Dystonia

INDEX

             Anterocollis                                          Anterocaput                                                Forward Sagittal  Shift

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

Anterocollis
The neck is tilted forwards in relation to the TS; the angle between the neck and head is normal1. Anterocollis affects muscles which originate from or insert at the cervical spine, resulting in abnormal posture of the cervical spine.

Anterocaput
Head and neck form too great an angle; the angle between the cervical and thoracic spine is normal2.

Distinguishing anterocaput and and anterocollis
Analysis of forward flexion (differentiation between anterocollis and anterocaput) can be accomplished by observation from the side of the respective angles between:

Figure 1. Anterocollis and Anterocaput

From: Reichel G. Dystonias of the Neck: Clinico-Radiologic Correlations. In: Dystonia - The Many Facets. InTech, 2012


 

ANTEROCOLLIS

Figure 1. A patient with anterocollis. 

 

Patient Image

From: Finsterer J, Maeztu C, Revuelta GJ, Reichel G, Truong D. Collum-caput (COL-CAP) concept for conceptual anterocollis, anterocaput, and forward sagittal shift. J Neurol Sci [Internet] 2015;355(1–2):37–43.

 

Figure 2. A patient with anterocollis. 

 

Patient Image

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

 

Treatment

Many experts consider anterocaput/anterocollis the most difficult pattern of cervical dystonia to successfully manage with botulinum toxin3.
In anterocaput/anterocollis, the targeting challenges associated with injection of the deep flexors has led many clinicians to limit injections to the more easily accessible superficial flexor muscles, the sternocleidomastoids, and scalenus anterior.  However, this traditional approach to the treatment of anterocollis is only occasionally effective and can also result in dysphagia. For example:

Injecting only these superficial flexor muscles may provide only limited or no benefit for those patients whose dystonic movements or postures are caused by longus capitis and longus colli over-activity.  In all patients with anterocaput and in some patients with anterocollis, injection of the longus capitis or longus colli may be required to improve symptoms.

Injections of longus colli are detailed here:  Section: Backward Sagittal Shift
 


 

Scalenus anterior   Max 25 u Botox; 1x40-60 - Max 100 u Dysport

Scalenus anterior lies behind the sternocleidomastoid, over the lateral aspect of the neck.
The muscle arises from the anterior tubercles of the transverse processes of C3-C6, and attaches onto the scalene tubercle, on the inner border of the first rib.  It is located between the subclavian vein and the subclavian artery. The roots of the brachial plexus pass posterior to it. The phrenic nerve crosses its anterior surface.

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.

                           WARNING: neurovascular structures

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

 


 

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

                 
               WARNING: risk of dysphagia with injections                         

 

Surface Anatomy: Injection Sites for Sternocleidomastoid muscle

Anatomy: insertion and Origin of sternocleidomastoid muscle


 

Alternative scheme for injection:

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

  1. Scalenus medius/posterior
  2. Levator scapulae
  3. Longus colli (secondary)

1. Scalenus medius/posterior   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.

The scalenus medius, the largest muscle of the scalenus group, 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. This muscle 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

 

2. The levator scapulae Posterior:  Max 25 u Botox; 1x40-60 - Max 100 u 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

 


 

ANTEROCAPUT

Figure 3. A patient with anterocaput.

 

Patient Image

From: Finsterer J, Maeztu C, Revuelta GJ, Reichel G, Truong D. Collum-caput (COL-CAP) concept for conceptual anterocollis, anterocaput, and forward sagittal shift. J Neurol Sci 2015; 355: 37–43.
 

Figure 4. A patient with anterocaput.

 

Patient Image

From: Finsterer J, Revuelta GJ. Anterocollis and anterocaput. Clin Neurol Neurosurg 2014; 127: 44–53.

Figure 5. A patient with anterocaput.

 

Patient Image

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

 

Treatment

Alternative scheme for injection:

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

BILATERAL

  1. Longus capitis
  2. Levator scapulae
  3. Sternocleidomastoid (Secondary)

1. Longus capitis  (In Section:  Treatment of anterocaput (longus colli and longus capitis injections)

2. The levator scapulae Posterior:  Max 25 u Botox; 1x40-60 - Max 100 u 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

3. 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

 


 

 

 

 

 

 

 

 

References

1            Finsterer J, Revuelta GJ. Anterocollis and anterocaput. Clin Neurol Neurosurg 2014; 127: 44–53.

2            Finsterer J, Maeztu C, Revuelta GJ, Reichel G, Truong D. Collum-caput (COL-CAP) concept for conceptual anterocollis, anterocaput, and forward sagittal shift. J Neurol Sci 2015; 355: 37–43.

3            Farrell M, Karp BI, Kassavetis P, et al. Management of Anterocapitis and Anterocollis: A Novel Ultrasound Guided Approach Combined with Electromyography for Botulinum Toxin Injection of Longus Colli and Longus Capitis. Toxins (Basel) 2020; 12

4            Reichel G. Cervical dystonia: A new phenomenological classification for botulinum toxin therapy. Basal Ganglia 2011; 1: 5–12.

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