Botulinum toxin injection - some practical points

Dr UMS Chennai Workshop on 22/7/12

For Cervical dystonia - torti, lateral, ante, retro
Watch the chin, watch the direction the head takes when the patient is at rest with eyes closed (this will be opposite to the direction where the tremor is maximum), and finally look for asymmetry of muscle hypertrophy. The chin is shifted in torti but not lateralocollis. If torti - needs contralateral SMD + ipsilateral SST complex, if lateral - needs LS, scaleni in addition to trap (?to check for lateral)

Gave inj. to a patient with retro + torti. Identification of SST complex - straight into paraspinal, the toxin will diffuse through to all three muscles. For semispinalis capitis, there is one more inj. point posterior to the insertion of the SMD away from the paraspinal. This is the only muscle here (no overlaps)

For Blepharospasm
Avoid midline (LPS) and give 2 to 3 units at each location, also avoid lower medial canthus (eversion)

For Ankle dorsiflexors (patients with spasticity and toe walking)
Two injections into each head of the gastroc (medial and lateral) and two injections into the middle of the soleus in the center of the bulk