47-year-old female with a 4-year history of cervical dystonia. She has been treated with botulinum toxin injections which were ineffective for her. In the expert's opinion, the success of Botulinum toxin in cervical dystonia depends on a thorough clinical assessment, exact targeting of the chosen muscles, and adequate doses of toxin injected. The expert also suggests additional or alternative treatment strategies: medical treatment by different oral drugs, or deep brain stimulation of the globus pallidus interna.
- A thorough clinical assessment of the abnormal posture of the neck, evaluation of the extent of movement limitation, presence and location of muscle tenderness and palpation for specific muscular hypertrophy.
- Exact targeting of the chosen muscles when injecting the material into the muscles (preferably by injecting through an EMG needle connected to an amplifier).
- Adequate doses of toxin injected to the chosen muscles.
- Medical treatment by oral drugs:
- Anticholinergics: Artane (trihexyphenydil) 2 mg, started 1 mg bid and increased slowly to 2 mg tid or maximally tolerated dose (up to a total of 8 mg/day)
- Benzodiazepines: Lorazepam 1 mg, started at 1 mg at bedtime, increased weekly to 1 mg bid and then 1 mg tid. Alternatively- Clonazepam 0.5 mg, started at 0.25 mg at bedtime, increased weekly to 0.25 mg bid ,then 0.25 mg tid and increased slowly up to a maximal dose of 0.5 mg tid.
- Baclophen 10 mg: started at 5 mg bid, increased weekly to 5 mg tid and then 5 mg tid, and increased continuously to a dose of 10 mg tid and then slowly up to 20 mg tid.
- Surgical treatment by deep brain stimulation (DBS):