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Directly acting muscle relaxants like dantrolene and botulinum toxin (BoNT) have distinct mechanisms and applications. Dantrolene, a hydantoin derivative, acts on the ryanodine receptor (RYR1) in skeletal muscle cells. RYR1 are calcium channels present at the sarcoplasmic reticulum membrane. In response to excitation, they release calcium ions from the sarcoplasmic reticulum to the cytosol. Calcium promotes actin-myosin-mediated contraction of muscles.
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Skeletal muscle relaxants are used to relax muscle tone and alleviate painful muscle contractions. However, the choice of skeletal muscle relaxants depends on the duration of the surgical procedure in order to minimize potential side effects. Skeletal muscle relaxants like neuromuscular blocking agents [NMBAs] are commonly employed as adjuvants alongside general anesthetics in clinical settings. NMBAs are also used to maintain controlled ventilation during surgery of the larynx or pharynx...
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Nondepolarizing neuromuscular blockers prevent the membrane depolarization of muscle cells and inhibit muscle contraction. These are usually administered with anesthetics to achieve complete muscle relaxation. Upon administration, these drugs first block the small, rapidly contracting muscles of the face and hands, followed by the larger muscles of the trunk and the intercostal muscles. The diaphragm is the last muscle to be affected.
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Updated: Sep 18, 2025

Ultrasound-guided Botulinum Toxin-A Injections: A Method of Treating Sialorrhea
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Comparing Injection Methods of Botulinum Toxin A for Cervical Dystonia: A Systematic Review.

Hristo Shipkov1,2, Petar Uchikov1, Abdulrahman Imran3

  • 1Department of Special Surgery, Faculty of Medicine, Medical University of Plovdiv, 4002 Plovdiv, Bulgaria.

Life (Basel, Switzerland)
|June 26, 2025
PubMed
Summary

Ultrasound- and EMG-guided injections improve botulinum toxin type A (BoNT-A) treatment for cervical dystonia (CD) by enhancing accuracy and safety over traditional methods. Combining both techniques may offer the best patient outcomes.

Keywords:
botulinum toxin injectioncervical dystoniaultrasound and EMG guidance

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Area of Science:

  • Neurology
  • Medical Imaging
  • Pharmacology

Background:

  • Cervical dystonia (CD) is a neurological disorder causing involuntary neck muscle contractions, pain, and functional impairment.
  • Botulinum toxin type A (BoNT-A) is the primary treatment, but its effectiveness relies on precise injection techniques.
  • Current methods include palpation-guided, ultrasound-guided, and electromyography-guided (EMG) injections, each with pros and cons.

Purpose of the Study:

  • To systematically review and synthesize evidence on the efficacy and safety of different BoNT-A injection techniques for cervical dystonia.
  • To compare the accuracy, muscle targeting, and adverse event profiles of palpation, ultrasound, and EMG guidance in CD treatment.

Main Methods:

  • A systematic literature search of PubMed and Scopus was performed up to December 30, 2024.
  • Studies reporting clinical outcomes of BoNT-A injection methods in adult CD patients were included.
  • Data on efficacy, safety, accuracy, and muscle targeting were extracted and synthesized.

Main Results:

  • Seven studies involving 239 patients were analyzed, with torticollis/torticaput being the most common CD subtype.
  • Ultrasound guidance showed superior accuracy and fewer adverse events due to real-time visualization.
  • EMG guidance excelled at identifying dystonic muscles, particularly in complex anatomy, while palpation was less accurate.
  • Mean BoNT-A doses varied by product: 117-118 units for onabotulinumtoxinA/incobotulinumtoxinA and 405 units for abobotulinumtoxinA. Adverse events were generally mild.

Conclusions:

  • Ultrasound- and EMG-guided BoNT-A injections offer improved precision, safety, and efficacy for cervical dystonia compared to palpation-guided methods.
  • Ultrasound enhances anatomical accuracy, while EMG is crucial for functional muscle identification; their combined use may optimize treatment.
  • Further high-quality, standardized trials are necessary to establish definitive best practices for BoNT-A injection techniques in CD.