Objective: To highlight the potential use of bupivacaine/analgesics in assessing cervical dystonia, where disabling local pain can be a confounder and limits clinical examination.

Background: Significant pain is common in CD. Voluntary or involuntary posturing may occur to relieve this pain, complicating underlying CD pattern  thereby impacting assessment and determination of botulinum toxin dose. Using local analgesics such as bupivacaine to relieve this pain acutely during assessment may address this issue.

Method: To illustrate this, we describe a patient where the use of local bupivacaine injection aided in confirming acute post-stroke torticollis and formulation of an effective injection pattern.

Results: A previously healthy 41-year-old female presented after a thunderclap headache and was found to have a large right frontotemporal intracerebral hemorrhage with superimposed diffuse subarachnoid hemorrhage, secondary to a ruptured right M2 aneurysm. Clinically, the patient had left hemiparesis. The patient has subsequently undergone emergent right craniotomy for evacuation of intracranial hemorrhage and clipping of aneurysm.
The patient was extubated on postoperative day 3. Significant pain was reported over the patient’s neck and shoulder, with her neck rotated towards the left, not correctable with passive maneuvers due to complaints of worsening pain. Her pain was not amendable to oral analgesics, and post-stroke rehabilitation was suspended.
Examination showed an extreme leftward torticollis. The range of motion (ROM) was significantly limited and accompanied by worsening pain in the right anterior neck. Palpation revealed a tense right sternocleidomastoid (SCM) and significant muscular tenderness over the right SCM, levator and trapezius muscles. CT scan of her cervical spine ruled out any causative etiology. Bupivacaine was injected intramuscularly in the right SCM, levator, and trapezius muscles, producing significant pain relief. Despite 10-15 degree improvement in the active ROM of her neck, there was a persistent, significant leftward turn suggesting dystonia. Botulinum toxin injection in the right SCM, levator, and trapezius substantially improved her ROM towards the midline.

Conclusion: Our case highlights the role of local analgesics as a valuable tool in evaluating secondary cervical dystonia complicated by pain.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/use-of-bupivacaine-in-the-evaluation-of-acute-secondary-cervical-dystonia-cd/