Botulinum Neurotoxin Injection Manual

The Essential Guide for Clinicians Who Prescribe and Inject BoNTs

This is a detailed and practical guide to botulinum neurotoxin therapy (BoNT) and the wide range of applications for neurological and pain disorders. A unique reference source for new injectors and experienced clinicians alike, this indispensable manual provides information on dose, dilution, and indications for all four FDA-approved toxins in one handy text.

Following a brief review of relevant pharmacology, the book provides product information and comparative distinctions between the four FDA-approved toxins (Botox^∆, Myobloc^∆, Xeomin^∆, and Dysport^∆), along with indications and doses for FDA-approved conditions, guidance techniques, and common and emerging clinical applications. The heart of the book is an injection manual, organized anatomically and by condition and covering all applications for medical treatment. For each condition or site, information is provided on typical muscle pattern or muscle groups involved, dosing guidelines and dilution for the applicable toxins, number of injection sites, and potential risks and benefits. Targeting techniques are organized in table format for quick retrieval. Anatomic illustrations and cross-sections are provided to orient injectors and help identify optimal insertion points. An appendix with useful clinical rating scales is also included.

• Presents state-of-the-art information about current indications for all four FDA-approved botulinum neurotoxins
• Compares and contrasts the four toxins along with common and emerging clinical applications
• Provides dosing guidelines for various indications and injection sites for each muscle
• Includes anatomic drawings and cross-sections to illustrate muscle relationships and insertion points
• Serves as a practical, portable, how-to guide for new and experienced clinicians

Contributors

Preface

Section One Botulinum Neurotoxin: Basic Science and Reconstitution

1. Pharmacology of Botulinum Neurotoxins

Katharine E. Alter, Fatta B. Nahab, and Barbara I. Karp

2. Comparison of Botulinum Neurotoxin Products

Katharine E. Alter and Fatta B. Nahab

3. Neurotoxin Storage, Reconstitution, Handling, and Dilution

Katharine E. Alter and Codrin Lungu

4. Guidance Techniques for Botulinum Neurotoxin Injections

Katharine E. Alter and Michael C. Munin

5. Phenol Nerve Blocks

Zachary Bohart, Stephen Koelbel, and Katharine E. Alter

Section Two Clinical Applications of Botulinum Neurotoxins

Part I Botulinum Neurotoxins for the Treatment of Muscle Overactivity Associated with Focal Dystonia Syndromes and Upper Motor Neuron Syndromes

Craniofacial Dystonia

6. Benign Essential Blepharospasm

Katharine E. Alter and Barbara I. Karp

7. Botulinum Neurotoxin Therapy for Hemifacial Spasm

Katharine E. Alter and Barbara I. Karp

8. Botulinum Neurotoxin Injections for Oromandibular Dystonias

Katharine E. Alter and Barbara I. Karp

Illustrations for Craniofacial DystoniaóChapters 6ñ8

Cervical Dystonia

9. Botulinum Neurotoxin Injections for Cervical Dystonia

Katharine E. Alter, Michael C. Munin, and Sherry A. Downie

Illustrations for Cervical DystoniaóChapter 9

Upper Limb, Lower Limb, and Trunk Dystonia

10. Botulinum Neurotoxin for the Treatment of Idiopathic Primary Focal Limb Dystonia

Katharine E. Alter, David Simpson, and Elie Elovic

11. Botulinum Neurotoxin for Treatment of Muscle Overactivity Associated with Upper Motor Neuron Syndromes

Katharine E. Alter, John McGuire, and Stephen Nichols

12. Botulinum Neurotoxin for the Treatment of Trunk Dystonia/Camptocormia

Katharine E. Alter and Codrin Lungu

13. Botulinum Neurotoxin Injections for the Treatment of Tremor

Katharine E. Alter and Pritha Ghosh

Illustrations for Upper Limb, Lower Limb, and Trunk DystoniaóChapters 10ñ13

Part II Botulinum Neurotoxins for Neurosecretory Disorders

14. Botulinum Neurotoxin Therapy for Problematic Sialorrhea

Katharine E. Alter

15. Botulinum Neurotoxin Therapy for Hyperhidrosis

Katharine E. Alter and Codrin Lungu

Part III Botulinum Neurotoxins for Urologic Disorders

16. Botulinum Neurotoxin for Urologic Conditions

Katharine E. Alter and Dallas A. Lea II

Part IV Botulinum Neurotoxins for Pain Conditions

17. Botulinum Neurotoxins for the Treatment of Headache

Katharine E. Alter and Pritha Ghosh

Illustrations for Migraine Injection PatternsóChapter 17

18. Botulinum Neurotoxin for Musculoskeletal Pain Conditions

Katharine E. Alter and Nicole A. Wilson

Appendices

A. Ashworth and Modified Ashworth Scale for Grading Muscle Hypertonia

B. Blepharospasm Disability Index Scale

C. Blepharospasm Disability Scale

D. BurkeñFahnñMarsden Dystonia Scale

E. Dystonia Discomfort Scale

F. Modified Tardieu Scale

G. Toronto Western Spasmodic Torticollis Severity Scale

References

Index

Anatomic Illustrations

Illustrations for Craniofacial Dystonia

Figure 1 Technique for intradermal botulinum neurotoxin injections.

Figure 2 Injection patterns for blepharospasm.

Figure 3 Muscles of facial expression, hemifacial spasm.

Figure 4 Temporalis muscle, oromandibular dystonia.

Figure 5 Medial and lateral pterygoid muscles, oromandibular dystonia.

Illustrations for Cervical Dystonia

Figure 1 Cervical muscles, anterolateral view, superficial and intermediate muscle layers.

Figure 2 Cervical muscles, anterior view, intermediate and deep muscle layers.

Figure 3 Cervical muscles, posterior view, intermediate and deep muscle layers.

Illustrations for Upper Limb, Lower Limb, and Trunk Dystonia

Figure 1 Thigh muscles, cross-sectional anatomy.

Figure 2 Calf muscles, cross-sectional anatomy.

Figure 3 Arm muscles, cross-sectional anatomy.

Figure 4 Forearm muscles, cross-sectional anatomy.

Figure 5 Abdominal muscles.

Illustrations for Migraine Injection Patterns

Figure 1 Botulinum neurotoxin injection pattern for migraine, facial muscle injection sites.

Figure 2 Botulinum neurotoxin injection pattern for migraine, facial and neck muscle injection sites.