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Botulinum Toxin Treatment in Spasmodic Torticollis

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Botulinum Toxin Treatment in Spasmodic Torticollis 640 Journal ofNeurology, Neurosurgery, and Psychiatry 1990;53:640-643 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.53.8.640 on 1 August 1990. Downloaded from Botulinum toxin treatment in spasmodic torticollis J D Blackie, A J Lees Abstract consent. There were 11 females and eight Botulinum toxin A was administered to males aged between 19 and 73 years (mean 49 19 patients in a double-blind placebo years). Disease duration ranged from 0-75-25 controlled trial. Toxin was more effec- years (mean 7-2 years). All patients had tive than placebo for improving both isolated torticollis, without evidence of a more head position and pain which was widespread dystonia. measured by an objective rating scale and videofilm assessments. Following the controlled trial, treatment with Method botulinum toxin was continued in an Botulinum toxin was supplied by the Vaccine open fashion. A total of 60 patients with and Research Laboratory, Porton Down, Sal- torticollis received toxin in a total of 117 isbury, United Kingdom as a freeze dried treatment periods. The mean follow up toxin-haemagglutinin preparation. A vial con- period was 8-4 months. In 39 patients tained 50 nanograms of the toxin-haemag- with pain there was benefit in 77% of glutinin which was equivalent to 2000 mouse treatment periods. Some improvement units. The dose of toxin per muscle was deter- in neck posture occurred in 83% of the mined by multiplying the amount of Porton treatment periods with a mean duration Down toxin currently being used for injection of 12 weeks. Side effects were frequent into an orbicularis oculus muscle9 by a factor with dysphagia being the most common of 4. This ratio of neck to eye muscle dose is (28% of treatment periods). Botulinum comparable with other reports.' 2 A pilot study toxin is an effective treatment for tor- in three patients using this dose did not result ticollis but treatment should be initiated in side effects. with doses at the lower end of the range Each patient was randomly allocated to used in this study (400-600 mouse units). receive either botulinum toxin or normal saline placebo injection with the cross-over injection three months later. The two most The treatment of torticollis by local injection active muscles of the sternomastoid, splenius of botulinum toxin A was first reported in capitis and trapezius pairs were injected. The 1985.' Other reports have also indicated the muscles to be injected were determined by http://jnnp.bmj.com/ usefulness of botulinum toxin in this con- clinical assessment,'0 and supplemented in dition.2' However, the dose used and the each patient by concentric needle EMG method of administration has varied con- assessment. EMG also assisted in determining siderably in these studies. This report details the depth of injection particularly for the our experience in treating 50 torticollis splenius capitis muscle. Fifty nanograms were patients with botulinum toxin. diluted in 2-5 mls of normal saline and 0 6 ml Botulinum toxin consists of seven antigenic was injected into each of two muscles. Each on September 24, 2021 by guest. Protected copyright. types of which only type A has been used muscle was injected at two sites, with an 0 3 clinically. Its potent neurotoxicity is attributa- ml aliquot per site. The total dose per muscle ble to irreversible inhibition of presynaptic was 12 nanograms or 480 mouse units. The release of acetylcholine.7 Botulinum toxin placebo injection consisted of an equivalent preparations vary in potency depending on volume of normal saline. The injections were the site and method of manufacture. It is all administered "blind" by one of the authors therefore preferable to refer to the dose in (JB). terms of mouse units rather than nanograms. Video recording was performed before the A mouse unit is the LD50 of a group of 18-20 injection and four weeks after. When the trial gram female Swiss-Webster mice. There are was completed the recordings were edited into still problems in using this unit because des- random order and independently scored, blin- The National Hospital pite equivalent mouse toxicity there may be a A clinical scale devised for Nervous Diseases, dly. rating and London variation in human neurotoxicity depending outlined by Tsui' was used to score the video J D Blackie on the source of the toxin.8 recordings. In addition patients were asked to A J Lees rate change in motor symptoms (nil, mild, Correspondence to: Dr A J moderate or marked) and to score their pain Lees, The National Hospital for Nervous Diseases, Queen Patients associated with the torticollis on a visual Square, London WCIN Initially 19 patients were enrolled in a double- analogue scale of 0-10. Onset and duration of 3BG, United Kingdom. blind placebo controlled crossover study. both benefit and side effects were recorded. Received 13 September 1989. Hospital ethical committee approval was After completion of the double blind study, Accepted 12 December 1989 obtained and each patient signed an informed open administration of botulinum toxin to Botulinum toxin treatment in spasmodic torticollis 641 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.53.8.640 on 1 August 1990. Downloaded from patients with torticollis was continued. Toxin ment was 10 8 (3 2) compared with 8-5 (2 8) was administered to a total of 50 patients, four weeks post injection. Subjective motor which included the initial 19 patients, in a response was rated as marked in two patients, total of 117 treatment periods. A treatment moderate in five, mild in seven and nil in five. period was the interval between subsequent Only one patient had improved motor symp- injections. In this group there were three toms following placebo and this was mild. In patients with oromandibular dystonia, one those patients that had a response the mean had a combination of blepharospasm and onset of effect was six days (range 1-21 days) writer's cramp, the second patient had gen- with a peak effect at 14 days (range 7-28 days) eralised torsion dystonia and the third writer's and duration of effect 12 weeks (range 6-20 cramp. There were 28 females and 22 males. weeks). In view of the prolonged effect in The follow up period ranged from three to 19 some patients beyond the three month cross- months with a mean of 8-3 months. The over period each scorer was tested for any muscles injected were determined clinically carry over effect in those patients that received and EMG was used only in complex cases or the toxin initially. This was not found to be where there had been a poor response to toxin significant (Mann-Whitney U p > 0 05). previously. A maximum of three muscles were Sixteen out of 19 patients had pain associated injected during any one treatment period. with their torticollis. Transient increase in Most injections were into the sternomastoid, local pain and stiffness was a common side trapezius or splenius capitis but additional effect after both toxin and placebo injections muscles injected included the levator and this persisted for a few days. In one patient scapulae, semispinalis capitis and platysma pain at the site of the injection persisted for 12 muscles. The dose ranged from 120-480 weeks following toxin injection. Sustained mouse units per muscle with a mean of 396 improvement in pain occurred in 12 patients mouse units. The mean total dose per treat- following toxin injections compared with two ment was 875 mouse units. The concentration patients in the control group. Mean pain scores of toxin was equivalent to that used in the in patients with pain fell from 6 1 to 3-3 four control study but a single aliquot only was weeks after the botulinum toxin injection. injected into each muscle. The subjects were The side effects of the controlled trial are asked to rate their response to injections for listed in table 1. The dysphagia in all three both pain and motor symptoms as nil, mild, patients was mild, with sticking of solids at the moderate or marked. post-cricoid level persisting for three to four weeks. ENT review of two of these patients revealed mild slowing of transit time on Results swallow cine-radiography in one patient but no In the controlled trial assessment the two other abnormality. There was wasting of neck scorers had a correlation coefficient of 0-64 muscles in 12 patients and this was commented between the objective clinical rating scores. As on by the patients themselves in a few instan- this was relatively poor, each scorer was asses- ces. This may have influenced the effectiveness sed independently using a Mann-Whitney U of a blinded controlled assessment with the test to see if the toxin had a larger effect than subjective ratings. However, muscle wasting http://jnnp.bmj.com/ placebo. This was significant for both scorers was not apparent on the video recordings used (scorer 1 p < 0-02, scorer 2 p < 0 05). Three for the objective clinical ratings. patients had no objective response from the There was no significant predictor of res- injections. The mean (SD) score before treat- ponse to toxin injection when analysing sex, age, duration or severity ofthe torticollis or the pattern of muscle involvement (agonist or antagonist") using Fisher's exact test. Table I Side effects of controlled trial (n = 19) In the group of 50 patients there was subjec- on September 24, 2021 by guest. Protected copyright. tive improvement in motor symptoms in 83% Side effect Placebo Botulinum toxin of the 117 treatment periods. This was marked Local pain 9 7 in 21 (18%), moderate in 48 (40%), mild in 28 Malaise,.
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