Botulinum Toxin Injections for Voiding Dysfunction Following SCI

Abstract

Botulinum toxin (BT) injections have been used successfully to treat spastic muscle conditions, including detrusor- sphincter dyssynergia (DSD) seen in spinal cord injury (SCI) patients. In our urology clinic, we used BT to treat three SCI patients who had voiding dysfunction, using a transperineal needle with electromyographic (EMG) monitoring. Two of the patients reported excellent results following the treatment. One patient, with whom the staff had difficulty doing intermittent catheterization (IC), improved significantly. The other patient had improved voiding with an external catheter and minimal urinary residual. The third patient had no improvement of leg spasms with his voiding dysfunction and required a sphincterotomy. Although patients may need repeat injections, BT is minimally invasive and easy to administer with no side effects. Overall, BT injection is an excellent method of managing voiding in SCI patients, especially those on continuous external catheters and with IC management who refuse or are not good candidates for surgery.     

Effects of Botulinum Toxin Type A on Bilateral Masseteric Hypertrophy Evaluated With Computed Tomographic Measurement

BACKGROUND: A paucity of reports exist on the use of botulinum toxin type A injections as an alternative noninvasive treatment for masseteric hypertrophy. OBJECTIVE: To evaluate the effects of botulinum toxin type A on masseteric hypertrophy using computed tomography. METHODS: Percutaneous intramuscular injections of botulinum toxin type A of 30 U per side was carried out in 11 subjects with masseteric hypertrophy. The changes in the masseteric muscle volume before and 12 weeks after injection were evaluated using computed tomography. The changes in the lower facial contours on the photographs were evaluated as excellent, good, fair, and no changes. RESULTS: Nine of the 11 subjects showed a mean reduction of approximately 22% in the masseteric muscle volume. The maximum reduction was 35.4% (range, 8.1% to 35.4%). Nine subjects showed aesthetically good results with a grade of good or excellent at 12 weeks after treatment. CONCLUSION: Botulinum toxin injections are a noninvasive alternative method for treating masseteric hypertrophy.     

Comparison Between Intramuscular and Perimuscular Injections of Botulinum Toxin Type A

Background Botulinum toxin type A (BTX-A) must be injected in the intramuscular area to exert its paralytic effect. The durability of the BTX-A effect varies in different patients, and this fact can result from different locations of the drug injection, for example, the muscle peripheral area (perimuscular). This study aimed to evaluate whether a difference exists in the effect duration of the muscle paralysis between intramuscular and perimuscular injections of BTX-A. Methods This study used 18 male New Zealand rabbits divided into two groups (A and B) based on the location of the BTX-A injection. The group A animals received 10 units of BTX-A diluted with 0.1 ml of normal saline injected perimuscularly. The group B animals received the same dosage injected in the intramuscular area of the left masseter muscle. An electroneurophysiologic study was performed 1 week before the experiment for all the animals, then repeated 1, 4, and 8 weeks after the toxin injection. Results The amplitude values recorded in the masseter muscle were significantly lower in both groups throughout the study than the physiologic amplitude. The comparison between groups A and B did not show any statistically significant amplitude variations throughout the 8 weeks. Conclusion No significant difference in the neuromuscular blockade induced by botulinum toxin type A was observed between injections into the muscle peripheral area and intramuscular injections.     

Endoscopic Ultrasound-Guided Gastric Botulinum Toxin Injections in Obese Subjects: A Pilot Study

Background Gastric injections of botulinum toxin A (BTA) may induce changes in gastric emptying and body weight, but results vary. BTA dose and depth of injection may affect efficacy. This study assessed changes in gastric emptying, satiation, symptoms, and body weight after endoscopic ultrasound (EUS)-guided injection of 100 or 300 U BTA into gastric antral muscularis propria of obese subjects. Methods Open label study of ten healthy, obese adults (age = 29–49 years, body mass index = 31–54 kg/m²) who received 100 U (n = 4) or 300 U (n = 6) BTA and were followed for 16 weeks. Measures included gastric emptying of solids (by scintigraphy), satiation (by maximum tolerated volume [MTV] during nutrient drink test), gastrointestinal symptoms (by the Gastrointestinal Symptom Rating Scale), caloric intake (by food frequency questionnaire), and body weight. Results For the entire cohort, MTV decreased from 1,380 cc (range: 474–2,014) at baseline to 620 cc (range: 256–1,180) 2 weeks after BTA injection; decreases were statistically significant in the subjects receiving 300 U BTA (p = 0.03). Average body weight loss was 4.9 (±6.3) kg after 16 weeks. Gastric emptying T_1/2 was prolonged in the 300 U BTA group, but not significantly different from baseline (p = 0.17). BTA injections were well tolerated without significant adverse effects. Conclusion EUS-guided injection of BTA into gastric muscularis propria can be performed safely with minimal adverse effects. A dose of 300 U BTA significantly enhances satiation, is associated with weight loss, and may slow gastric emptying. Further study of higher dose BTA in obese subjects is warranted.     

Epidural Catheter Tip Position and Distribution of Injectate Evaluated by Computed Tomography

Background: The distribution of solutions injected into the epidural space has not been determined. The author therefore examined the site of catheter tips and the spread of contrast material in the epidural space using computed tomographic (CT) imaging in patients receiving successful epidural analgesia.

Methods: Lumbar epidural catheters were placed in 20 female patients by a midline technique. Anesthetic effect was determined by motor and sensory examinations during analgesic infusion. CT images were obtained for identification of the catheter tip and after radiographic contrast injection of 4 ml and then an additional 10 ml.

Results: Catheter tips were most often found lateral to the dura in the intervertebral foramen. In these subjects with normally functioning epidural analgesia, there was remarkable interindividual variability in patterns of spread, including various amounts of anterior passage, layering along the dura, and compression of the dura creating a posterior fold. Accumulation becomes more symmetric with increasing injectate volume. Spread through the intervertebral foramina was seen in all subjects. Air and fat in the region of the catheter interfered with solution spread in three subjects, but only over a limited area. Asymmetry in anesthetic effect was attributable to catheter position. No substantial barriers to solution spread were observed.     

Treatment of Hypertrophic Scars With Intralesional Botulinum Toxin Type A Injections: A Preliminary Report

Background  Hypertrophic scar is the abnormal appearance of wound healing that usually causes major physical, psychological, and cosmetic problems. Treatment of the hypertrophic scar still is a dilemma due to the lack of effective and excellent methods and agents. Recent reports show that botulinum toxin type A (BTX-A) improves wound healing. Therefore, the authors hypothesized that BTX-A may be favorable for the improvement of hypertrophic scars. Methods  A total of 19 patients were randomly assigned to a prospective clinical study. At 1-month intervals, BTX-A (2.5 U per cubic centimeter of lesion) was injected in these patients for a total of 3 months. All the patients were followed up for at least half a year. Therapeutic satisfaction was recorded, and the lesions were assessed for erythema, itching sensation, and pliability. Results  The study was completed by 19 patients. At the half-year follow-up visits, all the patients showed acceptable improvement, and the rate of therapeutic satisfaction was very high. The erythema score, itching sensation score, and pliability score after the BTX-A injection all were significantly lower than before the BTX-A injection. The differences all were statistically significant (P < 0.01). Conclusion  For the treatment of hypertrophic scars, doctors and patients both found BTX-A acceptable because of its better therapeutic results. Its effect of eliminating or decreasing hypertrophic scars was promising. Zhibo Xiao and Fengmin Zhang are the primary authors of this article.     

Changes in Arterial and Portal Perfusion in Embolized and Nonembolized Hepatic Lobes After Portal Vein Embolization Evaluated by Helical Computed Tomography

We evaluated the changes in hepatic arterial and portal perfusion in nonembolized as well as in embolized lobes after portal venous branch embolization (PVE) with dynamic helical computed tomography (CT). Six patients with hepatic malignancies, who underwent PVE prior to a subsequent hepatectomy, were the subjects of this study. We performed CT examinations before PVE and 2 weeks after PVE to make a volumetric analysis. At the same time, we performed single-location dynamic sequences after the injection of a 50-ml bolus of contrast medium, and we then created time–density curves from circular regions of interest drawn over the aorta, parenchyma of the right and left lobe of the liver, and spleen. We calculated the arterial perfusion index (ml/min per ml of tissue) and the portal perfusion index by dividing the maximum rate of enhancement of the liver before and after the splenic peak by the peak aortic enhancement. We then calculated the arterial and portal flows (ml/min) from the perfusion index and values of CT volumetry. In the right lobe, where the portal flow was occluded, the arterial perfusion index and flow increased significantly after PVE. In contrast, the arterial perfusion index and flow both decreased in the left lobe after PVE in a reverse response to the increase in the portal perfusion index and flow. The total arterial flow of the liver thus seemed to slightly increase; however, the change was not significant. By performing PVE an increased arterial perfusion was induced in the embolized lobe, with a concomitant decrease in arterial perfusion in the nonembolized lobe. Received: September 7, 2000 / Accepted: July 17, 2001     

Repeated Botulinum Toxin A Injections for the Treatment of Lines in the Upper Face: A Retrospective Study of 4,103 Treatments in 945 Patients

BACKGROUND Although botulinum toxin type A (BoNT-A) is a common aesthetic intervention, there are few published data on treatment over more than two cycles.
OBJECTIVE To evaluate the effectiveness/safety of repeated doses of BoNT-A (Dysport, Ipsen Ltd., Slough, UK) in the upper face for reduction of wrinkles.
METHODS Retrospective, cross-sectional patient chart review from 945 patients who had received a minimum of three consecutive, documented treatment cycles.
RESULTS The glabella was treated most frequently (93.9%), with the majority (81.5%) of patients receiving treatment in more than one area of the face. BoNT-A treatments were combined with other aesthetic procedures in 57.5% of cases, mostly with fillers (37.1%). There was no evidence of tachyphylaxia: the dose applied, the interval between treatments, and satisfaction with the results remained stable over the course of treatment. Adverse events were those expected with BoNT-A treatment (most common: local bruising and ptosis) and were all mild or moderate in intensity. There was no sign of any cumulative adverse effects: indeed, the adverse-event rate decreased in later treatment cycles.
CONCLUSIONS Long-term, repeated injections of BoNT-A for corrections of wrinkles in the upper face yield a continuously high level of safety and effectiveness in actual practice.     

Asymmetrical Smiles Corrected by Botulinum Toxin Serotype A

OBJECTIVE The objective was to identify the cause of an asymmetrical smile and to ascertain whether or not it would be correctable by injections of Botulinum toxin A (BTX-A).
METHODS Five patients with asymmetrical smiles were identified and found to lower one side of their lower lip in an exaggerated fashion when smiling or laughing. After close observation, it was determined that the ipsilateral depressor labii inferioris of the lower lip was hyperkinetic and retracted that side of the lips lower than its contralateral side when smiling or laughing. Injections of low-volume and low-dose BTX-A (BOTOX, Allergan, Inc.) were placed into the depressor labii inferioris on the side where the lower lip retracted the lowest.
RESULTS All of the five patients with asymmetrical smiles presented with unilateral hyperkinetic depressor labii inferioris and responded to injections of BOTOX. Their lower lips became level and their smiles were symmetrical within 1 week of the BOTOX treatments. Their lip symmetry lasted for at least 6 months after their initial treatment. With each additional treatment, the duration of BOTOX lasted even longer, averaging approximately 7 months.
CONCLUSION BOTOX is an effective, safe, and long-lasting treatment for lower lip asymmetries caused by a hyperkinetic depressor labii inferioris.     

Pain Sensation during Intradermal Injections of Three Different Botulinum Toxin Preparations in Different Doses and Dilutions

BACKGROUND: Pain sensation associated with injections of botulinum neurotoxin (BoNT) is commonly reported. To date differences in pain sensation between the commercially available products containing BoNT have not been quantified. OBJECTIVES: The pain sensations during injection of Dysport, Botox, Neurobloc, and pure saline (control) were compared. In addition, the nociceptive effect of different volumes used for the dilution of the same BoNT dose was investigated. METHODS: In a prospective, double-blind, controlled trial, 10 healthy subjects were injected intradermally with Dysport (12 U), Botox (3 and 4 U), Neurobloc (150 and 300 U) reconstituted in 0.9% saline, and pure saline. Pain sensation was quantified during injections. RESULTS: Neurobloc injections caused significantly more injection pain than Botox, Dysport, and saline. No significant differences between Dysport, Botox, and saline were found, although there was a trend toward less pain with pure saline injections. Higher pain levels with higher volumes could not be demonstrated significantly. CONCLUSION: Our data demonstrate that BoNT type B injections are associated with substantial pain. There is a considerable difference between the commercially available BoNT type B compared to the two BoNT type A preparations. Therefore, considering mitigation of injection pain seems necessary when using BoNT type B.     

Head Computed Tomography Is Not Useful for Evaluating Patients Change in Mental Status Following Total Joint Arthroplasty

We retrospectively reviewed 187 patients who presented with neurologic abnormality after total joint arthroplasty to establish the incidence of diagnosed organic brain disorders in these patients and determine the utility of advanced head imaging studies. 139 of 187 (74.3%) patients underwent imaging for altered mental status (AMS) and 48 patients for a focal neurologic deficit (FND). Acute findings on head imaging were more common in the FND group. The incidence of stroke and transient ischemic attack was significantly lower in the AMS group compared to FND group (Stroke: 0% vs 12.5%, p < 0.001; TIA: 0% vs. 16.7%, P < .001). Advanced head imaging for evaluation of TJA patients with a change in mental status is of low yield. An algorithm for evaluation of these patients is proposed.     

三种干预方法对A型肉毒毒素眉间纹注射疼痛影响的研究

目的:观察捏提法、注射前冰敷、复方利多卡因乳膏封包麻醉对A型肉毒毒素眉间纹注射疼痛的影响。方法:纳入98名进行A型肉毒毒素眉间纹注射的患者,随机分为四组:干预组分别采用捏提法、注射前冰敷5min、注射前复方利多卡因乳膏封包麻醉60min进行干预;对照组按传统注射方式,不进行疼痛干预。注射结束后对疼痛进行VAS评分,并记录其他不良反应。结果:三干预组VAS评分均低于对照组(5.88±2.41)。局麻组(3.56±1.88)评分最低,捏提组(3.94±2.15)、冰敷组(4.17±2.23)间差异无统计学意义。结论:捏提法、注射前冰敷、复方利多卡因乳膏封包麻醉均可安全有效地减轻A型肉毒毒素眉间纹注射疼痛,其中捏提法简便实用,值得临床推广。     

Injections of Botulinum Toxin A into the detrusor to treat neurogenic detrusor overactivity secondary to spinal cord injury

Background  

To present a comprehensive experience of botulinum toxin A (BTX-A) injected into the detrusor muscle in patients with spinal cord injuries (SCI) causing neurogenic detrusor overactivity.