Botulinum Toxin Type A in Spasticity and Cervical Dystonia: Practical Clinical Recommendations from a Mexican Multidisciplinary Panel of Specialist Injectors

Cervical dystonia and spasticity are debilitating neuromuscular disorders that substantially impair quality of life. Botulinum toxin type A (BoNT-A) is a cornerstone therapy; however, heterogeneity in dosing, muscle selection, and guidance techniques can limit outcomes, and Mexico-specific practical guidance is limited. We convened a multidisciplinary panel of Mexican rehabilitation and neurology specialists with extensive experience in BoNT-A injection; recommendations were developed through a three-phase process: a targeted literature search, a structured online survey of Mexican rehabilitation and neurology specialists, and an in-person meeting (21 February 2025) where clinicians reviewed aggregated survey results and refined practical recommendations through structured deliberation. The manuscript provides pragmatic guidance on evaluation and goal setting, muscle selection, working dilutions, dosing ranges, and reinjection intervals, emphasizing ultrasound (US) and/or electromyography (EMG) for deep or high-risk targets. It also summarizes key adverse events and proposes a stepwise approach to inadequate response, prioritizing reassessment of diagnosis, goals, targeting, and techniques before considering immunogenicity testing, product switching, or alternative interventions. These recommendations aim to improve standardization, safety, and goal attainment in routine Mexican practice.