A 7-year-old Thoroughbred mare was referred to the Cornell Equine Orthopedic Surgery Service for surgical correction of Overriding Spinous Processes (OSP). The diagnosis was made via clinical history and radiographic changes. Roentgen signs consistent with OSP were identified at the spinous process apices of T13 - T17. Since catastrophic peri-anesthetic complications in recumbent horses are not infrequent, it was elected to perform a standing interspinous ligament desmotomy. Utilizing a minimally invasive approach, visualization of the interspinous space (ISS) with associated structures proved challenging. Furthermore, completeness of interspinous ligament transection was difficult to gauge. As such, the described technique was modified via ultrasonographic imaging of the ISS. Ultrasound-guidance promoted accurate surgical instrumentation, avoidance of pertinent anatomical structures, and proved a marker for transection completion. This case report discusses the complexity of back-associated lameness and evaluates a modified surgical technique for the alleviation of OSP’s.