Botulinum Toxin Injection Guide

In any field of medicine, the quality of care is proportional to the knowledge of the physician. For the clinician the real challenge is to stay abreast of new developments in clinical treatments and drug therapies. New indications for drug therapies are continually emerging. The first indication for treatment with botulinum toxin was approved by the US Food and Drug Administration (FDA) in 1989. Currently, there are six FDA-approved indications (hemifacial spasm, 1989; blepharospasm, 1989; strabismus, 1989; cervical dystonia, 2000; glabellar lines, 2002; and hyperhidrosis, 2004). In addition, there has been a wide-spread growth of applications beyond the FDA-approved indications for botulinum toxin. The toxin is used to treat numerous conditions across many specialties. Therefore, most of the current uses and about half of the applications in this manual are off-label, and thus should be applied with caution.

This handbook is designed to be a practical introductory and reference guide for the busy clinician and newcomers to the field of neurotoxin applications. To facilitate easy clinical use of this handbook the dosing range tables and related illustrations appear are on facing pages.

For some conditions, however, the anatomic illustrations required multiple pages of display (migraine, cervical dystonia-torticollis, adducted/ internally rotated shoulder, writer’s cramp, flexed hip, equinovarus foot, and valgus foot). In these cases, the dosing tables for the illustrations are repeated on the facing pages. The information contained in this book is no substitute for appropriate clinical training, knowledge of the anatomy, familiarization with the literature, and understanding of the risks and benefits associated with botulinum neurotoxin applications. Because treatments with botulinum toxins are individualized for the severity of the treated condition, the size of the individual, and potential adverse events, the doses listed must be modified accordingly. The listed doses are for adults only unless specifically noted. Botulinum toxin is a very powerful medication and must be used with great caution. Unfortunately, many of the applications, and even some of the FDAapproved indications, may not be covered by third-party payers. Thus, the codes listed are no guarantee of future coverage and reimbursement, but they should help with the process. Preapproval of a third-party payer is recommended for all procedures, with the exception of Medicare, which does not preauthorize.