Hubert H. Fernandez, MD - Florida Society of Neurology

Common Indications forBotox• Dystonia (ST, blepharospams, , focal andsegmental)• Hemi-facial spasms• Spasticity• Headache• Wrinkles• Drooling• Gait freezing

Dystonia“….is a neurologic syndrome characterized byinvoluntary, sustained, patterned, and oftenrepetitive muscle contractions of opposingmuscles causing twisting movements orabnormal postures. Partly because of its richexpression and a variable course, dystoniais frequently not recognized ormisdiagnosed” Fahn 1984.

Main features of dystonia• relatively long duration (unlikechorea or myoclonus)• simultaneous contractions of agonistand antagonist muscles• results in twisting of a body part• same muscle groups are generallyinvolved

Other Features• Primary dystonia almost always begins by affecting a singlepart of the body (focal dystonia); most often the spread isto contiguous body parts• The younger the age at onset, the more likely for dystoniato spread• Action dystonia: dystonic movement aggravated duringvoluntary movements• Task specific dystonia: abnormal movement appear duringspecial action• Overflow: as dystonia progresses, non-specific voluntaryaction can bring out dystonia, also actions in other parts ofthe body can induce dystonic movements of the primarilyaffected body part• Worsen with fatigue, stress; suppressed with sleep,hypnosis, relaxation• Sensory tricks (geste(antagoniste)• Pain is not very common except in cervical dystonia• Can present with tremor (dystonic tremor) or myoclonus(dystonia-myoclonus)

Overflow Dystonia

Task Specific Dystonia

Sensory Trick

Classification• By Age at Onset– Early onset (26 years)• By Distribution– Focal - single body region (e.g., writer’s s cramp, torticollis, blepharospasm)– Segmental - contiguous body regions (e.g., face+jaw [Meige’s], neck+arm)– Multifocal - non-contiguous body regions (e.g., arm+leg, bleph+writer’s cramp)– Generalized - both legs + at least one other body region (one or both arms)• By Cause– Primary (idiopathic) - dystonia is only sign in the absence of identifiableexogenous cause or other inherited or degenerative disease– Secondary (symptomatic)• Dystonia-plus(accompanied by parkinsonism or myoclonus)• Heredodegenerative dystonia (X-linked, autosomal dominant or recessive)• Acquired/exogenous (drugs, trauma, stroke)• Parkinsonian syndromes (PD, CBGD, PSP)

Focal Dystonias• Cervical dystonia (CD)or spasmodic torticollis• Blepharospasm• Laryngeal dystoniaor spasmodic dysphonia (SD)• Limb dystonia(writer’s s or musician’s s cramp, etc.)

Cervical Dystonia:idiopathic

Cervical dystonia: tardive

Cervical Dystonia: tardive

Blepharospasms

Apraxia of eyelid opening

Laryngeal Dystonia:adductor

Laryngeal Dystonia:abductor

Focal Limb Dystonia

Hemi-dystonia

Generalized Dystonia

Secondary Dystonia:Lubag

Secondary Dystonia:perinatal injury

Secondary Dystonia: PostTraumatic

Dystonia in CBGD

Dystonia in PD

Dystonia in PSP

Therapy• Pharmacotherapy– CNS active drugs• Anticholinergics• GABAergics (benzodiazepines, baclofen, tizanidine)• Dopaminergics (DA agonists, DA antagonists, DA depletors)• Other (carbamazepine, alcohol, lithium, cannabinoids)– Local injections (Botulinum toxin)• Physical and supportive therapy– PT and orthopedic devices (bracing)– Repetitive transcranial magnetic stimulation– Patient and caregiver education and support• Surgical therapy– Peripheral denervation– Central• Ablative procedures (thalamotomy, pallidotomy)• DBS

Botox for the face:Blepharospasmsxxx xx x x xxx x x

Botox for headache• Frontalis• Temporalis• Insertion of the SCM• Occipitalis• Upper Trapezius

Botox for HemifacialSpasmsxxxxxx

Jaw dystonia• Jaw closing dystonia– Masseter– Temporalis• Jaw opening dystonia– Lateral pterygoids– Digastric

Cervical Dystonia: : Whichmuscles to inject?• Torticollis (chindeviation)• Laterocollis (tilt)• Anterocollis (neckflexion)• Retrocollis (neckextension)• Shoulder elevation• Head tremor

Torticollis• Contralateral SCM• Ipsilateral spleniuscapitis• Ipsilateralsemispinalis capitis

Laterocollis• Ipsilateral scalenes• Ipsilateral levatorscapulae• Ipsilateral spleniuscapitis• Ipsilateral SCM

Shoulder elevation• Ipsilateral levatorscapulae• Ipsilateral uppertrapezius

Anterocollis• Bilateral SCM• Bilateral anteriorscalene• Bilateralsubmentalis

Retrocollis• Bilateral spleniuscapitis• Bilateral trapezius• Bilateralsemispinalis capitis

Head tremor• Main vscompensatorymuscles• 3 to 4: 1 dosingratio

Structures to avoid• Brachial plexus• Carotid sheath• Greater occipital nerve• Larynx and trachea• Pharynx andesophagus• Thyroid gland• Pleura and apex of thelung

Post-injectionexpectations• 70% get about 60-80% improvement• 3-44 months duration• Side effects– Dysphagia– Pain– Dry mouth– Fatigue• Secondary non-reponsiveness

Let’s s do some exercises!

Example 1

Example 2

Example 3

DosingIncrease• Low weight• Small muscle bulk• Mild disease• High probability ofweakness• Too muchweakness fromprevious injectionDecrease• Heavy weight• Large muscle bulk• Severe disease• Low concern forweakness

Materials Needed• 30G x ½” needle• 27G x 1¼” 1needle• 21G x 2” 2 needle• 1 cc syringe• Lidocaine 4% topical cream• Preservative free normal saline

Thank you!