Objective: To report the use of botulinum toxin (BoNT) for the treatment of dystonic scoliosis in children with cerebral palsy.

Background: Children with CP and severe functional limitations (GMFCS lV and V) have an increased frequency of scoliosis. We hypothesize that CP, dystonia is an important cause of scoliosis.  Literature depicts a rotation or twist of the spine occurs as  the lateral bend become more severe. 2  In our movement disorders clinic, surface EMG is used to evaluate muscle activity.  During our exams, increased dystonic muscle activity was audible on the concave side of the curve in some children.  A national perspective of surgery in children with cerebral palsy concluded that there was a need to develop interventions to improve the outcomes of orthopedic surgery particularly in the case of scoliosis surgery. 3 It is common and well excepted practice to treat dystonia in children with botulinum toxin to facilitate movement, joint preservation and or caregiving. However, it is less commonly utilized in the treatment of care for scoliosis, specifically dystonic scoliosis.

Method: Series report

Results: At 12 years of age our patient had increased scoliosis, we began treatment with BoTN injections into her thoracic paraspinal muscles, approximately every 3 months for 1 year. During this time she was also seen by ortho and spinal surgery was offered. She was also seen by neurosurgery who offered Baclofen pump trial. BoTN was given as needed for the next 6 months. At followup it was noted “a nearly straight spine” and “no twisting” of the spine. No further botulinum toxins have been needed. At an annual follow up visit she was noted to have mild thoracic left concave, lumbar right concave, no botox needed but will consider if no improvement with physical therapy or worsening of her scoliosis. Mom has been able to decrease oral medications and she continues with therapy. Four other children have received BoTN for treatment of dystonic scoliosis and similar results have been seen in those that that had audible activity on surface EMG.

Conclusion: We conjecture, that subset of children with dystonic scoliosis benefit from BoTN injections into the paraspinal muscles by delaying or aborting surgery for scoliosis. A multicenter, multidisciplinary study to document these effects and out comes would be useful to document and delineate our findings.

References: 1. Rutz E, Brunner R. Management of spinal deformity in cerebral palsy: conservative treatment. J Child Orthop. 2013;7(5):415-418. doi:10.1007/s11832-013-0516-5 2. Lovett RW. The mechanism of the normal spine and its relation to scoliosis. Bost Med Surg J. 1905;153(13):349-358. 3. Murphy NA, Hoff C, Jorgensen T, Norlin C, Firth S, Young PC. A national perspective of surgery in children with cerebral palsy. Pediatr Rehabil. 2006;9(3):293-300. doi:10.1080/13638490500523283

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MDS Abstracts - https://www.mdsabstracts.org/abstract/botulinum-toxin-for-the-management-of-dystonic-scoliosis-in-children/