Botulinum neurotoxin (BoNT) has applications in treating gastroenterological disorders from the esophagus to the rectum. This chapter describes and graphically illustrates BoNT injection techniques, both percutaneous and endoscopic, for a wide range of gastrointestinal disorders: cricopharyngeal dysphagia, achalasia, esophageal spasm, sphincter of Oddi dysfunction, obesity, gastroparesis, puborectalis syndrome, proctalgia fugax, anal fissure, dyssynergic defecation, anismus, anorectal pain and incisional hernia.

Spasmodic dysphonia is a focal dystonia characterized by task-specific, action-induced spasm of the vocal cords.

There are three types of spasmodic dysphonia: Adductor spasmodic dysphonia (ADSD) is characterized by a strained-strangled voice quality and intermittent voice stoppage or breaks, resulting in a staccato-like voice, caused by overadduction of the vocal folds.

Abductor spasmodic dysphonia (ABSD) is characterized by intermittent breathy breaks and associated with prolonged abduction folds during voiceless consonants in speech.

Mixed-type spasmodic dysphonia has features of both.

The efficacy of botulinum neurotoxin (BoNT) injection in the treatment of spasmodic dysphonia has been proven. This chapter enumerates the muscles involved in each type of spasmodic dysphonia, diagrams and describes different approaches for injection, along with the use of guidance techniques such as laryngoscopy and electromyography, and tabulates dose ranges of the different types of BoNT for each muscle.

Botulinum neurotoxin (BoNT) injections are established as a standard procedure for the treatment of muscles in spastic or dystonic children. Superficial and palpable muscles are easy to inject. In contrast, exact needle placement is more difficult and less controllable in deep muscles or those that are small and difficult to selectively identify. Exact needle placement is, however, essential for optimal functional result, avoidance of side effects and evaluation of therapeutic failures. However, clinical application of BoNT without guidance techniques has been shown to be inaccurate. Several techniques are available to guide needle placement for injection. Electromyography is good, but many muscles may be simultaneously active. Electrical stimulation is uncomfortable and painful and often requires anesthesia. CT guidance necessitates exposure to radiation and is costly. By comparison, the advantages of the ultrasound-guided technique are obvious: real-time observation of the injection readily available easily applicable after a manageable learning period cost effective no serious side effects.

This chapter details the use of ultrasound for injection guidance, and discusses indirect and real-time techniques, and both parallel and perpendicular orientations, for needle placement.

Neuropathic pain refers to pain caused by a lesion or disease of the somatosensory nervous system. Diabetic neuropathy, postherpetic neuralgia, radiculopathy pain, trigeminal neuralgia and complex regional pain syndrome are all neuropathic pain syndromes.

Local administration of botulinum neurotoxin (BoNT)) has proven significant effects on the treatment of neuropathic pain. Abnormal muscle contractions contribute to chronic pain. Botulinum neurotoxin serotype A (BoNT-A) is well known to have an effect on inhibition of muscle contraction and this may partially explain its effect on chronic pain. In preclinical models, BoNT-A was found to effectively block the release of several pain-related neurotransmitters, including norepinephrine, substance P, glutamate and calcitonin gene-related peptide, from afferent nerve terminals and dorsal root ganglia. These pain-related neurotransmitters can stimulate depolarization of C fibers, which are responsible for propagation of chronic pain. BoNT-A also decreases local inflammation around the nerve terminal.

This chapter offers clinical description and pictorial illustration for injection of BoNT for the particular conditions of diabetic neuropathy, postherpetic neuralgia and trigeminal neuralgia.

Botulinum neurotoxin (BoNT) is licensed for the treatment of a number of conditions characterized by striated muscle spasticity. However, in recent years, their unlicensed use in the treatment of lower urinary tract conditions has been described (Smith et al., 2004). Chief among these are conditions characterized by detrusor overactivity. Treatment of vulvodynia and chronic pelvic pain, benign prostate hyperplasia (BPH) and detrusor sphincter dyssynergia (DSD) are other emerging indications with promising positive results. This chapter details the use of BoNT for these conditions, giving a clinical definition of each condition, reviewing pertinent studies and describing the injection technique, percutaneous or endoscopic, using anatomical illustrations, and providing dosing recommendations.

In cervical dystonia (CD), outcome of treatment with botulinum neurotoxin (BoNt), is highly dependent on the correct identificationof the muscles involved. There are “simple” (in one plane) and “complex” (in two or more levels) forms of CD. The difficulty lies in the treatment of complex CD, requiring a more extensive analysis. For such analysis, different diagnostic methods are used. These include: ultrasound, CT neck soft tissue imaging (particularly the deep muscles of the neck), electromyography (EMG) of neck muscles, and standardized photographs of patients with measurements of angles (head, neck, thorax).

Cervical dystonia may occur in principle in three axes (rotation, lateral flexion and sagittal flexion). The head or the neck can be affected alone in each of these planes of movements. Therefore, eight clinical forms can be distinguished: torticollis, laterocollis, antecollis, retrocollis, torticaput, laterocaput, antecaput and retrocaput. In this chapter, involved muscles, their origins and insertions are presented in a table for each of these clinical forms. Injection under CT guidance is described.

Oromandibular dystonia (OMD) is a form of focal dystonia that involves the masticatory, lower facial, labial and lingual musculature affected by the trigeminal, facial and hypoglossal cranial nerves. OMD can be classified into various subtypes, which include jaw-opening, jaw-closing, jaw-deviating, lingual, perioral and/or pharyngeal dystonia. Dystonic spasms may result in clenching, or trismus; grinding of the teeth, or bruxism; tongue thrusting; lip pursing; and other movements.

Evidence-based reviews and clinical experience strongly regard botulinum neurotoxin (BoNT) injection as the first-line treatment for OMD. Patients with OMD require careful examination to determine the particular muscles involved and their pattern of contraction to enable proper selection and targeting for BoNT injection. This chapter enumerates the particular muscles involved in each subtype of OMD, discusses localization and approach for injection and use of guidance techniques where applicable, and tabulates typical dose ranges for different formulations of BoNT. Typical adverse events and techniques to avoid them are discussed.

PP> Hemifacial spasm (HFS) consists of involuntary irregular clonic or tonic twitch-like movements of the facial muscles innervated by cranial nerve VII on one side of the face, and is most often a result of vascular compression of the facial nerve at the root exit/entry zone. Non-vascular causes of HFS are less common, and include facial nerve injury, Bell’s palsy, demyelination presumed to involve the facial nucleus and various tumors and space-occupying lesions in the cerebellopontine angle. PP> Twitches usually begin in the periocular region and can progress to the cheek, perioral and platysma muscles. Hemifacial spasm is almost always unilateral. Muscles involved in HFS include the orbicularis oculi, orbicularis oris and zygomaticus predominantly with frontalis, corrugator, nasalis, buccinators, risorius, depressor angularis oris, mentalis and platysma. PP> Injections of botulinum neurotoxin (BoNT) are the preferred treatment of HFS. They are successful in over 90% of patients, with relief lasting approximately 12 weeks, and repeat treatments remaining effective for many years. This chapter lists the pertinent facial muscles along with their principal mechanical actions; illustrates their anatomy under the skin, showing the recommended injection sites; and tabulates the dose ranges of the various toxins in each of the muscles. <COMP: I can’t get rid of the PP coding here without seeming to lose text>

Migraine is a primary headache disorder characterized by enhanced sensitivity of the nervous system associated with a combination of neurological, gastrointestinal and autonomic disturbances (Silberstein, 2004). Chronic headache is a heterogeneous group of headache disorders that include chronic migraine (CM), chronic TTH (CTTH) and other headache types that occur 15 days or more per month (for a minimum of 3 months).

OnatotulinumtoxinA (onabotA) therapy has been used for a variety of disorders associated with painful muscle spasms. It is generally believed that, following intramuscular injection, onabotA produces partial chemical denervation resulting in a reduction in muscle activity and a broader inhibition of peripheral and central pain sensitization. OnabotA therapy is FDA-approved for use in patients with chronic migraine. This chapter discusses the definition of chronic migraine, patient selection for treatment with onabotA, and presents the PREEMPT injection protocol for the application of onabotA, with clinical description and pictural illustration of the injection site.

Botulinum neurotoxin (BoNT) injection is an effective treatment of spasticity in upper and lower limbs. Accuracy of injection needle placement in target muscles is of great importance in maximizing effectiveness of the treatment, and avoiding both treatment failure and adverse events such as weakening of adjacent musculature. Various guidance techniques improve effectiveness and avoid side effects, including anatomical landmark location and palpation, electromyographic guidance, and ultrasound guidance. In recent years, the availability of portable ultrasound devices has facilitated the application of ultrasound guidance, which is quick, painless, and now readily available. This chapter uses photographs, anatomical illustrations, and ultrasound images to illustrate injection techniques for specific muscles involved in the common patterns of spastic posturing.

Various disorders affecting the ears, nose and throat (ENT) are suited for treatment with botulinum neurotoxin (BoNT). This chapter focuses on the following disorders, describing symptomatology, application of BoNT injections, and dosing ranges: laryngeal dystonia, palatal tremor, dysphagia, hypersalivation (sialorrhea), gustatory sweating (Frey’s syndrome), rhinorrhea, hyperlacrimation and speech problems.

Tremor is one of the common movement disorders encountered by neurologists in clinical practice. Based on the history and phenomenology, the tremor can be classified commonly as Parkinson’s disease tremor, essential tremor , essential tremor plus, dystonic tremor, task-specific tremor and other tremor syndromes. This chapter describes the role of botulinum neurotoxin (BoNT) in several tremor conditions and provides some practical clinical pearls related to BoNT injection techniques. Specific muscles involved and the dose range of BoNT are tabulated.

Compared with the upper face, the lower face is a less common focus for treatment with botulinum toxin. However, with proper attention to muscular anatomy and function, the results of treatment in this area can be rewarding. Aging skin loses both its elasticity and thickness. These physiologicalchanges, coupled with repeated pleating and contraction of skin, result in rhytids (wrinkles).

In the upper face, relaxing the relevant underlying muscles of facial expression with botulinum neurotoxin (BoNT) injections will eliminate the so-called dynamic rhytids (wrinkles) and, over time, will soften the appearance of static rhytids. In the lower face, the cosmetic effect is less about the elimination of the wrinkles and more about changing appearance, often through paralyzing target muscles to allow unopposed action of complementary musculature. This approach can be useful, for example, to help correct age-related drooping of the nasal tip or the corners of the mouth. This chapter illustrates in detail the anatomy of lower facial muscles and specific injection sites, and discusses injection patterns to achieve specific results.

Blepharospasm is the most frequent cranial dystonia and consists of involuntary, symmetric, tonic or clonic bilateral contractions of the orbicularis oculi muscle, resulting in partial or complete eye closure. Blepharospasm can be primary (idiopathic), secondary or psychogenic. Primary blepharospasm is an adult-onset focal dystonia, manifesting with forceful eyelid closures. Rarely, blepharospasm is secondary to structural brain lesions, drug-induced or other neurodegenerative conditions like atypical parkinsonism. Blepharospasm’s severity may range from increased blinking frequency (only causing minor discomfort) to a persistent and forceful eyelid closure, leading to functional blindness

The orbicularis oculi muscle is the most frequently involved muscle; other involved muscles may include the corrugator supercilii, the procerus and the frontalis. Botulinum neurotoxin (BoNT) is considered the first-line treatment for blepharospasm. Typically, four injections are administered in the orbital or preseptal portion of the orbicularis oculi muscle, but the number of injections can be increased to include the lateral canthus and the pretarsal component of the orbicularis oculi. This chapter diagrams typical injection sites, tabulates dose ranges for different preparations of neurotoxin and lists frequencies of common adverse events.

Cerebral palsy is not a specific disease, but a clinical syndrome caused by a non-progressive injury to the developing brain that results in a disorder of movement and posture that is permanent but not unchanging. Spasticity is the most common movement disorder, affecting between 60% and 80% of children with cerebral palsy, and can manifest as spastic hemiplegia, spastic diplegia and spastic quadriplegia. Dystonia is characterized by involuntary sustained or intermittent muscle contractions that cause twisting and repetitive movements, abnormal postures or both. Athetosis, or intermittent writhing movement, is also very common. These movement disorders are all amenable to treatment with botulinum neurotoxin (BoNT). This chapter discusses topographical symptom distribution and illustrates the typical forms of cerebral palsy using an anatomical approach to management. Common clinical patterns of spastic posturing, the major involved, muscles and dose ranges for the different toxin preparations are tabulated.

Raynaud’s phenomenon is a vasospastic disorder with a reported prevalence of between 3% and 5% of the general population, is nine times more common in females and typically occurs between the ages of 15–40 years. It may be primary or occur in the setting of connective tissue disorders. Exaggerated vasoconstriction of the digital arteries in response to certain environmental triggers, typically cold temperatures, leads to pale, cold, numb and sometimes painful digits. In extreme cases, digital artery vasospasm leads to diminished blood supply to the fingertips, which causes pain, disuse and exposure of the distal phalanx, and may necessitate amputation.

Injection of botulinum neurotoxin (BoNT) into the hand, typically at the base of the fingers, produces increased blood flow, oxygenation saturation, pain reduction and promotion of ulcer healing, with prolonged benefit over several months. This chapter details the use of BoNT for ischemic digits caused by Raynaud’s phenomenon, including injection technique, dosing and quantification of perfusion and oxygenation using laser Doppler.

Plantar fasciitis (PF) is the most common cause of chronic heel pain, predominantly impacting those who perform heavy footwork, are avid runners or lare ong-distance walkers. Overuse injury leads to repetitive microtears of the plantar fascia near the calcaneus, irritating pain fibers and producing secondary inflammation. Patients typically have intense heel pain, described as aching, jabbing or burning. Pain usually starts with the first few steps in the morning and is reproduced by palpation of the median tubercle of the calcaneum and with dorsiflexion of the toes.

Conventional treatments such as ice, heel cup orthoses, deep-tissue massage and night splints, periods of immobilization and stretching/strengthening exercise programs can reduce pain satisfactorily. Persistent discomfort may respond to treatments such as ultrasound, iontophoresis and phonophoresis. More severe and recalcitrant cases require extracorporeal shock wave therapy (ECSWT) or local corticosteroid injections. When medical approaches fail, surgery is advocated but can only offer modest results.

This chapter reviews pertinent studies to date on the application of botulinum neurotoxin to plantar fasciitis, and discusses injection technique and dosing, including the WRAMC–Yale technique for injecting the soleus muscle, along with the plantar fascia. Clear anatomical illustrations are provided.

Hyperhidrosis is excessive sweating, beyond physiological needs. It may be divided into generalized and localized/focal types, and into primary/idiopathic and secondary forms. Primary axillary hyperhidrosis appears to be the most frequent type, followed by palmar hyperhidrosis and other patterns. Hyperhidrosis may negatively affect many fields of daily life to a significant extent, including emotional status, personal hygiene, work and productivity, leisure activities and self-esteem.

When injected intra- or subdermally, botulinum neurotoxin (BoNT) blocks the release of acetylcholine from the sympathetic nerve fibers that stimulate the eccrine sweat glands and causes a localized, long-lasting but reversible abolishment of sweating. This chapter describes in detail the techniques for BoNT injection to treat primary axillary and palmar hyperhidrosis, as well as showing treatment of scalp and segmental hyperhidrosis. Techniques for assessing the degree and distribution of hyperhidrosis, the area to be treated and the degree of benefit are described.

Botulinum toxin injection is a safe and effective procedure, with outcomes improved if selection and targeting of intended muscles is precisely executed. Individual differences in patient anatomy, and in muscle location or size, render the standard landmark-based, blind approach less effective. Also, adjacent structures such as blood vessels, nerves, the lung, or the thyroid gland, may be injured when hit by the cannula. Therefore, image-based guidance is recommended.

Ultrasound is a very safe imaging modality and is superior in image quality and more flexible during the procedure compared to other modalities (fluoroscopy, CT and MRI). Finally, the costs of acquisition and maintenance of a clinical ultrasound system are moderate, compared to other imaging modalities.

In this chapter, we performed selective ultrasound-guided injections using cadaver specimens to illustrate the muscles relevant in the treatment of cervical dystonia. With ultrasound, we advanced the needle using the in-plane technique to the center of each muscle, and performed a selective intramuscular injection using dilute India ink. The specific muscle was then exposed in a standard dissection and the extent of the staining was photo documented. In the last section we present panoramic still images of neck regions with a difficult muscle topology.

Focal hand dystonia (FHD) is characterized by dystonic hand contractions that are often aggravated by purposeful actions and may be specific to a particular task. The term “occupational dystonia” is used when dystonia affecting performance of the job arises in individuals with a particular occupation, usually an occupation requiring repetitive and excessive fine motor activity.

One task-specific FHD, writer’s cramp, causes disabling spasms of the hands when attempting to write, and is particularly likely in people whose profession involves excessive writing. Musician’s dystonia (cramp) is applied to a focal dystonia localized to hand muscles controlling fine movements of the digits or the embouchure muscles involved in playing instruments.

Injection of botulinum neurotoxin (BoNT) is effective in writer’s cramp and other occupational dystonias. This chapter discusses the different common patterns of dystonic movement of the hand and arm, identifies the particular muscles active in each dystonia pattern to aid in target selectio, and illustrates the muscular anatomy and injection approach using anatomical diagrams. Guidance of injections with EMG is discussed. Dosing recommendations for three different BoNT formulations are tabulated.