Dystonia

INDEX

 

                                                                                  SCALENUS ANT, POST & MEDIAL                SPLENIUS CAPITIS                SPLENIUS CERVICIS

 

LEVATOR SCAPULAE 

 

 

Figure 1.  The middle to upper portion of levator scapulae lies in the posterior triangle, covered superiorly by SCM; anterior lies scalenus medius and posterior is splenius capitis. 
Inferior portion of levator scapulae is covered by trapezius.


 

Figure 2. Insertion of levaltor scapulae.


Muscle is shown lying deep to trapezius, and immediately ventral to splenius cervicis and splenius capitis.

 

Anatomy: Muscles related to the Levator Scapulae Origin & Insertion of Levator Scapulae muscle
   
Anatomy: Insertion and Origin of  Levator Scapulae muscle Surface Anatomy: Injection Sites for Levator Scapulae muscle
Figure 3. Trajectory of approach and relationships of the surrounding muscles to OCI
 

 

Video 1.  Use of ultrasound to inject levator scapulae

(vv)levator scapulae.mp4(tt)

The muscle is typically injected just ventral to the border of trapezius; if there insufficient activation, ask the patient to elevate their shoulder.

This muscle is organized in four bundles inserted onto the transverse processes of C1, C2, C3 and C4. These bundles are visible in ultrasonographic images and can be injected selectively with botulinum toxin to act at a given vertebral level.
(Note that the transverse process of the atlas (C2) is easily palpable just posterior to the posterior border of the ramus of the mandible, directly inferior to the ear, and directly anterior to the mastoid process of the temporal bone.)

The largest part of the levator scapulae muscle, where the four bundles meet, is located at the muscle's insertion into the medial border of the scapula. Injecting at this site affects the muscle globally and needs a careful approach because of the risk of hitting the pulmonary apex and causing a pneumothorax.

Figure 4. Ultrasound of the lateral and lower muscles of the neck

From: Fietzek UM, Nene D, Schramm A, Appel-Cresswell S, Košutzká Z, Walter U, Wissel J, Berweck S, Chouinard S, Bäumer T. The Role of Ultrasound for the Personalized Botulinum Toxin Treatment of Cervical Dystonia. Toxins (Basel). 2021 May 20;13(5):365. 

 

Figure 5. Ultrasound image at C4 level

From: Fietzek UM, Nene D, Schramm A, Appel-Cresswell S, Košutzká Z, Walter U, Wissel J, Berweck S, Chouinard S, Bäumer T. The Role of Ultrasound for the Personalized Botulinum Toxin Treatment of Cervical Dystonia. Toxins (Basel). 2021 May 20;13(5):365.

 

 


SCALENUS ANT, POST & MEDIAL 

 

 

Figure 6. Relationships of the scalene muscles to sternocleidomastoid and levator scapulae
 

 

 

Relationship of scalene muscles to SCM and splenius (partly transparent) Anatomy: Origin of scalenus muscle from cervical vertebrae
Surface Anatomy: Injection Sites for Scalenus muscle Anatomy: Overview of Scalenus muscle
Figure 7. Trajectory of approach and relationships of the surrounding muscles to scalenus
 

 

Video 2. Scalenus muscle injection.  The video shows positioning of the EMG needle under ultrasound guidance.

(vv)Post Scalenus.mp4(tt)

Figure 6. Ultrasound view of lateral structures of the neck, SCM anteriorly.

Figure  7. Ultrasound view of the anterior neck at C6 level.

From: Fietzek UM, Nene D, Schramm A, Appel-Cresswell S, Košutzká Z, Walter U, Wissel J, Berweck S, Chouinard S, Bäumer T. The Role of Ultrasound for the Personalized Botulinum Toxin Treatment of Cervical Dystonia. Toxins (Basel). 2021 May 20;13(5):365. 

Figure  8. Ultrasound view of the anterior neck at the level of the first rib.

 

From: Fietzek UM, Nene D, Schramm A, Appel-Cresswell S, Košutzká Z, Walter U, Wissel J, Berweck S, Chouinard S, Bäumer T. The Role of Ultrasound for the Personalized Botulinum Toxin Treatment of Cervical Dystonia. Toxins (Basel). 2021 May 20;13(5):365. 

 

Figure  9. Ultrasound view of the lateral and lower muscles of the neck.

 

From: Fietzek UM, Nene D, Schramm A, Appel-Cresswell S, Košutzká Z, Walter U, Wissel J, Berweck S, Chouinard S, Bäumer T. The Role of Ultrasound for the Personalized Botulinum Toxin Treatment of Cervical Dystonia. Toxins (Basel). 2021 May 20;13(5):365.

 


 

 SPLENIUS CAPITIS

 

 

Surface Anatomy: Injection Sites for Splenius muscle

                                                         

Anatomy: Insertion and Origin of  Splenius muscle
Figure 10. Trajectory of approach and relationships of the surrounding muscles to Splenius capitis
   
 

 

Figure 11. Sequential removal of muscles of the neck. Trapezius and sternocleidomastoid muscles removed showing splenius occupying the floor of the posterior triangle of the neck.

 

 

Figure  12. Ultrasound view of the muscles of the neck at the C4 level

From: Fietzek UM, Nene D, Schramm A, Appel-Cresswell S, Košutzká Z, Walter U, Wissel J, Berweck S, Chouinard S, Bäumer T. The Role of Ultrasound for the Personalized Botulinum Toxin Treatment of Cervical Dystonia. Toxins (Basel). 2021 May 20;13(5):365.

 

Video 3. Injection of splenius capitis with ultrasound guidance.

(vv)Splenius.mp4(tt)

 

Figure 13. Relationships of splenius capitis to related muscles

 

 

 


 

 SPLENIUS CERVICIS

 

Anatomy: splenius cervicis, viewed from posteriorly  
   
Figure 14. Relationships of the surrounding muscles to Splenius cervicis

 

Figure  15. Ultrasound view of the neck at C4 level

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

References