Dystonia

INDEX

Laterocollis, Laterocaput & Lateral shift

 

 

                           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 

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

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

 


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)
     

 

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.
 

 


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.