Botulinum toxin injections, often called Botox® injections, are commonly being used these days as a part of a cosmetic makeover. However, its use is not limited to that, and it is in fact extremely useful in managing a number of clinical conditions that involve muscle spasticity.
Botox® is a toxin that is produced by the bacterium Clostridium botulinum. The injection form used in treatments is the sterile lyophilised form of botulinum toxin type A. There a variety of formulations available on the market these days, and most of them are used for the same purposes.1 In a nutshell, they are useful to get rid of wrinkles on the face (cosmetic purpose), in managing spasticity associated with cerebral palsy, spastic paraparesis, blepharospasm and also for management of pain.
Botulinum toxin is delivered as an injection to the relevant muscle groups.
Technique of Botox® injection administration
The general technique for injecting Botox® consists of using a 1.0 mL Tuberculin type syringe along with needles of varying size depending on the muscle being injected. For superficial injections into the skin and the muscles around the eye, a short 25 gauge to 30 gauge needles may be used. However, for larger muscles, a longer 25 gauge may be used.
Prior to performing the procedure, it is essential to identify the right muscle or muscle groups that require injecting. A thorough clinical examination is warranted, and once this is concluded electromyography studies may be conducted to identify the muscles clearly. Once this has been done, a motor point should be identified on the surface of the muscle. This is the point that is injected with Botox®. The skin is cleaned with alcohol and the alcohol allowed to evaporate. The toxin is then injected into the muscle, taking care not to inject it intravascularly.
The time duration taken to inject the toxin depends on the operator experience and the number of muscles that need injecting. Following the procedure, patients may feel a mild amount of pain and discomfort, and this is easily treated with simple analgesics.
Additional clinical conditions that require Botox® injections.
1. Cerebral palsy
Target muscles that are spastic in children with cerebral palsy (CP) need to be identified using gait analysis.2 While passive movement of the muscles and joints can help identify muscle groups that need injecting, some groups advocate using ultrasound with or without electromyography to ensure accuracy.3 Following the injection, the appropriate post injection care such as physical therapy and orthotic management should be considered.
Here, Botox is diluted with normal saline and is injected using a 30 gauge needle into the orbicularis oculi muscle carefully at around 4 to 5 points around the eye. Care should be taken to ensure ptosis does not occur during injection.4
Botox® injections are common practice in managing muscle spasticity and for cosmetic reasons. Techniques are complicated and require expert care when being administered. When used correctly, they can demonstrate a tremendous result.
1. Jankovic J. Botulinum toxin in clinical practice. J Neurol Neurosurg Psychiatry. 2004;75:951–957. doi: 10.1136/jnnp.2003.034702.
2. Gage JR. Gait analysis in cerebral palsy. London: Mac Keith Press; 1991. pp. 101–131.
3. Heinen F, Desloovere K, Schroeder AS, Berweck S, Borggraefe I, van Campenhout A, Andersen GL, Aydin R, Becher JG, Bernert G, Caballero IM, Carr L, Valayer EC, Desiato MT, Fairhurst C, Filipetti P, Hassink RI, Hustedt U, Jozwiak M, Kocer SI, Kolanowski E, Krägeloh-Mann I, Kutlay S, Mäenpää H, Mall V, McArthur P, Morel E, Papavassiliou A, Pascual-Pascual I, Pedersen SA, Plasschaert FS, van der Ploeg I, Remy-Neris O, Renders A, Di Rosa G, Steinlin M, Tedroff K, Valls JV, Viehweger E, Molenaers G (2010) The updated European Consensus 2009 on the use of Botulinum toxin for children with cerebral palsy. Eur J Paediatr Neurol 1:45–66.
4. Aramideh, M., et al. “Pretarsal application of botulinum toxin for treatment of blepharospasm.” Journal of Neurology, Neurosurgery & Psychiatry 59.3 (1995): 309-311.
Botox is a trademark of Allergan Inc.;
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