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(Ed. Note: Much has been written and discussed in the medical community about the proper procedures of injecting Botox (A) or Myobloc (B). Is palpation best.or is the EMG procedure better? What muscles should be injected? How often should you have an injection? Well. in conjunction with our medical advisor, Dr. Jim Auberle, we hope you will find the following questions and answers to be a big help in solving some of the mysteries. Please bear in mind these will be our views; your doctor, or other doctors, may have differing views, but this is good, as discussion is much needed if we are to be helped. Should you have any questions, please let us know so that we can ask the experts. Howard Thiel).

Q: Dr. Auberle, how long have you been injecting patients with ST? How many patients would you have injected?

A: I started injecting Botox in the latter half of 1990. Prior to that I had been doing injections during my residency with phenol about five years earlier. In 1997 we started recording patients’ and injections in a database. Since then we have about 600 different patients listed there. Starting in early 1997 until now, the database allows me to keep many different statistics on what we inject, how much and when. I have done about 1,600 injections since starting those records. The vast majority of patients have been those with torticollis but some have included the limb dystonias, a few hemifacial spasms and spasmodic dysphonias as well.

Q: What procedure do you prefer and use and why? Palpation? EMG? Would you explain briefly each method.

A: In a palpation technique the physician injector simply uses the knowledge of anatomy of the human body and their own personal touch to determine where they are going to place an injection. The theory here is that muscles that overwork themselves become larger. A bodybuilder exercises his muscles to get bigger just like many dystonic muscles get bigger. I believe that there are some problems with just palpating. First, not all muscles that are large are participating with the dystonic process. Secondarily, there are deeper muscles of the neck that simply cannot be palpated. The EMG technique goes further. One can see and hear the muscle firing. It eliminates the guesswork. The overall procedure becomes more quantifiable.

Q: You also inject phenol. Would you explain what this is and how does it differ from botulinum toxins? When would you use it and why?

A: Phenol is a chemical as opposed to one of the botulinum toxins which is a complicated protein. Phenol destroys just about every thing in its path without regard whether it is a nerve, muscle or any other structure. In the past, we wanted a treatment option for those patient’s who became resistant or developed antibodies to the Botox (A). Now we also have Myobloc (B) as an alternative treatment.

Q: There are some doctors who inject many patients and use the palpation method, many of them well known. Why in your estimation, do they do this? Are they missing muscles with the palpation method?

A: Quite frankly I personally do not trust the palpation technique. All that one must do is simply listen or watch an injection that demonstrates no muscle activity and then movement of a needle just a few millimeters to hear some raging electrical discharges to understand that there may be some significant technical issues to the injections. There is absolutely no way to palpate the deeper muscles of the neck. The benefits to the injections are that they take less time without the EMG. These days in medicine time is money.

Q: There are different types of EMG machines .what are they and which do you prefer? I know from our previous discussions and from my own experience that different muscles can be detected with different EMG machines and/or procedures e.g. placement of the needles?

A: There are EMG machines that have no screens and act as stereo sound amplifiers. Most EMG machines have some sort of screen or computer panel where the waveforms can be watched. This is helpful because often there are telltale changes on the screen that suggest that further manipulation of the needle may get one closer to the active dystonic reaction. Several EMG machines are multi-channel allowing the opportunity to record from several different sites or muscles at the same time. These are good for attempting to identify different patterns of muscle involvement that participate in the dystonia. Multiple channels means multiple needle sticks/pokes.

Q: Now that we’ve established the procedures, let’s move on to other questions. Do you inject Botox(A) or Myobloc (B)? Do you have a preference? Does the type of torticollis determine which is used?

A: In my practice, I’m relatively conservative but we inject both types of botulinum toxin. I have being injecting Botox (A) for the longer time and feel very comfortable with it. Myobloc (B) has only been available for about a year now. As time goes on I’m sure we will develop the same degree of comfort with Myobloc (B). I feel that we are still learning the best ways to use botulinum toxin (B). Each has some advantages and disadvantages. However, I cannot say that I have a particular preference. To my knowledge, there is no information available to say that a particular type of torticollis responds to a particular type of botulinum toxin. (Ed. Note: Professor Edward Schantz, one of the 2 developers of Botox, explained years ago that Botox (strain A) was picked at that time because it had the most toxicity associated with it).

Q: There are four basic types of torticollis – laterocollis, retrocollis, rotational, and anterocollis. Which type of torticollis responds to botulinum toxin A or B the more frequently? .least frequently?

A: I don’t think we can say at this point that a particular type of torticollis responds to a particular botulinum toxin. I will however comment that the anterocollis are usually the most difficult to treat.

Q: How much of A or B would you use for the above? What is your maximum amount you would inject. Some doctors use more for anterocollis, do you?

A: Most patients routinely receive somewhere between 200 and 300 units of Botox (A). The maximum I personally have used has been 400 units on a resistant patient with severe torticollis. However, with some other situations of spasticity I have gone as high as 700 units. For Myobloc(B) we’re still feeling our way but average would be 5,000 to 13,000 units. For anterocollis if I use a relatively large amount I will alternatively inject the SCM’s. One SCM this time and the other is injected next time.

Q: What do you recommend the minimum period to be between injections?

A: I subscribe to every three months a minimum time between injections. On some occasions, we will shorten that to about 10 weeks. However, the insurance companies have started to monitor this and will only allow every three months in most cases.

Q: For people with segmental dystonia, truncal dystonia or a fixed contracture, will either toxin work as well? Please explain each of these. If the toxins won’t work, is phenol a viable substitute?

A: For any situation where there is overactive muscle activity e.g. dystonias, spasticity, twitches, tics etc., the botulinum toxins will work. The only example where it will not work is if there is a fixed muscle contraction. This is a situation where the muscle has been replaced by thick fibrous tissue. The botulinum toxins only work at the connection of the nerve / muscle. No muscle means no nerve which means the botulinum toxins will not work.

Q: What are the main muscles that are injected? Any secondary muscles?

A: The most frequent are probably the SCM, trapezius, and splenius capitus and longissimus capitus. Any muscle that I can reach with a needle is fair game.

Q: Do the muscles vary in the different forms of ST or do injection sites vary?

A: The answer to this question strikes at the very heart of what a

physician should do when performing injections. In the various types

of ST the pattern of individual muscles involved can vary a great

deal. Let’s take an example of a Right looker. For some Right

lookers the major muscle involved may be the Left sternocleidomastoid

muscle (SCM). For other Right lookers, the SCM may be very quiet and the more active muscles would be the Right splenius capitus and /or

the Right longissimus capitus. In my opinion, the best way to

determine this is by EMG. At various times we have found that individual muscles may act in independent ways. For example, a big

muscle like the trapezius may have “hot” spots where muscle activity

is greater in certain portions of the muscle. This can even lead to

certain muscles performing certain types of activity in different

forms of torticollis. Let’s go back to the SCM for a moment. The sternal portion of the SCM participates in the rotary form of ST but the cleido portion of the SCM particpates in the lateral form of ST. Depending on which is more active or participating in controlling neck movements is the one I treat. In most regards, in treating the SCM we inject in the posterior cleido portion to avoid any swallowing problems. However, I’ve been known to break my own rules to get a better result for a patient if I hear that something is just not working.

For a Right looker:

Left SCM

Right Splenius capitus

Right Longissimus capitus

Perhaps several others

For a Left looker:

Right SCM

Left Splenius capitus

Left Longissimus capitus

Perhaps several others

For retrocollis:

Both Splenius capitus

Both Longissimus capitus

Both Trapezius

Both Semispinalis capitus

Perhaps several others

For anterocollis:

Both SCM

Perhaps several others

For laterocollis:

My mom and I wanted to thank you for hosting such a great symposium this year. This was our third year and we are looking forward to next years. E. Mathews