Dystonia

INDEX

 

 

                           Laterocollis                                                                                 Laterocaput                                                         Lateral Shift

 

Distinguishing between laterocollis and laterocaput is clinically possible, without the need for additional tests, such as CT or MRI of the cervical spine.

Laterocollis
If muscles are involved whose sites of origin or insertion lie between C2 and C7, this will result in the neck being flexed, corresponding to laterocollis.  In this case, the head and neck are in the same plane.

Laterocaput
Dystonia of the muscles which have their sites of origin or insertion in the skull or the first cervical vertebra, results in an abnormal posture which is limited to the head only, and where the cervical spine is normal.

Combinations of laterocaput and laterocollis are commonly found1.

Distinguishing laterocaput and and laterocollis

It is usually possible to differentiate clinically between laterocollis and laterocaput. In addition, an analysis of the position of the sternal notch towards the thyroid notch is helpful.  Should the diagnosis remain unclear, a simple anterior-posterior X-ray is normally sufficient to resolve the problem.

In combinations of laterocaput and laterocollis, the angles between the thoracic spine and the cervical spine and/or between the cervical spine and the skull typically provide sufficient information in order to determine the distribution of botulinum toxin dose between the two different muscle groups.

 



Laterocollis

Figure 1. Patient with laterocollis: the neck is tilted, and head and neck are lined up2.

 

Patient Image

From: Reichel G, Stenner A, Jahn A. The phenomenology of cervical dystonia. Fortschr Neurol Psychiatr 2009;77(5):272–7.

Figure 2. Laterocollis: the neck is tilted relative to the shoulder line, neck and head are in one plane3.

 

Patient Image

From: Reichel G. Cervical dystonia: A new phenomenological classification for botulinum toxin therapy. Basal Ganglia [Internet] 2011;1(1):5–12.

Figure 3. Patient with laterocollis and laterocaput: Head (A) and neck (B) form an angle; the neck is tilted relative to the shoulder line2.

 

Patient Image

From: Reichel G, Stenner A, Jahn A. The phenomenology of cervical dystonia. Fortschr Neurol Psychiatr 2009;77(5):272–7.
 



 

TREATMENT
 

  

Levator scapulae 

The levator scapulae lies directly ventral from the edge of the trapezius. In thin patients, the levator is clearly visible if the treated shoulder becomes lifted.
Activation: the patient can be asked to lift the shoulder.

Surface Anatomy: Injection Sites for Levator Scapulae muscle Anatomy: Insertion and Origin of  Levator Scapulae muscle 


 

Scalenus posterior/medius/anterior  Posterior:  Max 25 u Botox; 1x40-60 - Max 100 u Dysport

Scalenus is identified between the sternocleidomastoid and the levator scapulae. With insertion of the EMG needle into the scalenus muscle, the patient is asked to breathe in as deeply as possible. Since the scalenus is an auxiliary respiratory muscle, EMG activity should be clearly heard on the EMG. Generally either the scalenus posterior or the scalenus medius is treated. Both muscles have the same function: to elevate the rib to which they attach, and to bend and rotate the neck.

Scalenus medius is the largest muscle of the scalenus group, and arises from the transverse processes of the cervical vertebrae and inserts into the superior portion of the first rib. This muscle can elevate the first rib or bend and rotate the neck. A needle can be placed into the scalenus medius muscle by palpating the belly of the muscle, in the floor of the posterior triangle, two finger breadths anterior to the anterior border of the trapezius muscle. At this point the muscle is just beneath the skin. The upper portion can be inserted by placing the needle just anterior to the lateral edge of the splenius capitis muscle to a depth of 1.5 to 3.0 cm.

Scalenus posterior arises from the posterior portion of the transverse processes of C5–6, passing medially and posteriorly to the scalenus medius, and inserts into the outer surface of the second rib, deep to the attachment of the serratus anterior.  The scalenus posterior elevates the second rib or bends and slightly rotates the neck.
 

                           WARNING: neurovascular structures

Surface Anatomy: Injection Sites for Scalenus muscle Anatomy: Insertion and Origin of  Scalenus muscle 


Left Trapezius  2 x 7.5-10 u Max 50 u Botox;  2 x 30-40 max 200 u Dysport

The trapezius is superficial and is generally easily palpated at the base of the neck palpate. It is likely that the trapezius does not play a major role in causing abnormal head posture, but the muscle often seems to cause pain, which is effectively treated with botulinum toxin.

Recommended to inject trapezius at the base of the neck with one or two injections.

Surface Anatomy: Injection Sites for Trapezius muscle Anatomy: Insertion and Origin of  Trapezius muscle 



Alternative scheme  and muscles for injection shown(After: Jost WH, Tatu L. Selection of Muscles for Botulinum Toxin Injections in Cervical Dystonia. Mov Disord Clin Pract 2015;2(3):224–6)

Ipsilateral to side of lateroflexion

  1. Levator scapulae
  2. Semispinalis cervicis
  3. Scalenus medius (secondary)
  4. Longissimus cervicis (secondary)

     

1. Levator scapulae: see above
 


 

2. Semispinalis cervicis 10 u Botox per side; Max 20 u 

The muscle arises from the transverse processes of T1-T6, and inserts into the posterior spinous processes of C2-C7. It acts to extend the cervical spine (principal action), and to rotate the head contralaterally.

Technique: (from Mezaki T. Ultrasound‐guided botulinum toxin therapy for deep muscles in cervical dystonia. Neurol Clin Neurosci 2020; 8: 3–10.)

1. Place the linear transducer on the posterior aspect of the neck horizontally at the fifth cervical (C5) spinous process level.
2. The muscle is located at the fourth layer: From superficial to deep, the trapezius, the splenius capitis (and cervicis), the semi‐ spinalis capitis, and the semispinalis cervicis are identified. Deep to this muscle, there is the multifidus muscle.
3. Compare the muscle thickness between both sides. Because the contribution of this muscle for head rotation is usually minor, a small difference may be ignored.
4. Inject botulinum toxin above and below the C5 level, 3‐4 centimeters apart. The convenient needle size is 27 gauge, 38 mm.

Ultrasound approach to Semispinalis Cervicis  muscle

Anatomy of Semispinalis Cervicis muscle Gross Anatomy: Insertion and Origin of Semispinalis Cervicis muscle (#5)


3. Scalenus medius: see above



4. Longissimus cervicis 10 u Botox per side; Max 20 u 

The longissimus capitis arises from transverse processes of C3-T3. It inserts into the mastoid process.
This muscle is deep to the levator scapulae muscle at the C5 level, and its depth greatly varies from patient to patient, being often unexpectedly superficial. In some adults.

Technique

1. Palpate the spinous process of the axis and move the operator's finger to the third cervical (C3) spinous process.
2. Place the linear transducer horizontally at this level over the triangle formed posteriorly by the trapezius, anteriorly by the sternocleidomastoid, and inferiorly by the middle third of the clavicle.
3. Move the transducer a little dorsally and localize the transverse process of C3 on the right lower part of the screen. The longissimus capitis muscle can be seen in the direction of 10‐11 o'clock from the transverse process with a deformed and widened letter D‐chape (the vertical line of the letter D represents the fascia, discriminating it from the semispinalis capitis
muscle)
4. After the injection, repeat the procedure at the C5 level. Color Doppler imaging at this level occasionally detects an artery, which is  the superficial branch of the transverse cervical artery. .

Ultrasound approach for Longissimus capitis muscle Anatomy: Insertion and Origin of Longissimus capitis muscle

  


 

Laterocaput   

Figure 4. A patient with laterocaput: head (A) and neck (B) form an angle; the neck is perpendicular/vertical on the shoulder line2

 

Patient Image

From:  Reichel G, Stenner A, Jahn A. The phenomenology of cervical dystonia. Fortschr Neurol Psychiatr 2009; 77: 272–7.

 



TREATMENT (After: Jost WH, Tatu L. Selection of Muscles for Botulinum Toxin Injections in Cervical Dystonia. Mov Disord Clin Pract 2015;2(3):224–6)

Ipsilateral to side of lateroflexion

  1. Sternocleidomastoid
  2. Trapezius (Descending portion)
  3. Splenius capitis
  4. Semispinalis capitis (secondary)
  5. Longissimus capitis (secondary)
  6. Levator scapulae (secondary)

7.  Additionally, obliquus capitis superior may be injected.
 



1. Sternocleidomastoid

2 x 30 u Max 60 u Botox;  2 x 30-40 max 200 u Dysport

Surface Anatomy: Injection Sites for Sternocleidomastoid muscle

Anatomy: insertion and Origin of sternocleidomastoid muscle

 



2. Trapezius  2 x 7.5-10 u Max 50 u Botox;  2 x 30-40 max 200 u Dysport

The trapezius is superficial and is generally easily palpated at the base of the neck palpate. It is likely that the trapezius does not play a major role in causing abnormal head posture, but the muscle often seems to cause pain, which is effectively treated with botulinum toxin.

Recommended to inject trapezius at the base of the neck with one or two injections.

Surface Anatomy: Injection Sites for Trapezius muscle Anatomy: Insertion and Origin of  Trapezius muscle

 



3. Splenius capitis 

Bilateral 2 x 10-12.5 u; Max 20 u Botox; 2 x 40-50;  Max 2 x 80 u Dysport
Locate the mastoid process (marked with the semicircle in the image) and the border of the sternocleidomastoid. Posterior to the sternocleidomastoid is the splenius capitis, and the initial injection is given there. The length of the muscle is followed diagonally backwards and downwards, and the second injection given. If no EMG activity is heard, the muscle may be activated by asking the patient to turn their head to the ipsilateral side.

Surface Anatomy: Injection Sites for Splenius muscle

Anatomy: Insertion and Origin of Splenius muscle

 



4. Semispinalis Capitis

One injection is given one centimeter below the hairline, and the 2nd about 2.5 cm below that, as shown in the figure.
The semispinalis is covered by the trapezius. If the neck is flexed (chin towards the chest) the muscle is relaxed and injections less painful; activation of the muscle is achieved by moving the head backwards against the examiner’s hand.

Surface Anatomy: Injection Sites for Semispinalis capitis muscle

Anatomy: Insertion and Origin of Semispinalis capitis muscle



5. Longissimus capitis

The longissimus capitis arises from transverse processes of C3-T3. It inserts into the mastoid process.
This muscle is deep to the levator scapulae muscle at the C5 level, and its depth greatly varies from patient to patient, being often unexpectedly superficial. In some adults.

Technique

1. Palpate the spinous process of the axis and move the operator's finger to the third cervical (C3) spinous process.
2. Place the linear transducer horizontally at this level over the triangle formed posteriorly by the trapezius, anteriorly by the sternocleidomastoid, and inferiorly by the middle third of the clavicle.
3. Move the transducer a little dorsally and localize the transverse process of C3 on the right lower part of the screen. The longissimus capitis muscle can be seen in the direction of 10‐11 o'clock from the transverse process with a deformed and widened letter D‐chape (the vertical line of the letter D represents the fascia, discriminating it from the semispinalis capitis
muscle)
4. After the injection, repeat the procedure at the C5 level. Color Doppler imaging at this level occasionally detects an artery, which is  the superficial branch of the transverse cervical artery. .

Ultrasound approach for Longissimus capitis muscle Anatomy: Insertion and Origin of Longissimus capitis muscle

 



6. Levator Scapulae  

1 x 10-15 u Max 25 U Botox; 1x40 -60 - max 100U Dysport

The levator scapulae lies directly ventral to the edge of the trapezius. In thin patients, the levator is clearly visible if the treated shoulder becomes lifted.
Activation: the patient can be asked to lift the shoulder.

Surface Anatomy: Injection Sites for Levator Scapulae muscle Anatomy: Insertion and Origin of  Levator Scapulae muscle

 



7.  Obliquus capitis superior

The muscle arises from the lateral mass of the atlas bone. It passes superiorly and posteriorly to insert into the lateral half of the inferior nuchal line on the external surface of the occipital bone.
Obliquus capitis superior extends the head, and also results in ipsilateral head flexion.

Anatomy: insertion and Origin of obliquus capitis superior



Lateral Shift

Lateral shift is always a result of laterocollis to one side and laterocaput to the opposite contralateral side: Thus, muscles attached to the cervical spine on the side of the shift, and the muscles attached to the skull on the opposing side, require treatment.

Figure 5.  Patient with lateral shift: the neck (line B) is at angle to the shoulder line.  The head is perpendicular to the shoulder line, but is shifted to the right.
The neck and head (line A) are oriented in opposite directions;

 

From: Reichel G, Stenner A, Janh A. [Cervical dystonia: clinical-radiological correlations and recommendations for the correction of botulinum therapy]. Zh Nevrol Psikhiatr Im S S Korsakova. 2012;112(1):73-9. Russian. PMID: 22678680.

 

Figure 5. Patient with lateral shift: the neck is oblique to the shoulder line, the lines of the neck (c) and head (h) are angled in opposite directions; the head is vertical on the shoulder line but displaced to the left3.

 

From: Reichel G. Cervical dystonia: A new phenomenological classification for botulinum toxin therapy. Basal Ganglia [Internet] 2011;1(1):5–12. Available from: http://dx.doi.org/10.1016/j.baga.2011.01.001

 

 

 

 

 

 

 

 

 

 

References

1.          Jost WH, Tatu L. Selection of Muscles for Botulinum Toxin Injections in Cervical Dystonia. Mov Disord Clin Pract 2015;2(3):224–6.

2.          Reichel G, Stenner A, Jahn A. The phenomenology of cervical dystonia. Fortschr Neurol Psychiatr 2009;77(5):272–7.

3.          Reichel G. Cervical dystonia: A new phenomenological classification for botulinum toxin therapy. Basal Ganglia [Internet] 2011;1(1):5–12.