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Wolfgang Jost, Dept. of Neurology, University of Freiburg, Parkinson-Klinik Ortenau, Wolfach
Techniques for BoNT injection-EMG vs US vs Palpation
Disclosure: WH Jost is consultant and speaker forAllergan/Abbvie, Ipsen and Merz
Col-Cap –
Classification of cervical dystonia
Transverse plane
RotationCoronal plane
LateroflexionSagittal plane
Ante-retro flexion
Tatu L, Jost W. Anatomy and cervical dystonia: “Dysfunction follows form” J Neural Transm 2017; 124: 237-243
Head and neck movements: old school
Jost W. Atlas of Botulinum Toxin Injection. KVM-Verlag, Berlin, 2019
Head and neck movements: „new“ school
The head-neck complex
Anatomic basics of
the Col-Cap concept
Tatu L, Jost W. Anatomy and cervical dystonia: “Dysfunction follows form” J Neural Transm 2017; 124: 237-243
Torticollis:ipsilateralM. semispinalis cervicis (M)M. levator scapulae (M)M. splenius cervicis (S)M. longissimus cervicis (S)
Torticaput:contralateralM. trapezius pars descendens (M)M. sternocleidomastoideus (M)M. semispinalis capitis pars med. (S)ipsilateralM. obliquus capitis inferior (M)M. longissimus capitis (S)M. splenius capitis (S)
Laterocollis:ipsilateralM. levator scapulae (M)M. semispinalis cervicis (M)M. scalenus medius (S)M. longissimus cervicis (S)
Laterocaput:ipsilateralM. sternocleidomastoideus (M)M. trapezius pars descendens (M)M. splenius capitis (M)M. semispinalis capitis (S)M. longissimus capitis (S)M. levator scapulae (S)
Anterocollis:bilateralM. scalenus medius (M)M. levator scapulae (M)M. longus colli (S)
Anterocaput:bilateralM. longus capitis (M)M. levator scapulae (M)M. sternocleidomastoideus (S)
Retrocoliis:bilateralM. semispinalis cervicis (M)
Retrocaput:bilateralM. obliquus capitis inferior (M)M. semispinalis capitis (M)M. trapezius pars descendens (M)M. splenius capitis (S)
Lateral shift:Combination of laterocollis toone side and laterocaput tothe opposite siteCorrespondent muscles
Anterior shift:Combination of anterocollisand retrocaputCorrespondent muscles
Jost WH, Tatu L. MDCP 2015
Torticaput Torticollis LatrocaputLaterocollis Retrocaput RetrocollisAntecaput Antecollis Shift
Torticaput
Antecaput Antecollis Laterocaput Laterocollis Retrocaput Retrocollis Torticaput Torticollis Shift
1.6% (5) 2.6% (8) 16.7% (51) 9.8% (30) 4.6% (14) 2.9% (9) 49% (150) 8.8% (27) 3.9 (12)
Torticaput
Torticollis Laterocaput LaterocollisRetrocaput Retrocollis AntecaputAntecollis
Jost WH et al. J Neural Transm 2020; 127: 45-50
N=306 N=150
Frequency of different subtypes of cervical dystonia
- Clinical examination
- Landmarks
- Sonography
- Electromyography
Clinical Approaches
AA
1. Active groupDystonic muscles
Abnormal movements
Posture
2. Antagonist groupPassively stretched muscles
« Tremor »
3. Compensatory group
Tatu L, Jost W. Anatomy and cervical dystonia: “Dysfunction follows form” J Neural Transm 2017; 124: 237-243
Muscles in CD: general considerations
Torticaput
Torticollis
Torticollis Torticaput
Larynx
with courtesy of G. Reichel
Example of rotation
personal photo by W. Jost with the approval of the patient
Sternocleidomastoideus
Laterocaput Laterocollis
with
cou
rtesyo
f G. R
eiche
l
anterocaputanterocollis retrocollis retrocaput
Neck foldArticulatio atlantooccipitalis
Double chin
with
cou
rtesyo
f G. R
eiche
l
personal photo by W. Jost with the approval of the patientwith courtesy of G. Reichel
pers
onal photo
by
W. Jost w
ith
the a
ppro
valof th
e p
atient
pers
onal p
hoto
by
W. J
ost w
ithth
e a
ppro
valof th
e p
atie
nt
with
cou
rtesyo
f G. R
eiche
l
Laterocollis, Torticaput, Retrocaput
Antecaput Antecollis Laterocaput Laterocollis Retrocaput Retrocollis Torticaput Torticollis
4.7% 6.7% 46.0% 12.7% 20.7% 3.3% Ø 18.7%
Main subtype torticaput (n=150)
Antecaput Antecollis Laterocaput Laterocollis Retrocaput Retrocollis Torticaput Torticollis
5.9% 15.7% Ø 33.3% 23.5% 0 45.1% 0
Main subtype laterocaput (n=51)
Main subtype laterocollis (n=30)
Antecaput Antecollis Laterocaput Laterocollis Retrocaput Retrocollis Torticaput Torticollis
3.3% 16.7% 67.7% Ø 16.7% 6.7% 46.7% 3.3%
Main subtype torticollis (n=27)
Antecaput Antecollis Laterocaput Laterocollis Retrocaput Retrocollis Torticaput Torticollis
7.4% 11.1% 22.2% 14.8% 7.4% 7.4% 51.8% Ø
Jost WH et al. J Neural Transm 2020; 127: 45-50Combinations of the main subtype with secondary and third subtype
Jost WH et al. Neurol Neurochir Polska 2020
Frequency of injections (all patients)
SCM: Sternocleidomastoideus; SM: Scalene muscles; LS: Levator scapulae; SsCap:
Semispinalis capitis; SsCer: Semispinalis cervicis; SCap: Splenius capitis; SCer:
Splenius cervicis; OCI: Obliquus capitis Inferior; Trap: Trapezius; Long: Longissimus
All others: 20.1%
Involved muscles: frequency of injections
SCM SM LS SsCap SsCer SCap SCer OCI Trap Long
79.1
%
11.1
%
48.7
%
38.2
%
22.9
%
83.0
%
6.9% 35.3
%
58.5
%
16.7
%
293 patients with idiopathic CD who were all treated with botulinum toxin (BTX). Results: The dystonic head tremor (DHT+) was present in 57.6 % of CD patients and they had a significantly longer duration of symptoms than patients without headtremor (DHT–). In DHT+ patients torticaput was the most common subtype and the majority(63.3%) had one or two subtypes only. There was no significant difference betweenthe number of unilateral injections for any of the muscles in the DHT+ and DHT–groups, while the number of patients receiving bilateral injections weresignificantly more in the DHT+ group. The mean doses of all three types of BTX/A were not significantly different between the two groups.
Conclusions: The frequency of head tremor was 57.6% in our CD patients and torticaput was the most common subtype associated with tremor.
Simple forms of CD seemed more likely associated with head tremor, than complexforms of CD. Most of the DHT+ patients received bilateral injections. The use of ‘ColCap’ classification was helpful in the identification of muscles likely to beinvolved in tremor in CD patients.
Pan
de
y S, et al. Tre
mo
r in Id
iop
athic
CervicalD
yston
ia–
Po
ssible
Imp
lication
sfo
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otu
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mTo
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Classificatio
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ther
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ents
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© Tatu&Jost
Anatomic landmarks
Superficial: TrapeziusMiddle: Semispinalis capitisDeep : OCI
© Tatu&Jost
C2 level: Close to the midline
Superficial: TrapeziusMiddle: Splenius capitis
Semispinalis capitisDeep: Semispinalis cervicis
© Tatu&Jost
C4-C5 level: 2-3 cm near to the midline
© Tatu&Jost
Semispinalis capitis
Improves the precision of injection- Accuracy of placement- Improves thereby safety and efficacy- Allows standardization- Teaching
Schramm A, et al. Relevance of sonography for botulinum toxin treatment of cervical dystonia an expert recommendation. J Neural Transm 2015; 122: 1457-63
Peter Hall on twitter
Sonography
Mu
scles: IH = in
frahyo
id, SC
M = stern
ocleid
om
astoid
eus, , SA
= scalen
us
anterio
r, SMP
= scalenu
sm
ediu
sp
osterio
r, LEV = levato
rscap
ulae, TR
A = trap
ezius, SEM
= semisp
inalis
capitis, SP
L = sp
leniu
s capitis, O
CI = o
bliq
uu
scap
itisin
ferior, LC
= lon
gissimu
scap
itis, LCo
= lon
gus
colli, LC
a= lo
ngu
scap
itis, RM
i= rectus cap
itisp
osterio
r min
or, R
Ma
= rectus cap
itisp
osterio
r majo
r, OC
S = o
bliq
uu
scap
itissu
perio
r. Oth
er: CA
= carotid
artery, BP
= brach
ial p
lexus, V
C5
= vertebra C
5, R
C5
= roo
t C5
, VN
= vagus
nerve
Schramm A, et al. Relevance of sonography for botulinum toxin treatment of cervical dystonia an expert recommendation. J Neural Transm 2015; 122: 1457-63
Sterno
cleido
masto
ideu
s
personal ultrasound pictures by W. Jost
Lev
ato
rsc
ap
ula
e
personal ultrasound videos by W. Jost
Lev
ato
rsc
ap
ula
e
personal photo by W. Jost with the approval of the proband
personal ultrasound pictures by W. Jost
Jo
st W
. A
tla
s o
f B
otu
linu
m T
oxin
In
jectio
n. K
VM
-Ve
rla
g, B
erlin
, 2
01
9
M. obliquus capitis inf.
personal ultrasound picture by W. Jost
Longissimus capitis
Improves the precision of injection- accuracy of placement- Improves thereby safety and efficacyIdentification of the target and the most activemusclesEMG is well adapted in neurology- May differentiate between dystonic and non dystonic musclesTyślerowicz M, et al. Cervical dystonia - improving the effectiveness of botulinum toxin therapy. Neurol Neurochir Pol 2020; 54: 232-242 Wu C, Xue F, Chang W, et al. Botulinum toxin type A with or without needle electromyographic guidance in patients with cervical dystonia. Springerplus. 2016; 5(1): 1292, doi: 10.1186/s40064-016-2967-x
Electromyography
© W.Jost
Electromyography
Ante
roco
llis:
Le
va
tor
scap
ula
e
Co
mb
inatio
n o
f EMG
un
d So
no
graph
y
© Heitmann&Jost
Co
mb
inatio
n o
f EMG
un
d So
no
graph
y
personal photos by W. Jost with the approval of the patient
personal photo by W. Jost with the approval of the patient
• It is important to distinguish between neck and head types (–collisand –caput) because different groups of muscles are affected)
• Visual observation and proper examination of the patient is usually sufficient
• Sonography is indispensable
• Electromyography is useful in complicated cases and in combination with sonography
• Techniques for BoNT injection are EMG and US and Palpation
Reichel G. Cervical dystonia: A new phenomenological classification for botulinum toxin therapy. Basal Ganglia 2011; 1: 5-12
Jost WH, Tatu L. Selection of muscles for botulinum toxin injections in cervical dystonia. Mov Disord Clin Pract 2015; 224-226
Tatu L, Jost W. Anatomy and cervical dystonia: “Dysfunction follows form” J Neural Transm 2017; 124: 237-243
Tyślerowicz M, et al. Cervical dystonia - improving the effectiveness of botulinum toxin therapy. Neurol Neurochir Pol 2020; 54: 232-242
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