Severe Dysphagia After Botulinum Toxin B Injection to the Lower Limbs and Lumbar Paraspinal Muscles

Serious and long-term adverse events associated with the therapeutic and cosmetic use of botulinum toxin

Although botulinum toxin is generally considered safe, its widespread use and the constantly expanded indications raise safety issues. This study aimed to review the serious and long-term adverse events associated with the therapeutic and cosmetic use of botulinum toxin. Serious adverse events included dysphagia, respiratory compromise, generalized muscle weakness, marked bilateral ptosis, pseudoaneurysm of the frontal branch of the temporal artery, necrotizing fasciitis, sarcoidal granuloma, Fournier gangrene, and cervical kyphosis. Death was attributed to botulism or anaphylactic shock. In conclusion, botulinum toxin may cause serious adverse events, which are more common after its therapeutic use, but can also be noticed after its cosmetic use. Thorough knowledge of the anatomy of the treated muscles and of the pharmacology of the drug is imperative to avoid serious adverse events.

Use of rimabotulinum toxin for focal hypertonicity management in children with cerebral palsy with nonresponse to onabotulinum toxin

OBJECTIVE

The aim of this study was to review the effect of rimabotulinum toxin (BoNT-B) for focal hypertonicity management in children with cerebral palsy and secondary nonresponse to onabotulinum toxin treated at the authors' tertiary care academic medical center.

DESIGN

A retrospective review of the medical treatment of children was conducted at the authors' institution (March 16, 2001, to August 2, 2002) using the key words botulinum toxin B and Myobloc (Solstice Neurosciences Inc, South San Francisco, CA). Demographic information was analyzed using descriptive statistics (number [percentage] and mean [range]). The Pearson χ test was used to evaluate differences in incidence of adverse events.

RESULTS

Eighty-two children had BoNT-B injections (116 treatments). Overall, 26.8% (19/71) of the children or their parents/guardians reported no or minimal response to the injections, with 89.5% (17/19) of these children having secondary nonresponse to onabotulinum toxin. Adverse events were frequent but did not require hospitalization of any patient. No significant differences were found in incidence of adverse events related to BoNT-B dosing, medical fragility, or Gross Motor Function Classification System level.

CONCLUSIONS

More than one-fourth of the children receiving BoNT-B injections had nonresponse, with most having previous nonresponse to onabotulinum toxin. Adverse events related to BoNT-B injections were frequent and unpredictable but not severe.

Contralateral weakness following botulinum toxin for poststroke spasticity

INTRODUCTION

We describe 2 patients who received botulinum toxin A (BoNT) for poststroke spasticity and developed contralateral limb weakness.

METHODS

Both patients received high doses of BoNT with large dilution volumes and injection in the proximal upper extremity muscles, and developed weakness of the contralateral upper limb. These patients then underwent electrodiagnostic testing of the affected limb.

RESULTS

Repetitive nerve stimulation of the axillary and spinal accessory nerves revealed decrements of 23% and 16%, respectively. EMG revealed abnormal spontaneous activity and small polyphasic motor unit potentials with reduced recruitment. These findings indicated blockade of the neuromuscular junction. Both patients improved.

CONCLUSIONS

Isolated weakness of the contralateral limb after BoNT injection for poststroke spasticity suggests diffusion of toxin through tissue planes from proximal upper extremity muscles, across the midline, to contralateral muscles. High doses of botulinum toxin, high dilution volumes, and injection of proximal upper extremity muscles appear to be risk factors for this adverse effect.

The updated European Consensus 2009 on the use of Botulinum toxin for children with cerebral palsy

An interdisciplinary European group of clinical experts in the field of movement disorders and experienced Botulinum toxin users has updated the consensus for the use of Botulinum toxin in the treatment of children with cerebral palsy (CP). A problem-orientated approach was used focussing on both published and practice-based evidence. In part I of the consensus the authors have tabulated the supporting evidence to produce a concise but comprehensive information base, pooling data and experience from 36 institutions in 9 European countries which involves more than 10,000 patients and over 45,000 treatment sessions during a period of more than 280 treatment years. In part II of the consensus the Gross Motor Function Measure (GMFM) and Gross Motor Function Classification System (GMFCS) based Motor Development Curves have been expanded to provide a graphical framework on how to treat the motor disorders in children with CP. This graph is named "CP(Graph) Treatment Modalities - Gross Motor Function" and is intended to facilitate communication between parents, therapists and medical doctors concerning (1) achievable motor function, (2) realistic goal-setting and (3) treatment perspectives for children with CP. The updated European consensus 2009 summarises the current understanding regarding an integrated, multidisciplinary treatment approach using Botulinum toxin for the treatment of children with CP.

Iatrogenic botulism in a child with spastic quadriparesis

Botulinum toxins are potent neurotoxins used in a variety of neurological disorders. Few pediatric reports have been published to date regarding the potential hazards of therapeutic use of botulinum toxins. We describe the case of a 10-year-old boy who developed systemic weakness following treatment of spasticity with botulinum toxin type B. The patient developed iatrogenic botulism with ptosis, facial diplegia, neck flexor and extensor weakness, and profound hypopharyngeal laxity with respiratory compromise from which he eventually recovered. Clinicians should be mindful of the risk for systemic botulism when using local injections of the neurotoxin.