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Schematic representation of all forms of cervical dystonia: From the left: upper row – laterocaput, laterocollis, lateral shift; second row – torticaput, torticollis; third row – anterocaput, anterocollis, forward sagittal shift; bottom row – retrocaput, retrocollis. 

Schematic representation of all forms of cervical dystonia: From the left: upper row – laterocaput, laterocollis, lateral shift; second row – torticaput, torticollis; third row – anterocaput, anterocollis, forward sagittal shift; bottom row – retrocaput, retrocollis. 

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Context 1
... was a large study that was conducted to elucidate the characteristics of abnormal head and neck postures among patients with CD in order to maximize treatment outcomes with botulinum toxin. In contrast to the previously accepted classification of CD (four basic forms), our clinical and imaging findings support the differentiation of the disorder into 10 variations of posture and/or movement (Figure 8), which allows better delineation of the muscles involved in the particular form of CD (Table 4). Analyses of the prevalence of the characterized forms of CD in our study population revealed that, in the case of lateral flexion and rotation, the abnormal movement and/or posture involved only the head joints (latero- and/or torticaput) in approximately 20% of patients and only the region of the cervical spine (latero- and/or torticollis) in approximately a further 20% of patients. The remaining patients, approximately 60%, had both disorders, albeit with varying degrees of involvement of -caput and -collis. Thus, the incidence of these three forms represented a ratio of 1:1:3. A similar ratio of incidence was observed for forward and backward flexion forms involving the head joints (antero- and/or retrocaput) or the cervical spine (antero- and/or retrocollis) or both in our study ...

Citations

... Concerning the distribution of the target muscles, symmetrical participation of bilateral muscles is expected in RCD based on functional anatomy, and a bilateral injection scheme was also suggested by some researchers (12). Although most of our patients showed bilateral muscle activation, unilateral or asymmetric activation of cervical muscles also occurred. ...
... Our study results suggested that SPCa and SSCa, the two biggest posterior cervical muscles, were the most commonly involved, and both of them were bilaterally injected in the majority of the patients. This result was consistent with the aforementioned view of Reichel (12). In the study of Papapetropoulos et al., a bilateral injection was also applied to SPCa in the majority of patients, but their frequency of injection for SSCa was much lower than that in our study (33/34 vs. 4/53) (6). ...
... Although the main function of LS is to elevate the shoulder, bilateral contraction of LS could retract the head and neck (13), and this action is facilitated by TPZ because the bilateral contraction of the TPZ pars descendens causes an extension of the head and neck (14). Bilateral injection of TPZ pars descendens has been suggested in several investigations (3,6,12), whereas bilateral LS injection was suggested in only one study (6). ...
Article
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Introduction Retroform cervical dystonia (RCD), which includes retrocaput and retrocollis, is a rare form of cervical dystonia. Few reports have been published on RCD. The present study aimed to characterize the target muscles involved in RCD and the efficacy of botulinum toxin type A (BTX-A) injection. Methods Patients with consecutive cervical dystonia with RCD as the most problematic feature were retrospectively analyzed over a 10-year period. Target muscles were screened and confirmed based on clinical evaluation, single-photon emission computed tomography, and electromyography. In addition, efficacy and adverse events following BTX-A injection in patients with RCD were evaluated. Results A total of 34 patients with RCD were included, 18 of whom presented with retrocaput and 16 with retrocollis. The most frequently injected muscles in RCD were splenius capitis (SPCa, 97.1%) and semispinalis capitis (SSCa, 97.1%), followed by levator scapulae (LS, 50.0%), rectus capitis posterior major (RCPM, 47.1%), trapezius (TPZ, 41.2%), and sternocleidomastoid muscle (SCM, 41.2%). Besides cervical muscles, the erector spinae was also injected in 17.6% of patients. Most muscles were predominantly bilaterally injected. The injection schemes of retrocaput and retrocollis were similar, possibly because in patients with retrocollis, retrocaput was often combined. BTX-A injection achieved a satisfactory therapeutic effect in RCD, with an average symptom relief rate of 69.0 ± 16.7%. Mild dysphagia (17.6%) and posterior cervical muscle weakness (17.6%) were the most common adverse events. Conclusion SPCa, SSCa, LS, RCPM, LS, and SCM were commonly and often bilaterally injected in RCD. Patients with RCD could achieve satisfactory symptom relief after BTX-A injection.
... We found that the primary muscles involved were SCM, OCI, SPCa, LsCa, and TPZ, and the secondary muscles involved were Lev, scalenus, SPCe, and SmCa. Based on MRI measurements, Reichel summarized that the primary muscles involved in torticaput were SCM, TPZ, and OCI, and the secondary muscles were SPCa, SPCe, SmCa, and LsCa (Reichel 2012). ...
Article
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Torticaput is the most common primary form of cervical dystonia (CD). Obliquus capitis inferior (OCI) plays a major role in ipsilateral rotation of the head. The present study aimed to use single-photon emission computed tomography (SPECT/CT) to determine the involvement of OCI in torticaput and in torticaput associated with no–no tremor. We retrospectively analyzed the SPECT/CT images of 60 patients with torticaput as the main abnormal posture and ranked the affected muscles. The affected muscles in patients with no–no tremor were also ranked. The correlation between the radioactivity of OCI and the thickness of OCI measured by ultrasonography was analyzed. The agreement between SPECT/CT and electromyography in detecting OCI was also analyzed. After sternocleidomastoid muscle (81.7%), OCI was the second most affected muscle (70.0%) in torticaput, followed by splenius capitis (63.3%). In 23 patients with no–no tremor, OCI (78.3%) and sternocleidomastoid muscle (78.3%) were the most frequently affected muscles, followed by splenius capitis (69.6%). Furthermore, bilateral muscle involvement was commonly seen in patients with no–no tremor, especially for OCI (12/23) and sternocleidomastoid muscle (11/23). A positive correlation was found between the radioactivity and thickness of OCI (r = 0.330, P < 0.001). The total agreement rate between SPECT/CT and electromyography in the diagnosis of OCI excitement was 94.0%, with kappa value = 0.866 (P < 0.001). OCI plays a critical role in torticaput and no–no tremor. SPECT/CT could be a practical tool to help clinicians detect abnormally excited OCI.
... La déviation entraînée par la dystonie peut prendre diverses formes (Figures 1 à 4) : torticolis, latérocolis, rétrocolis, antécolis, et des combinaisons variables et complexes de ces différents mouvements sont souvent observées (7,8). Cinquante-quatre muscles influencent, en effet, la posture de la tête et du cou, et ceux- ...
Article
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Cervical dystonia is one of the most frequent form of focal dystonia. However, there's a great lack of awareness of this condition : a long delay to diagnosis is quite common and misdiagnosis is often seen. Nevertheless, this pathology is invalidating and improving diagnosis could have an impact on the treatment and the patient's quality of life.
... This is important because suboptimal muscle selection may be a leading cause of non-response to treatment (Ferreira et al., 2012). The importance of distinguishing between the different neck and head types of CD is increasingly recognized, since different groups of muscles are affected (Reichel, 2012). Tailored treatment requires appropriate training in how to inject all the various muscles involved in CD. ...
Article
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Botulinum toxin is a well-established treatment for a number of conditions involving muscle hyperactivity, such as focal dystonia and spastic paresis. However, current injection practice is not standardized and there is a clear need for structured training. An international group of experts in the management of patients with cervical dystonia (CD) and spastic paresis created a steering committee (SC). For each therapeutic area, the SC developed a core slide set on best practice, based on the literature. International sites of expertise were identified for training and courses were designed to include lectures and casebased learning. Where possible, courses received accreditation from the European Union of Medical Specialists (UEMS). Each course was peer reviewed by the SC, the UEMS accreditation board and the attendees themselves (through evaluation questionnaires). Attendees' feedback was shared with the SC and the trainers to tailor future training sessions. From the program launch in 2012 to December 2014, 328 physicians from 34 countries were trained in a total of 58 courses; 67% of the courses focused on spastic paresis and 33% on CD. Of the 225 (69%) physicians who completed feedback forms, 95% rated their course as 'above average/excellent' in meeting the preset learning objectives. Most (90%) physicians declared that attending a course would lead them to change their practice. The development of the 'Ixcellence Network' for continuous medical education in the fields of spastic paresis and CD has provided a novel and interactive way of training physicians with previous experience in botulinum toxin injection.
... Employing this imaging technique is based on the new phenomenological classification for CD by Reichel with reference to the position of the cervical vertebrae from the head position. Torticollis and laterocollis involves the same angle of rotation from across all cervical vertebrae; however, when there is torticaput or laterocaput, the base of the skull and C1 are on the same degree of rotation but differ from the rest of the cervical spine [48,49]. The challenge for the injector confronted with these movements is to target deeper and smaller muscles. ...
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Cervical dystonia (CD) is the most common focal dystonia that is characterized by involuntary contraction of cervical muscles causing abnormal head movements and postures. The treatment for CD was previously limited to oral medications, however, with consequent systemic side effects. In recent years, botulinum toxin (BoNT) has demonstrated efficacy in several studies and thus has received level A recommendation from both the American Academy of Neurology and the European Federation of Neurological Sciences in the treatment of dystonia. In many countries, it is the first‐line treatment for CD. There are four types of toxin approved for the use in CD, three type A [OnabotulinumtoxinA (OnaBoNTA), AbobotulinumtoxinA (AboBoNTA), and Incobotulinumtoxin A (IncoBoNTA)] and one type B [RimabotulinumtoxinB (RimaBoNTB)]. Proper selection of affected muscles and dose of toxin are important parameters in successfully providing symptomatic treatment. Good response rate is defined as improvement of more than 25 % from baseline using the Toronto Western Torticollis Rating Scale. The most common side effect of chemodenervation with BoNT for CD is dysphagia.
... Similarly, the patients may also have retrocaput and anterocollis causing anterior sagittal shift, resulting in a gooseneck posture. [5] Selection of muscles for injection of botulinum toxin in such patients is difficult and requires ultrasound (US) and electromyography (EMG) guidance. [6] We are reporting a patient with posterior sagittal shift type of cervical dystonia having a double-chin posture. ...
... In 1953, Hassler described the basic dystonic movements of the neck, Neurology India / May 2016 / Volume 64 / Issue 3 lateral shift (9%; n = 8), and sagittal shift (5%; n = 5). [5] They found that the most frequent form of complex cervical dystonia was lateral flexion with rotation (34%; n = 32) and the least common was posterior sagittal shift (1%; n = 1). The authors conducted this large, noninterventional study using clinical examination, CT, and MRI, with the overall aim of elucidating a more precise method of differentiating the different forms of head and neck postures in patients with cervical dystonia. ...
... This has been shown to be particularly true when injecting patients with complex dystonia involving deep-cervical muscles, which are notoriously difficult to inject [16]. To address this issue of technique, new CD classifications based on the precise positioning of the head and neck have been developed to aid the accurate targeting of the appropriate muscles for each patient's CD subtype [17]. However, the inclusion criteria of the present study should have avoided such technical issues as SNR patients had to have had insufficiently improved posture after three consecutive injection cycles (indicative of a long-term problem). ...
Article
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The development of secondary non-response (SNR) to botulinum neurotoxin type-A (BoNT-A) is considered a key issue in the management of cervical dystonia (CD). This case-controlled study was performed to systematically identify factors influencing SNR during BoNT-A therapy.Methods This was a retrospective, international, non-interventional study of CD patients. Patients with SNR were matched with up to three responder patients (control) on the basis of duration of therapy and number of injection cycles. Factors influencing the development of SNR were screened using a univariate logistic regression model and confirmed using a multivariate conditional logistic regression model.Results216 patients were enrolled, and 201 (SNR=52; responder=149) were matched and subdivided into blocks (doublets, triplets or quadruplets). At baseline, a significantly higher proportion of SNR patients had received previous or concomitant therapies (p=0.038) and surgery for CD (p=0.007) compared with controls. Although disease severity at onset was similar between groups, a significantly higher proportion of SNR patients experienced severe CD at the time of SNR compared with controls at the last documented visit. Multivariate analyses identified five factors that were significantly associated in predicting SNR (odds ratio [OR]>1 indicated higher chances for being SNR): previous surgical procedure for CD (OR 9.8, p=0.013), previous BoNT-A related severe adverse event (AE) (OR 5.6 p=0.027), physical therapy (OR 4.6, p=0.028), neuroleptic use (OR 3.3, p=0.019) and average BoNT-A dose (OR 2.7, p=0.010).Conclusions These findings suggest that SNR may not reflect true pharmacological resistance to BoNT-A therapy, but may be related to underlying disease severity.
Article
Zervikale Dystonien sind die häufigsten fokalen Dystonien. Botulinumtoxin (BoNT) ist das therapeutische Mittel der Wahl. Der apparativen Diagnostik muss eine gründliche allgemeine klinische neurologische Untersuchung sowie eine exakte phänomenologische Bewertung und Einteilung in eine der acht einfachen und drei zusammengesetzten Dystonieformen vorangestellt werden, die Basis für die Muskelauswahl zur BoNT-Behandlung sind.
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This was an international survey undertaken to assess cervical dystonia (CD) patients own perceptions of their illness and its management. A total of 1,071 self-identified respondents with CD in 38 countries completed the online survey between March and December 2012. The mean time since diagnosis was 9.6 years and over half (54 %) of patients surveyed were not diagnosed in the first year. When asked how the symptoms of CD affected them, two-thirds (66 %) of patients reported they experienced a lot of pain, and 61 % said that they suffered depression and mood alterations; only 7 % reported no impact on their lives. Despite problems with the diagnosis, almost 70 % of respondents reported being satisfied with the overall relationship with their doctor. Patient treatment expectations were high, with 63 % expecting freedom from spasms and 62 % expecting freedom from pain. Over half (53 %) expected to be able to return to a normal routine (53 %). The most common treatment reported was botulinum toxin (BoNT) (86 %), followed by oral medication (58 %) and physiotherapy/physical therapy (37 %). Among patients treated on BoNT, 56 % were fairly/very satisfied, 25 % were fairly/very dissatisfied and 20 % were neither satisfied nor dissatisfied with the outcome. In conclusion, this international survey highlights the broad impact of CD on several aspects of patient life. Taken overall, the survey suggests that that patients need to be better informed about their condition, treatments available and the limitations of those treatments. It may be that realistically managing patient expectations of treatment would reduce the dissatisfaction of some patients.