrees. First angle (A1) was determined between the markers head2, C1 and C2,

second angle (A2) between markers C1, C2 and C7 and third angle (A3) between markers head1,

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C1 and C7. Nuchal ligament length was determined between NL1 and NL2, NL2 and NL3,

NL3 and NL4 and NL4 and NL5 and the overall nuchal ligament length was calculated as their

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sum. Statistical data analysis was carried out in SPSS (IBM SPSS Statistics 24, IBM). Normal
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distribution of the data was tested with Kolmogorov-Smirnov test. One-way ANOVA tests with

Bonferroni correction were used to compare A1, A2 and A3 between the three head and neck
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positions (n = 10), to compare pressure values between the three head and neck positions (n =
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6), to compare nuchal ligament length between the three head and neck positions (n = 6) and to

compare angles and nuchal ligament lengths between the three measurement situations (without

pressure measurement device, with pressure measurement device at C1/C2; n = 6). Pearson
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correlation coefficients were calculated to identify the relation between angles, nuchal ligament

lengths and pressure values and the three measurement situations (without pressure
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measurement device, with pressure measurement device at C1/C2) and between angles and
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nuchal ligament length, respectively pressure values in the three measurement situations. A

paired t test was used to compare the pressure values at C1 and at C2 in the three head and neck

positions. For all statistical tests, P<0.05 was considered significant.

Results

The mean ± standard deviation (SD) neck circumference of the specimens was 78 ± 7

cm just caudal to the occiput (NC1) and 99 ± 9 cm at the midpoint between the occiput and the

withers (NC2), with NC2 representing 106%-142% of NC1 of the same animal. Neck

circumference was not significantly correlated with body mass. In six specimens, fibrous

structures were noted; specifically, fibres or septum-like structures were seen in two specimens

and membrane like structures in three specimens; the sixth specimen showed both structure

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types. None of the specimens presented a bursa-like structure as previously described (Abuja

et al., 2014). In five specimens, the fibrous structures were located between the nuchal ligament

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and C2 and in one specimen they were located both at C1 and C2 (Table 1, Fig. 3).
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Data were normally distributed. Smallest angles were found for HNP3 compared to
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HNP1 and HNP2 (Table 2). Without the pressure measurement device, nuchal ligament length
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was highest in HNP3 (HNP1: 753 ± 115 mm; HNP2: 775 ± 124 mm; HNP3: 817 ± 127 mm);

nuchal ligament length increased significantly (P<0.001) with insertion of the pressure

measurement device at the level of C1 by 3-11% and at C2 by 5-12%, with the largest increase
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in HNP3. Pressure values were highest in HNP3 for both potential bursa locations. Pressure

values were significantly higher at C1 than at C2 in HNP3 (P<0.04) and significantly lower at
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C1 than at C2 in HNP1 (P<0.05; Table 3). Over all three head and neck positions, each angle
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(A1, A2, A3) was highly significantly correlated over the three measurements situations

(without pressure measurement device, with pressure measurement device at C1/C2; all

P<0.001). This correlation was strongest for A2 (r2 > 0.98), slightly less for A3 (r2 > 0.88) and

weakest for A1 (r2 range 0.65 to 0.86). Moreover, there was a significant and very positive
correlation of nuchal ligament length over the three head and neck positions (r2 > 0.99,

P<0.001).

Over all three head and neck positions, but within each measurement situation (without

pressure measurement device, with pressure measurement device at C1/C2), there was a

moderately positive, highly significant correlation between A1 and A3 (r2 range 0.63 to 0.72,

P<0.001), as well as between A2 and A3 (r2 range 0.81 to 0.91, P<0.001). However, this was

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not the case between A1 and A2, where P-values ranged from 0.050 to 0.160 and r2 ranged

from 0.35 to 0.46. This shows that flexion was achieved in all angles by the passive positioning

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of head and neck of the specimens.
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Pressure values at C1 and C2 were highly significantly correlated over all three head
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and neck positions (r2 0.88, P<0.001). Furthermore, pressure values at the level of C1 and C2
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were significantly and markedly negatively correlated with all three angles (A1 to A3) over all

three head and neck positions. This correlation was strongest for A3, followed by A2, and

finally by A1 for both locations of pressure measurements, showing pressure at both locations
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was increasing with flexion (Table 4).

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During data tracking, data loss occurred due to light reflexions around some markers
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and therefore nuchal ligament length values were only obtained for specimens V, VI, VII, IX

and X (Table 1).

Discussion
 The inconsistent nature of nuchal bursae has been described in horses (McIlwraith,

2002; Dyson, 2011b). The pressure at these sites had not been documented, although pressure

and friction are the most likely causative factors for the development of such adventitious

bursae. In the present study, a marked increase in pressure at the locations of the nuchal bursae

was associated with increase in flexion of the head and neck and elongation of the nuchal

ligament. No attempt was made to assess friction at these locations in the cadaver specimens,

despite its potential relevance for the development of acquired bursae (Sisson, 1975; McIlwraith,

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2002; Dyson, 2011b).

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Only horses without signs of bursitis were included in the present study, and during
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dissection no fluid accumulation was found at the location of either nuchal bursa. This is in

accordance with previous studies, where nuchal bursae in the absence of bursitis are described
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to be potential spaces, containing no visible fluid (Reef, 1998; McIlwraith, 2002), or only a
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very small amount of fluid volume (Abuja et al., 2014). In none of the ten necks dissected in

the present study, structures resembling a bursa were found (García-López et al., 2010; Dyson,

2011a; van Wessum, 2011; Abuja et al., 2014), with six of ten necks showing some fibrous
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bands that may well be early stages of the development of acquired bursae (McIlwraith, 2002;

Dyson, 2011b). The absence of nuchal bursae in all specimens of the present study is in contrast
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with one study where cranial nuchal bursae were found in all 32 horses (Abuja et al., 2014).
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The significance of fibrous bands for the development of a bursa is unclear, as bursa

development starts with the disruption of connective tissue (Wissdorf and Otto, 2010; Redding,

2011), and no such disruption was noted. However, the presence of fibrous bands in the absence

of other features of a bursa, may represent a mild chronic change, as fibrous bands have been
described to develop after the development of the capsule of the bursa (Dyson, 2011a; Baxter,

2012).

Clinical signs associated with cranial or caudal nuchal bursitis include neck pain,

abnormally low head carriage with extension of the neck and swelling of the respective region;

however swelling or pain may also be absent in mildly affected horses (García-López et al.,

2010). The difference in pressure at the cranial and caudal bursa location during hyperflexion

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noted in the present study may be associated with the higher incidence of cranial nuchal bursitis,

which is more frequent encountered as a clinical problem than caudal nuchal bursitis (García-

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López et al., 2010; Abuja et al., 2014; Bergren et al., 2018). However, in the live horse there
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may be additional differences between these two locations, for example in the friction created

during locomotion in the different head and neck positions.

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Various factors may lead to the development of acquired nuchal bursae in individual

horses. One of these factors may be neck conformation (as documented in the present study

using neck circumference measurements) which is associated with differing levels of head and
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neck flexibility (Clayton and Townsend, 1989; van Weeren and Crevier-Denoix, 2006).

Previously, no association between the presence of the nuchal bursae and age was found in
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horses of different breeds (Wagner, 2002); nonetheless, in our study, five of six specimens with
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bursa related structures were middle-aged as previously defined (Brosnahan and Paradis, 2003;

McGowan, 2009; Ireland, 2016) or older. A similar age distribution has been described for the

presence of clinically relevant nuchal bursitis (García-López et al., 2010; Bergren et al., 2018).

On the other hand, young horses have also been documented to develop nuchal bursitis, and in
the present study, one specimen of a 2-year-old horse showed specific fibrous structures,

indicating the contribution of factors beyond age in the development of nuchal bursae.

Furthermore, as changes in the intervertebral discs and in the vertebral bones increase with

increasing age (Bergmann et al., 2018)), it is possible that an associated reduced flexibility of

the neck might actually reduce the risk for the development of a bursa or clinically relevant

bursitis at older age.

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Nuchal bursitis has been poorly understood and therefore this study may aid in

understanding the biomechanics within the neck. The head and neck positions chosen for the

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present study are very close to those studied in live horses (Rhodin et al., 2005; Gómez Álvarez
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et al., 2006; von Borstel et al., 2009), allowing some extrapolation of the results to the live

situation. Hyperflexion created the largest elongation of the nuchal ligament both with and
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without the presence of the pressure measurement device, indicating that its use did not change
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the nature but did change the magnitude of the relationship between head and neck flexion and

nuchal ligament elongation. In the present study, only the length of the funicular part of the

nuchal ligament was considered; future studies may also focus on the much thinner lamellar
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part, of which the mechanical relevance is still unclear.

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The use of cadaver specimens is an important first step to show a principle that may
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later be validated in vivo. Similar to our results, previous studies in live horses (Rhodin et al.,

2005; Gómez Álvarez et al., 2006; Sleutjens et al., 2010) showed that hyperflexion decreases

the intervertebral angles. The removal of half of the soft tissues of the neck was based on

conflicting priorities: Firstly, the priority of precise anatomical placement of markers in the
osseous and ligamentous structures of the neck allowing measurement of these structures

without skin and soft tissue movement artefacts; secondly, the priority of preserving the soft

tissues (such as muscles, tendons and fasciae) and their effect on the movement, as even in

cadavers the presence of muscle tissue has been shown to stabilise spinal movement (Valentin

et al., 2012). Clearly, this is one of the limitations of the present study, as less flexion might

have been possible if all soft tissues had remained intact. Considering the clinical relevance of

our findings, we would like to emphasise that in live, standing horses, the pressure at the site

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of the cranial and caudal bursae would be much higher than in the cadaver specimens in lateral

recumbency, due to the mass of the head and neck segment (Buchner et al., 2000).

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Hyperflexion is known to have a wide range of physical and mental effects on horses

even in horses without clinical signs of nuchal bursitis (von Borstel et al., 2009; Elgersma et
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al., 2010; Christensen et al., 2014). Horses with clinical signs associated with cranial or caudal
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nuchal bursitis, often adopt an extended neck position to reduce tension in the nuchal ligament

and consequently lower pressure in the nuchal bursae (García-López et al., 2010; Dyson, 2011b;

García-López, 2018). The pressure measured underneath the nuchal ligament therefore supports
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the recommendation not to perform hyperflexion in horses with nuchal bursitis (García-López

et al., 2010; Dyson, 2011b).

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Conclusions

This study demonstrated an increase in pressure at the sites of both cervical bursae

caused by head and neck flexion, especially hyperflexion. Care should be taken when using
neck hyperflexion during training in horses diagnosed with nuchal bursitis and in those that are

considered at risk of developing it.

Conflict of interest statement

None of the authors of this paper has a financial or personal relationship with other people or

organisations that could inappropriately influence or bias the content of the paper.

Acknowledgements

The authors thank the Institute of Pathology and Forensic Veterinary Medicine, Vetmeduni

of
Vienna for their help collecting the specimens used in the present study.

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Supplementary material

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Supplementary data associated with this article can be found, in the online version, at doi:

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treadmill. Equine Veterinary Journal 38, 387–392.

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& H. Schaper GmbH, Hannover, Germany, pp. 261–262.

Fig. 1. Marker setup and coordinate system. The markers were set at the following locations:
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nasal bone (head1), frontal bone (head2) and crista facialis (CF), three tripods (first (C11, C12,
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C13), second (C21, C22, C23), seventh (C71, C72, C73) cervical vertebra) and five single retro-

reflective markers (NL1 to NL5) evenly distributed between the occiput and the fourth thoracic
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vertebra (T4).
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Fig. 2. The pressure measurement device consisted of a conventional blood pressure cuff which
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was folded and wrapped in duct tape to the size of 10 x 5 x 2 cm to document the pressure

between nuchal ligament and C1 and nuchal ligament and C2 in the different head and neck
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positions.
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Fig. 3. Picture of the septa/fibrous structures (black arrows) found in specimen IV between the
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nuchal ligament (NL) and the second cervical vertebra (left). The right side shows a close-up

view of the fibrous structures found in specimen IV. Cranial is to the right, dorsal to the bottom
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of the picture.
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 Table 1 Age, body mass, breed, neck circumference just caudal to the occiput (NC1) and at the

midpoint between the withers and the occiput (NC2), and location (Loc), dimension (Dim), and

wall thickness (WT) of the fibrous structures (FS) related to the cranial nuchal bursa and caudal

nuchal bursa found in the ten specimens.

Specimen Age Body mass NC1 NC2 Dim WT

Breed FS Loc
number (years) (kg) (cm) (cm) (cm) (mm)
1 6 546 Furioso 80 91 N - - -
Hungarian
2 26 463 90 95 N - - -

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warmblood
3 3 545 Crossbred 84 105 N - - -
4 26 463 Trotter 74 94 septa C2 7x5 2

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5 22 - Hanoverian 78 111 N - - -
membrane
6 13 552 Furioso 76 90 C2 2x4 1
and septa
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Oldenburger
7 14 400 77 106 isolated C2 3x3 1
horse
fibres
8 17 558 Westphalian 74 104 membrane C2 2x2 2
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9 12 647 Huzule 61 83 membrane C2 2x2 1
closely
C1 2x2 1
10 2 400 Quarter horse 80 109 placed fibres
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membrane C2 5x3 1
N, no fibrous structures related to the cranial or caudal nuchal bursa found; -, no data; C2,
second cervical vertebra; C1, first cervical vertebra.
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Table 2 Mean and standard deviations (SD) of angles (°) in the different head and neck

positions but without the placement of the pressure measurement device.

A1 A2 A3
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(n = 10) (n = 10) (n = 10)

(head2 - C1 - C2) (C1 - C2 -C7) (head1 - C1 - C7)
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HNP1 138a ± 14° 179c ± 11° 111e,f ± 9°

HNP2 135b ± 11° 179d ± 13° 102e,g ± 8°
HNP3 127a,b ± 9° 146c,d ± 10° 75f,g ± 5°
Head2, reflective marker at frontal bone; C1, cervical vertebra 1; C2, cervical vertebra 2; C7,
cervical vertebra 7; head1, reflective marker at nasal bone; HNP1, neutral position; HNP2,
mildly flexed position; HNP3, hyperflexion.
Identical superscripts (a – g) indicate significant differences in angles A1, A2 and A3 between
the different head and neck positions (i.e. within each column; a, P=0.002; b, P<0.001; c,
P<0.001; d, P<0.001; e, P<0.001; f, P<0.001; g, P<0.001).

Table 3 Mean and standard deviations (SD) of angles (°), nuchal ligament lengths (mm) and

pressure values (mmHg) in the different head and neck positions.

A1 A2 A3 NL length Pressure
n=6
(head2 - C1 - C2) (C1 - C2 - C7) (head1 - C1 - C7)
C1HNP1 136a ± 13 184c ± 5 110g,h ± 9 740m,n ± 117 23s,u ± 11
C1HNP2 129a ± 10 183d ± 8 100g,i ± 7 764m,o ± 113 49v ± 26

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C1HNP3 124 ± 10 149c,d ± 5 76h,i ± 3 818n,o ± 129 99t,u,v ± 24
C2HNP1 133b ± 11 183e ± 5 107j,k ± 5 726p,q ± 131 29s,w,x ± 12

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C2HNP2 126 ± 11 183f ± 8 98j,l ± 6 765p,r ± 112 38w,y ± 16
C2HNP3 122b ± 9 150e,f ± 5 75k,l ± 5 811q,r ± 141 77t,x,y ± 30
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NL, nuchal ligament; head2, reflective marker at frontal bone; C1, cervical vertebra 1; C2,
cervical vertebra 2; C7, cervical vertebra 7; head1, reflective marker at nasal bone; SD, standard
deviation; C1HNP1, neutral position, pressure measurement device at C1; C1HNP2, mildly
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flexed position, pressure measurement device at C1; C1HNP3, hyperflexion, pressure
measurement device at C1, C2HNP1, neutral position, pressure measurement device at C2;
C2HNP2, mildly flexed position, pressure measurement device at C2; C2HNP3, hyperflexion,
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pressure measurement device at C2.

Identical superscripts (a – l) indicate significant differences in angles A1, A2 and A3 between
the different head and neck positions (a, P=0.017; b, P=0.006; c, P<0.001; d, P=0.001; e,
P<0.001; f, P<0.001; g, P<0.001; h, P<0.001; i, P<0.001; j, P=0.014; k, P<0.001; l, P=0.001).
Identical superscripts (m – r) indicate significant differences in changes of NL length between
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the different head and neck positions (m, P=0.001; n, P=0.003; o, P=0.009; p, P=0.016; q,
P=0.002; r, P=0.005; P=0.045; t, P=0.038).
Identical superscripts (s – w) indicate significant differences in changes in pressure between
the different head and neck positions (s, P<0.001; t, P=0.001; u, P=0.034; v, P=0.004; w,
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P=0.002).
All comparisons of values are within the columns.
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Table 4 Pearson´s correlation coefficients and P values for pressure and angles.

A1 A2 A3
n = 18 (head2 - C1 - C2) (C1 - C2 - C7) (head1 - C1 - C7)

pressure at the level of C1 r2 -0.55 -0.76 -0.83

 P 0.020 <0.001 <0.001
2 -0.59 -0.71 -0.74
r
pressure at the level of C2
P 0.010 <0.001 <0.001
Head2, reflective marker at frontal bone; C1, cervical vertebra 1; C2, cervical vertebra 2; C7,

cervical vertebra 7; head1, reflective marker at nasal bone.

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