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.

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.

Idiopathic cervical dystonia (CD) is characterized by sustained muscle contraction leading to abnormal postures and twisting movements of the head and neck. BoNT is the gold standard for treatment of the abnormal postures and movements associated with CD. It provides a long duration of symptomatic relief of the pain or postures associated with CD with minimal side effects.

The complex regional anatomy in the craniocervical region increases the potential risks of injections in this area. Ultrasound guidance provides useful information about the depth and thickness of the target muscles, structures to be avoided when inserting/advancing a needle, a safe path to the target and the location of the injectate within the muscle. When treating patients with CD, ultrasound is frequently combined with EMG guidance which provides additional information about muscle activity and potential contribution to a posture. This chapter provides a review of ultrasound guidance for injections for craniocervical dystonia

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.