Surgery Spotlight: Botulinum Toxin Therapy for Raynaud's Disease-Surgery Spotlight: Botulinum Toxin Therapy for Raynaud's Disease

Surgery Spotlight: Botulinum Toxin Therapy for Raynaud's Disease

Video Transcription

Hi, I'm Mike Neumeister from Southern Illinois University School of Medicine. This is a very interesting case of Raynaud's disease in a young 18-year-old girl who has  tried multiple modalities of treatment. She presents today for a Botox injection to help resolve the ischemic tenderness and pain that she has.  So this young gal has Raynaud's phenomenon. She arrived in my office. Her fingers are actually purple. They go in and out of these various colors. They've been white to purple.  She's developing an ulcer on this tip. Very painful to touch, limits her activities, and makes her hands rather functionless actually.  So what I'm doing here is injecting Botox around each one of the neurovascular bundles. Botox is, this is an off-label use for Botox, and that should be noted that it's not an  on-label use at all. But we have seen significant improvement in most patients that have received Botox. So I'm going to inject around each one of the neurovascular bundles.  This is an unusual case in that because of the severe needle phobia and pain that she has, this is actually being done in the operating theater.  Usually it's a procedure that's done in the clinic. We get a pre-operative Doppler scan, which shows the perfusion, and then a post-operative  one, usually about 20 minutes after the procedure. In her case, it'll be as soon as she recovers. So there's about 100 units in this 10cc vial here.  Inject right at the neurovascular bundle, and essentially just put in about 2cc per site there.  For the ulnar side, I'll course across and get it just by using the same needle area. Second shot. Again, I'm focusing as if I'm doing nerve blocks.  I'm just focusing around the neurovascular bundles.  So one of the concerns we might have is, is Botox, could I paralyze the intrinsic muscles? I certainly could. That's a temporary thing, however.  Since Botox works by blocking acetylcholine release and lasts up to 3 to 4 months' time,  the SNAP25 proteins, which are actually the element that's blocked by Botox, are reconstituted in that time. The intrinsics will come back in 2 to 4 months or so.  However, the effects of Botox could last years and years and years, if not be permanent. We don't really know the duration.  But we have injected people dating back to 2004 that have not had a recurrence. What it should cause is a flush to the fingers almost immediately.  It helps that the fingers were pink to begin with. But we've seen all patients that have had injections, those ulcers go on to heal after the Botox.  In the office, if this was done with her not being asleep, I would have done a wrist block  because the injections themselves are rather painful. It lasts about 5 minutes, the burning pain that they have, and then that goes away.  And as that goes away, the pain or the ischemic pain that they have from Raynaud's should dissipate as well.  So this is actually the second hand of this young 18-year-old girl who has Raynaud's, the second hand that I'm going to inject with Botox.  The mechanism of action in this particular case is actually unknown. It probably blocks either neurotransmitters or has some effect directly on ectopic sodium  channels or ectopic adrenergic receptors on chronically irritated nerves. I do think there is a direct effect on the nerves themselves, not just the blood vessels.  So I've injected around each one of the neurovascular bundles here, the idea being that I'm just going to bathe the nerves themselves with the Botox.  Sorry. You okay? Oh yeah.  And so that's the injection of the Botox. Following this, she'll actually have another perfusion scan to show that the perfusion is increased.  It's a laser Doppler that we can actually get quantitative data from and show us both in numeric form and in graphic form the improved perfusion.  These ulcers that she's developed should go on to heal as a result of this. And what it does is tends to pink up the fingers almost like a sympathectomy or chemical sympathectomy.  However, their ischemic pain resolves almost immediately, which makes me think the nerves are somehow affected by the Botox.  So as you can see, following the Botox injections, the fingers pinked up almost immediately.  The increased perfusion should permit resolution of the ischemic pain and healing of the ulcers. Using Botox for Raynaud's disease is an off-label use of this medication.  There are numerous publications in the literature for this indication. However, it should be noted, again, that it is off-label use.

Video Summary

Dr. Mike Neumeister discusses the off-label use of Botox to treat an 18-year-old girl's severe Raynaud's disease, characterized by discolored fingers and painful ulcers. Despite needle phobia, the procedure was done in an operating theater. Botox is injected around neurovascular bundles, temporarily blocking acetylcholine release, with effects potentially lasting long-term. Doppler scans confirm improved perfusion, expected to heal ulcers and relieve pain. While Botox use in Raynaud's is off-label, significant positive outcomes have been reported, suggesting a direct nerve effect beyond vasodilation.

Asset Caption

Michael W. Neumeister, MD demonstrates the use of botulinum toxin to treat an 18 year old woman with Raynaud's disease who presents with ischemic pain and tenderness. This is an off-label treatment.

Surgeon Michael W. Neumeister, MD

This product is not certified for CME.

Keywords

surgery spotlight

Surgical Videos

Hand

Nerve

Michael W. Neumeister MD; Memben

Botox

Raynaud's disease

off-label use

neurovascular bundles

Doppler scans