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Cardio/Pulm/Peds Part I > Cervical Botox workshop > Flashcards

Cervical Botox workshop Flashcards

1
Q

What do you use for diagnostic nerve block? (2)

Neurolytic? (2)

A

lidocaine/bupivicaine - could be used to block med vs ulnar to discern culprit

ethanol/phenol

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2
Q

What are four ways to assist during botox injections?

A
  1. Clinical exam/anatomical localization
  2. electromyography - tells when the muscle is misbehaving (assesses muscle activity/end plate noise)
  3. E stim - localization of desired muscle for injection
  4. Ultrasound guidance - localization of desired muscle for injection
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3
Q

What are four ways to assist during botox injections?

A
  1. Clinical exam/anatomical localization
  2. electromyography - tells when the muscle is misbehaving (assesses muscle activity/end plate noise)
  3. E stim - localization of desired muscle for injection
  4. Ultrasound guidance - localization of desired muscle for injection
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4
Q

Botox:

  1. can be administered without _____
  2. Diffuses readily into _____
  3. facilitates ____
  4. Effects are ____ and ____
  5. Can be used with _____
A
  1. anesthesia
  2. muscle
  3. treatment goals
  4. localized, dose-dependent
  5. other therapies: including ITB therapy, DBS, Oral meds, PT/OT, casting/splinting, etc
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5
Q

Botox:

  1. can be administered without _____
  2. Diffuses readily into _____
  3. facilitates ____
  4. Effects are ____ and ____
  5. Can be used with _____
A
  1. anesthesia
  2. muscle
  3. treatment goals
  4. localized, dose-dependent
  5. other therapies: including ITB therapy, DBS, Oral meds, PT/OT, casting/splinting, etc
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6
Q

Clinical success of botox requires ____

A

delivery of toxin to appropriate muscle

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7
Q

Botox toxin can diffuse up to ____ after ____ Unit injection even across fascia

A

4cm after 10U injection

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8
Q

Spread of botox is more impacted by _____ than _____.

A

concentration

volume

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9
Q

Spread of botox is more impacted by _____ than _____.

A

concentration

volume

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10
Q

What is the way to minimize diffusion of botox?

A

use multiple injections of smaller doses per muscle over a single larger dose to minimize diffusion. Multiple injections have also been shown to be more effective.

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11
Q

MOA of botox?

A

acts pre-synaptic at the nerve terminal to prevent acetylcholine release. Commercially available toxin A or B

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12
Q

Which botox?

indications: cervical dystonia, severe primary axillary hyperhidrosis, strabismus, blepharospasm, upper limb spasticity in the elbow, wrist, and finger muscles, adult patients with chronic migraine, moderate-to-severe glabellar lies, detrusor overactivity

A

onabotulinum toxin A (botox)

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13
Q

which botox?

indications: cervical dystonia, moderate-to-severe glabellar lines

A

abobotulinumtoxin A (dysport)

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14
Q

which botox?

indications: cervical dystonia, moderate-to-severe glabellar lines, blepharospasm

A

incobotulinumtoxin A (Xeomin)

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15
Q

which botox?

cervical dystonia

A

rimabotulinumtoxin B (myobloc)

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16
Q

What is important to remember about botox types?

A

dosing is not 1:1. A does not equal A and brand does not equal brand

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17
Q

Due to differences in specific details such as the ____, _____, and _____ for various mouse LD50 assays, units of biological activity for one botulinum toxin cannot be compared to or converted into units of another botox toxin. Differences in species sensitivitiesto different botulinum neurotoxin stereotypes preclude extrapolation of animal dose-activity relationships to human dose estimates

A

vehicle, dilution scheme, laboratory protocols.

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18
Q

Name most common adverse effects of botox (4)

A
  1. flu-like illness with fever for 1-3 days
  2. weakness and temporary loss of function in injected muscles
  3. temporary pain
  4. local irritation and bruising
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19
Q

Name most common adverse effects of botox (4)

A
  1. flu-like illness with fever for 1-3 days
  2. weakness and temporary loss of function in injected muscles
  3. temporary pain
  4. local irritation and bruising
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20
Q

Distant spread of toxin occurs from ____ or ____ spread

A

circulatory or lymphatic spread

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21
Q

Name 7 things that can occur secondary to distant spread of the toxin

A
  1. asthenia
  2. generalized muscle weakness/breathing difficulties
  3. diplopia/blurred vision
  4. ptosis
  5. dysphagia (especially in setting of oral injection for increased salivation)
  6. dysphonia/dysarthria
  7. urinary incontinence
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22
Q

Name 7 things that can occur secondary to distant spread of the toxin

A
  1. asthenia
  2. generalized muscle weakness/breathing difficulties
  3. diplopia/blurred vision
  4. ptosis
  5. dysphagia (especially in setting of oral injection for increased salivation)
  6. dysphonia/dysarthria
  7. urinary incontinence
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23
Q

Distant spread of toxin

  1. reported ____ after injection
  2. ____- and ____ can be life threatening
  3. Risk of symptoms is greatest in _____
  4. Cases of spread of effect have occurred at ______
A
  1. hours to weeks
  2. swallowing and breathing difficulties
  3. children treated for spasticity but can occur in adults
  4. doses comparable to those used to treat cervical dystonia and at lower doses
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24
Q

Distant spread of toxin

  1. reported ____ after injection
  2. ____- and ____ can be life threatening
  3. Risk of symptoms is greatest in _____
  4. Cases of spread of effect have occurred at ______
A
  1. hours to weeks
  2. swallowing and breathing difficulties
  3. children treated for spasticity but can occur in adults
  4. doses comparable to those used to treat cervical dystonia and at lower doses
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25
Q

Botulinum toxin serves as ____ when injected into humans

A

antigen (has protein carrier with it)

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26
Q

Neutralizing antibody repose is dependent on (5)

A
  1. presence of complexing proteins
  2. persistence of antigen in tissues
  3. frequency of exposure
  4. quantity of antigen
  5. Risk in CD is 1.2%
27
Q

Neutralizing antibody repose is dependent on (5)

A
  1. presence of complexing proteins
  2. persistence of antigen in tissues
  3. frequency of exposure
  4. quantity of antigen
  5. Risk in CD is 1.2%
28
Q

Botox benefits

  1. Decreases ____ and _____
  2. Improves ____ and ____
  3. Increases _____ with decreased _____
A
  1. spasticity scores, spasticity/tone in non-injected limbs
  2. range of motion, functional status
  3. muscle length with decreased contracture formation
29
Q

Botox benefits

  1. Decreases ____ and _____
  2. Improves ____ and ____
  3. Increases _____ with decreased _____
A
  1. spasticity scores, spasticity/tone in non-injected limbs
  2. range of motion, functional status
  3. muscle length with decreased contracture formation
30
Q

Treatment of cervical dystonia starts with

A

botox (not oral meds)

31
Q

____ is a relatively sustained excessive muscle contraction causing abnormal posture of the neck and shoulder

A

cervical dystonia

32
Q

Is primary cervical dystonia or secondary cervical dystonia more common

A

primary CD

33
Q

secondary CD caused by ____ or _____

A

medication use

structural CNS lesions (MS, CP, TBI)

34
Q

What are the 4 planes of motion targeted when making a botox recipe for cervical dystonia

A
  1. rotation
  2. lateral tilt
  3. flexion
  4. extension
35
Q

What are the 4 planes of motion targeted when making a botox recipe for cervical dystonia

A
  1. rotation
  2. lateral tilt
  3. flexion
  4. extension
36
Q

Name the muscles responsible for rotation in torticollis

5

A
  • contralateral SCM
  • ipsilateral splenius captitis
  • ipsilateral levator scapulae
  • ipsilateral semispinalis
  • ipsilateral longissimus
37
Q

what are the muscles responsible for lateral tilt in toriticollis (6

A
  • middle/anterior scalene
  • splenius capitus
  • levator scapulae

other:
- SCM
- trapezius
- longissimus capitus

38
Q

Name the muscles responsible for retrocollis (4)

A

Bilateral semispinalis capitis
bilateral longissimus capitis

other:
splenius capitis/cervicis
rectus capitus

ALL BILATERAL

39
Q

Name the muscles responsible for anterocollis (2)

A

Bilateral

  • scm
  • middle/anterior scalene
40
Q

____ elevation is common in cervical dystonia

A

shoulder elevation

41
Q

What are the two muscles responsible for shoulder elevation in cervical dystonia?

A

Ipsilateral trapezius

Levator scapulae

42
Q

Pain in cervical dystonia is usually due to:

A

dystonic muscle contraction or antagonist muscles contraction to counter posturing is common

43
Q

Pain in cervical dystonia is usually due to:

A

dystonic muscle contraction or antagonist muscles contraction to counter posturing is common

44
Q

structures to avoid: (10)

A

1 brachial plexus

  1. carotid artery
  2. lesser and greater occipital nerve
  3. larynx and trachea
  4. pharynx and esophagus
  5. thyroid gland
  6. pleura and apex of lung
  7. internal and external jugular veins
  8. great auricular nerve
  9. inferior belly of the omohyoid muscle
45
Q

injection technique:

Splenius Cervicis:

A

lateral approach is at the angle of the trapezius and SCM

46
Q

Injection technique:

Levator Scapulae:

A

inject at origin +/- insertion

47
Q

Injection technique:

Scalene

A

stay parallel to the clavicle

48
Q

Injection technique:

SCM

A

mid-belly with fingers on pulse

49
Q

injection technique:

Semispinalis

A

1 FB lateral to C3

50
Q

injection technique:

splenius capitus

A

1 FB lateral to C5

51
Q

Injection technique:

splenius cervicis

A

1FB lateral to T1

52
Q

INjection technique:

Longissimus

A

2 FB lateral to C7 (at TP)

53
Q

3 pros of EMG guidance

A
  1. greater confidence the needle tip is within the muscle sheath
  2. can identify individual muscles with selective activation
  3. can assess the degree of contraction/activity in each muscle
54
Q

3 cons of EMG guidance

A

need additional equipment
increases cost
cannot differentiate compensatory vs primary contraction, or spasms induced by the needle poke to do the procedure

55
Q

_____ is the first line of treatment for Cervical dystonia

A

neurolytic injection

56
Q

Use the ______ dose in treatment of cervical dystonia

A

lowest effective dose

57
Q

Initial dose of botox for cervical dystonia:

A

100-200U

58
Q

In dosing for cervical dystonia, choose ____ muscles involved

A

4-8 primary muscles

59
Q

Place the largest amount of the toxin in (3)

A
  1. muscles most responsible for primary postural deviation
  2. muscles most active on EMG or by exam for hypertrophy
  3. muscles most painful by patient report/exam
60
Q

No less than ____ units of botox per CD muscle, no more than _____ for each muscle on initial injection.

Rarely > ________ unit per muscle ever

A

10U

35U

> 100U

61
Q

No less than ____ units of botox per CD muscle, no more than _____ for each muscle on initial injection.

Rarely > ________ unit per muscle ever

A

10U

35U

> 100U

62
Q

Clinical improvement after botox for CD begins in ____ days

A

3-10

63
Q

Maximal clinical effect of botox for CD is seen at _____ weeks

A

6

64
Q

Return to pre-treatment status of botox for CD is see at _____

A

3 months post treatment

Cardio/Pulm/Peds Part I (7 decks)

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