April 15, 2024/Neurosciences/Podcast

Balancing Benefits and Pitfalls of Neurotoxin Injections (Podcast)

Determining the right dose and injecting in the right muscle can be challenging

Indications for neurotoxin injections continue to expand, with clinicians using them to treat everything from migraine to hyperactive bladder. However, there are pitfalls associated with neurotoxin delivery.


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“Botulinum toxin injection is a very individualized treatment,” says Hubert Fernandez, MD, Director of Cleveland Clinic’s Center for Neurological Restoration. “It only works if it’s at the right dose and in the right muscle and for the right indication. This is a treatment where the art truly blends with the science, and therefore patients should really find the most comfortable and clinically trained injector.”

In the latest episode of Cleveland Clinic’s Neuro Pathways podcast, Dr. Fernandez and Francois Bethoux, MD, Chair of the Department of Physical Medicine and Rehabilitation, share their experiences treating patients with neurologic disorders using botulinum toxin injections. They discuss:

  • Various FDA-approved neurotoxins and their mechanisms of action
  • Neurologic disorders commonly treated with botulinum toxin injections
  • Who makes a good candidate for neurotoxin injections, and how to select the right formulation
  • Potential risks, such as weakness and other unwanted side effects
  • What’s on the horizon, including longer-acting toxins and combinations with other treatments

Click the podcast player above to listen to the episode now, or read on for a short edited excerpt. Check out more Neuro Pathways episodes at clevelandclinic.org/neuropodcast or wherever you get your podcasts.

This activity has been approved for AMA PRA Category 1 Credit™ and ANCC contact hours. After listening to the podcast, you can claim your credit here.

Excerpt from the podcast

Podcast host Glen Stevens, DO, PhD: Do you use EMG for placement of your botulinum toxin?


Dr. Bethoux: Yes, it's recommended by the FDA and now it's widely accepted in the field that the injections are safer and more accurate if we use some form of guidance. So it can be EMG or it can be electrical stimulation where we stimulate the muscle to see it contract before we inject it. Another mode of guidance that has gained a lot of traction is ultrasound. So we literally visualize the muscle and we can visualize the botulinum toxin going into the muscle, which really guarantees 100% accuracy in the injection.

Dr. Hubert Fernandez: Yes, in our field I would say some still do anatomical localization, meaning no external guidance other than the anatomical landmarks of the body. I think that might be okay for some indications. But it is the clinician’s preference. At our center we do, at the very least, EMG-guided botulinum toxin. So the muscle involved emits a certain sound, and when we hear that sound, then we are assured that this is the right muscle and we inject. But even better than hearing, at least in my opinion, is seeing the muscle itself and seeing the needle and seeing the botulinum toxin spread within that muscle. And so for my own practice, I have mainly transitioned to ultrasound-guided botulinum toxin injections, but this is not for everyone. There is some technical expertise and a little bit of lag time that is required for ultrasound-guided botulinum toxin injections. So it takes some practice before one becomes efficient with it.


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