Botulinum Neurotoxins: Origins and Basic Mechanisms of Action

Multidisciplinary management of people with spina bifida across the lifespan

The average worldwide prevalence of neural tube defects (NTDs) is 1.0 per 1000 births. Its development is multifactorial due to genetic and non-genetic factors. Spina bifida (SB) is one of main representatives of NTD. The spinal cord lesion level is the main determinant of the level of paralysis, numbness, and difficulties with bladder/bowel functions. Myelomeningocele prenatal repair reduces hydrocephalus and hindbrain herniation and improves motor function. The severity of hydrocephalus is associated with poorer neurodevelopmental outcomes whether operated on prenatally or after birth. People with SB tend to have a lower IQ and cognitive difficulties. Early diagnosis, proactivity, and lifelong multidisciplinary follow-up are key protective issues. Invasive urological interventions should be considered in selected patients after failure of conservative treatment. Transition to adult care should be well planned as it is challenging. Health literacy is directly associated with success at transition. Sexuality and fertility should be addressed before/during puberty. Overall, the rates of fecal and urinary continence and skin breakdown increase with age, whereas the ability to ambulate declines with age. Bowel and urinary incontinence are independent predictors of lower health-related quality of life (HRQoL) in adults with SB. Bowel incontinence has negative impact on HRQoL regardless of frequency or amount. Long-term caregiver support should be offered at diagnosis. Survival at a mean of 50 years is poor, at 32%, due to central nervous system deaths, cancer, urological disease, and sepsis. Challenges to implementation of recommended practices exist, especially in low and middle-income countries.

Neurologic uses of botulinum neurotoxin type A

This article reviews the current and most neurologic uses of botulinum neurotoxin type A (BoNT-A), beginning with relevant historical data, neurochemical mechanism at the neuromuscular junction. Current commercial preparations of BoNT-A are reviewed, as are immunologic issues relating to secondary failure of BoNT-A therapy. Clinical uses are summarized with an emphasis on controlled clinical trials (as appropriate), including facial movement disorders, focal neck and limb dystonias, spasticity, hypersecretory syndromes, and pain.

Botulinum Toxin a Injection of the Obturator Internus Muscle for Chronic Perineal Pain

Chronic perineal pain is often a difficult condition to manage. Current treatments include pudendal nerve injections and pudendal nerve release surgery. The obturator internus muscle has a close relationship to the pudendal nerve and might be a potential target for therapeutic intervention.

PERSPECTIVE

A case is presented of refractory perineal pain that was successfully treated by injecting the obturator internus muscle with botulinum toxin A.

Treatment of Chronic Refractory Intractable Headache with Botulinum Toxin Type A: A Retrospective Study

Chronic refractory daily headache is a relatively common problem in the Australian population. Several million working hours per year are lost due to this illness. Generally not responding to conventional therapies. We treated 22 such patients diagnosed as severe refractory migraine and/or mixed tension headache at our multidisciplinary pain management center. Before inclusion to our study, they received maximal medical management, which included cognitive behavior therapy, but failed to respond. These patients received between 30 and 100 units of botulinum toxin type A. Our study showed 84% (19 of 22) achieved significant improvement in their pain complaint. There was significant reduction of medications particularly opioids. The duration of pain relief ranged from 1 to 6 months. Repeat injections were necessary in several of the patients. There were minor complications but these reversed spontaneously without further treatment.