Botulinum toxin treatment with EMG and ultrasound guidance for focal and segmental dystonia. Writer's cramp can be an initial part of segmental dystonia as well.

1. Botulinum toxin kezelés fokális
dystoniában: írásgörcs. Esetbemutatás.
Dr. Szirtesiné Dr. Varga Edina Tímea
8th June 2018.
Botulinum toxin treatment of focal dystonia:
writer’s cramp. Case report.

2. Botulinum toxin kezelés fokális
dystoniában: írásgörcs. Esetbemutatás.
Dr. Szirtesiné Dr. Varga Edina Tímea
8th June 2018.
Botulinum toxin treatment of focal dystonia:
writer’s cramp. Case report.
Sandoz

3. Writer’s cramp: task-specific focal hand dystonia initiated
or worthened by voluntary muscle contraction
http://pn.bmj.com/content/early/2017/08/26/practneurol-2017-001719

4. Bernardino Ramazzini
1633-1714.

5. Focal limb dystonia
• adult onset: IV-V. decade
• limited to one limb or a part of a limb
• (but can be a part of hemisegmental,
multifocal or generalized dystonia)
• spreads towards proximal mucles, affects
both hands
• develop during weeks/months
• can later progress, though rather a static
condition
• 25% + family history (DYT6, arylsulfatase G
gene variants: musician’s cramp and writer’s
cramp)
Toxins 2018:10,20
„mirror dystonia”

6. Case report
• 49 y old male, teacher
• symptom onset: Sep 2017, progression
• presented at clinic: May 2018
• dominant right hand involvement
• progression during task (writing), but can
shave, brush tooth
• muscle cramp, pain in upper
arm, shoulder
• cramp is reduced by
extended elbow

8. Case report
• 49 y old male, teacher
• symptom onset: Sep 2017, progression
• presented at clinic: May 2018
• dominant right hand involvement
• progression during task (writing), but can
shave, brush tooth
• muscle cramp, pain in upper
arm, shoulder
• cramp is reduced by
extended elbow

9. Selected muscles
• M. brachioradialis
• M. pronator teres

10. M. brachioradialis
Innervation: C5-6/radial nerve
Function: forearm flexion,
pronation/supination
Recommended dosage (Jost) – 1-3 points:
 IncobotulinumtoxinA: 20-100 IU
 OnabotulinumtoxinA: 20-100 IU
 AbobotulinumtoxinA: 50-400 IU
W. Jost: Picturial Atlas of Botulinum Toxin Injections 2008.
2-3cm

11. M. pronator teres
Innervation: C6-7/median nerve (musculocutaneous)
Function: forearm pronation (flexion)
Recommended dosage (Jost) – 1 or 2 points:
 IncobotulinumtoxinA: 10-30 IU
 OnabotulinumtoxinA: 10-30 IU
 AbobotulinumtoxinA: 40-100 IU
W. Jost: Picturial Atlas of Botulinum Toxin Injections 2008. 1-2 cm

12. EMG-guided injection of brachioradial muscle
50 IU (1 p)

13. EMG-guided injection of pronator teres muscle
20 IU (1 p)

14. 3 weeks follow-up

15. prior treatment
3 weeks after treatment reduced pain

16. Conclusion, plan
Partial, initial effect on writing after 21 days
Pain reduction!
Plan:
↑ the dose injected into m. pronator teres
select other muscles:
palmar interossei

17. Conclusion, plan
Partial, initial effect on writing after 21 days
Pain reduction!
Plan:
↑ the dose injected into m. pronator teres
select other muscles:
palmar interossei
lumbricals manus

18. Conclusion, plan
Partial, initial effect on writing after 21 days
Pain reduction!
Plan:
↑ the dose injected into m. pronator teres
select other muscles:
palmar interossei
lumbricals manus
flex.dig.prof.

19. Conclusion, plan
Partial, initial effect on writing after 21 days
Pain reduction!
Plan:
↑ the dose injected into m. pronator teres
select other muscles:
palmar interossei
lumbricals manus
flex.dig.prof.
combine US+EMG
(myojet/boject needles)

20. How to improve botulinum toxin treatment?
https://www.poole.nhs.uk/
Dystoni:Enbevᴂgelsesforstyrrelse2008.

21. www.intechopen.com/books

22. Thank you for your attention!
Dr. Gárdián Gabriella
Dr. Zárodi Dénes
Prof. Dr. Klivényi Péter