Spasmodic Torticollis/Cervical Dystonia (CD)
64616 (chemodenervation cervical spinal muscle(s))
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Daniel Vardeh
CPT
Procedure
64616 (chemodenervation cervical spinal muscle(s)) 95874 (needle electromyography for guidance in conjunction with chemodenervation)
Position: usually sitting IV: not required unless previous vaso-vagal episodes Antibiotics: not required
Indications
Steps
Botulinum toxin is considered the first-line treatment for the majority of focal dystonias, including Cervical Dystonia (CD). Only types A (onabotulinumtoxinA, commercially available as Botox®, Dysport®, or Xeomin®) and B (rimabotulinumB, commercially available as Myobloc® or NeuroBloc®) are FDA approved for cervical dystonia.
–– Observation of abnormal head position or movement both at rest and during provoking maneuvers to identify target muscle(s). Distraction can help to prevent the patient from activating compensatory muscles. –– Muscles should be palpated for hypertrophy or asymmetry. –– Supplementary techniques like EMG can help to confirm clinically identified muscle groups. Compensatory muscle activation is sometimes hard to distinguish from primary dystonic muscle groups on electrophysiological grounds alone, and clinical observation of the primary dystonic movement is paramount. If muscles are superficial and hence readily accessible, EMG guidance might not be needed. –– Based on severity of symptoms, muscle bulk, clinical response and activity on EMG, and injection doses can vary considerably. Typical range per single injection is 10–100 U (onabotulinumtoxinA) and 750–5000 U (rimabotulinumB).
Equipment/Materials 1 cc tuberculin syringe with 25 ga × 5/8 in. needle Botulinum toxin
D. Vardeh, MD (*) Interventional Headache and Neck Pain Management, Department of Neurology and Anesthesia, Lahey Hospital & Medical Center, 41 Mall Road, Burlington, MA 01805, USA e-mail: [email protected]
© Springer International Publishing Switzerland 2017 R.J. Yong et al. (eds.), Pain Medicine, DOI 10.1007/978-3-319-43133-8_72
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D. Vardeh
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Complications
Clinical Pearls
[US Boxed Warning]: Distant spread of botulinum toxin beyond the site of injection has been reported; dysphagia and breathing difficulties have occurred and may be life threatening; other symptoms reported include blurred vision, diplopia, dysarthria, dysphonia, generalized muscle weakness, ptosis, and urinary incontinence which may develop within hours or weeks following injection. The risk is likely greatest in children treated for the unapproved use of spasticity. Systemic effects have occurred following use in approved and unapproved uses, including low doses.
• Ultrasound can also be used in lieu of EMG to correctly identify muscle groups and ensure intramuscular injection.
Specific Complications –– Neutralizing antibody formation, often caused by higher and/or more frequent dosing, which can result in decreased efficacy. –– Dysphagia (common) due to weakness of pharyngeal muscles. Risk factors include small neck muscle mass, bilateral injections into the sternocleidomastoid muscle, or levator scapulae. –– Patients with neuromuscular ju
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