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Injections

 

There are a number of different injections that can be performed as therapy in neurological conditions. These can be performed for conditions ranging from headache, spastic muscles, movement disorders, neuralgia, and nerve entrapments.

 

 

 

 

What is Botulinum Toxin and why is it used?

 

OnabotulinumtoxinA (Botox), also called botulinum toxin type A, is made by the bacteria that cause botulism. Botulinum toxin blocks nerve activity at the muscle, leading to a temporary reduction in muscle contraction ability. 

 

In large doses, Botox can be lethal and leads to loss of breathing. In small doses when delivered at specific sites, it can be very helpful for certain neurological disorders. We use it in certain conditions including the following:

 

  • Cervical dystonia (severe spasms in the neck muscles)

  • Dystonia of other forms, including muscle spasms in the face or in the arms and hands

  • For severe underarm sweating (hyperhidrosis).

  • Blepharospasm, which is uncontrolled blinking or spasm of the eyelids

  • Overactive bladder and incontinence (urine leakage) caused by conditions such as spinal cord injury or multiple sclerosis

  • Chronic migraine headaches in adults who have migraines for more than 15 days per month, each lasting 4 hours or longer. Botox should not be used to treat a common tension headache as it does not necessarily help other forms of headaches.

 

Botox is also used for cosmetic purposes, but this is not a neurological reason.

 

What are the possible side effects of Botox (Botox)?

 

Rarely, there can be an allergic reaction with hives, difficulty breathing, feeling like you might pass out, or with swelling of your face, lips, tongue, or throat.

 

The botulinum toxin injected can spread to other body areas beyond the injection site. This can lead to trouble breathing, talking, or swallowing. Sometimes, hoarse voice or drooping eyelids may occur. In rare circumstances, unusual or severe muscle weakness (especially in a body area that was not injected with the medication) may develop.

 

As botulinum toxin causes muscle weakness, there may be weakness develop near where the medicine was injected. Sometimes, even muscle atrophy, or loss can occur near sites of injection.

 

Because this is an injection, there can also be bruising, bleeding, pain, redness, or swelling where the injection was given.

 

Botulinum Toxin Injections

What are the Risks of Botulinum Injections?

 

Botox injections are quite safe when performed by an experienced doctor.

 

The most common side effects include swelling or bruising after the injection has occurred right at the needle site.

 

Doctors generally recommend against using Botox when you're pregnant or breast-feeding, since the effects on the baby aren't known.

 

If you have a condition called myasthenia gravis, or another condition that leads to weakness, be sure to see an experienced doctor prior to receiving botulinum toxin, as your weakness could be exaggerated.

 

Always avoid botulinum toxin if you had an allergic response to it previously.

 

 

This is a botox injection being provided in someone with spasticity of the hand and forearm. A very thin needle delivers the botulinum toxin into specific locations of the muscles.

What you can expect in botulinum injections

 

Although most people tolerate the injection discomfort well, you may want your skin to be numb beforehand. Several options are available, including:

  • Injections - your doctor can inject a numbing medication into your skin or place a freezing ointment on the skin.

  • A prescription cream can be applied 60 to 90 minutes before the procedure.

  • Cold spray. A blast of very cold air is directed at the skin for about 10 seconds. The numbness only lasts a few seconds. An ice pack also works well for this effect.

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  • A thin needle is used to inject tiny amounts of botulinum toxin into your skin or muscles (see above picture). The number of injections varies based upon the condition and the extent of the condition. Botox injections are usually done in a doctor's office, and do not require an operating room or other special location.

 

  • If deeper muscles or small muscles are to be injected, a machine to help localize the muscles will be used. This will show the muscle contracting or may deliver a pulse of electricity to make the muscle move. This is helpful in localizing these muscles to ensure that the right ones are injected.

 

After the injection is complete, there can be some slight tenderness at the injected areas. Sometimes, there can be a small blood collection.

 

After completed, you can resume your normal daily activities. You should avoid rubbing or massaging the treated areas, as this can lead to the botulinum toxin spreading to other areas not intended for the treatment to act.

Can botulinum injections be used in headache?

 

Yes, although they are only effective in chronic migraine conditions.

 

We do not understand how botulinum toxin injections in the scalp help headache, but it may be due to relaxation of scalp muscles improving biofeedback to the brain, lessening severity of pain.

 

Botulinum toxin is quite successful in this situation, improving headache frequency and severity as much as one of our best headache medications, but without many long term side effects.

 

Where are botulinum injections given for headache?

Injections are given around the entire scalp (see right), even if your headache pain due to migraine is only on one side.

 

These injections need to be delivered every 3 months in order to be successful.

 

What are the side effects of botulinum injections given for headache?

After the injection is complete, there can be some slight tenderness at the injected areas. Sometimes, there can be a small blood collection.

 

Sometimes, there can be muscle weakness afterwards, giving an eyebrow droop in some cases.

 

After completed, you can resume your normal daily activities. You should avoid rubbing or massaging the treated areas, as this can lead to the botulinum toxin spreading to other areas not intended for the treatment to act.

Botolinum toxin injections are delivered to a number of sites around the scalp to both sides of the head. Each injection is a small amount at each site. In order to remain effective, repeat injections should be at every 3 months or the botulinum toxin will lose efficacy.

Nerve Entrapment Injections

Nerves can be entrapped in the arms or legs. The two most common entrapments are:

  • Carpal Tunnel Syndrome (pinching of the median nerve at the wrist) (see below left)

  • Cubital Tunnel Syndrome (pinching of the ulnar nerve at the elbow) (see below right)

 

 

Carpal tunnel syndrome leads to numbness, tingling, and pain at the first 3 and a 1/2 fingers, but also leads to weakness of hand muscles. It is best managed with surgery at the transverse carpal ligament, but splinting at night can also be helpful. In cases where injections are needed, these are provided at the transverse carpal ligament also.

Ulnar neuropathy leads to numbness, tingling, and pain at the last 1 and a 1/2 fingers and over the medial palm regions, but also leads to weakness of hand muscles. It is best managed with surgery at the cubital tunnel (shown with arrows) at the elbows, but splinting at night can also be helpful. In cases where injections are needed, these are provided at the cubital tunnel also.

Both of these lead to numbness, tingling, and pain in the hand. Sometimes, they will lead to weakness of hand muscles also.

 

These are best treated with either surgery to release the pressure or move the nerve, or with splinting of the wrist or elbow while you are sleeping at night. However, in some patients unable to have surgery or with no improvement due to the standard treatments, injection of steroid at the location of the nerve pinching can help reduce the symptoms. This steroid injection helps with the symptoms, but does not reverse the underlying condition. The injection needs to be performed monthly.

 

How are the injections performed?

A thin needle goes through the skin to be near the tendons at either the wrist or elbow. Prednisone (50 mg usually) is injected under the skin over about 30 seconds. The procedure is quick and you can return to regular daily activites right afterwards.

 

What are the side effects of these injections?

Anytime that a needle is used, there is going to be some mild discomfort. There is a small chance of bleeding or infection, but it is performed under sterile conditions. Sometimes, a small bruise may be present afterwards.

 

There is a very small chance that the solution injected could give some compression of the nerve, contributing to tingling or numbness - this usually only lasts up to 30 minutes.

 

Prednisone is a steroid. When injected locally, less of this medicine gets into the body, but some certainly will. Prednisone in large doses when given repeatedly can lead to high blood pressure, high blood sugars, thinning of the skin, bruising, weight gain, change in facial appearance and fat deposition, and other unlikely complications. The risk of these problems is far less than when prednisone is taken as a pill.

 

There is an extremely low chance that the needle would touch the nerve or puncture it, but this is a small risk that would always be an extremely unlikely chance.

Occipital Neuralgia  Injections

What is occipital neuralgia?

 

Occipital neuralgia occurs when the occipital nerve running through a spinal root from the top of the spinal cord at the base of the neck up through the back of the scalp is injured or inflamed (see below left). Occipital neuralgia is sometimes diagnosed as a migraine, or even other types of headache.

 

Occipital neuralgia is a distinct disorder presenting with specific symptoms:

  • Very intense pain felt like a sharp, jabbing, electric shock at the back of the neck and head

  • This may be aching, burning, and throbbing with radiation to the scalp

  • In some, there can be pain behind the eye

  • Although other features of migraine are absent, there can be sensitivity to light

  • There is tenderness of the posterior scalp

  • Pain is present during neck movements

 

What are the causes of Occipital Neuralgia?

Occipital neuralgia occurs due to the compression or irritation of the occipital nerves due to injury, nerve entrapment, or due to  inflammation. It is not unusual that no cause is determined. Specific medical causes include:

  • Trauma at the back of the head or top of neck

  • Osteoarthritis

  • Tumors in the neck

  • Cervical disc disease

The occipital nerve provides sensation to the back of the scalp on one side. The area of sensation is shown on the left side of this head, while the nerve and its branches are shown on the right.

The occipital nerve injection is performed at the back of the scalp as shown. The injection helps with inflammation and numbs the nerve to provide relief. In most cases, this is only to be performed on one side.

What happens in occipital nerve injections?

A thin needle goes through the skin at the back of your scalp to be near the occipital nerve on the affected side (see above right). Lidocaine, an anesthetic, and a form of steroid is injected under the skin near the nerve over about 30 seconds. The procedure is quick and you can return to regular daily activites right afterwards.

 

Usually, these injections need to be repeated regularly if they are effective. 

 

What are the side effects of these injections?

Anytime that a needle is used, there is going to be some mild discomfort. There is a small chance of bleeding or infection, but it is performed under sterile conditions. Sometimes, a small bruise may be present afterwards.

 

There is a very small chance that the solution injected could give some compression of the nerve, contributing to tingling or numbness - this usually only lasts up to 30 minutes.

 

Lidocaine will give numbing, so there will be some numbness over the scalp where the nerve goes to.

 

Prednisone is a steroid. When injected locally, less of this medicine gets into the body, but some certainly will. Prednisone in large doses when given repeatedly can lead to high blood pressure, high blood sugars, thinning of the skin, bruising, weight gain, change in facial appearance and fat deposition, and other unlikely complications. The risk of these problems is far less than when prednisone is taken as a pill.

 

There is an extremely low chance that the needle would touch the nerve or puncture it, but this is a small risk that would always be an extremely unlikely chance.

 

Are there other methods to treat occipital neuralgia?

We use medicines to treat neuralgia in many cases. These can be used in combination with occipital nerve injections.

 

In some cases, patients can receive a surgical decompression of the nerve. In severe, refractory cases, an occipital nerve stimulator can be placed in a surgery to help reduce symptoms.

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