Objective: Case report of a patient with a severe form of cervical dystonia (CD)

Background: Unsuccessful treatment with botulinum toxin of CD may result from inadequate muscle selection, mistargeting of selected muscles or insufficient doses. Injections assisted by ultrasound help ensure accurate delivery of the toxin, namely to deeper cervical muscles.

Methods: Clinical evaluation and botulinum toxin treatment of a 56-year-old woman, with cervical dystonia (CD). There was no relevant personal or familial history pertaining to dystonia. The patient gave a history of a head tremor with insidious onset and progressive worsening over the past 4 years, evolving into a permanent and disabling involuntary leftward head turn. The patient complained of severe neck pain and reported great difficulties in performing her professional tasks and daily household chores.

Results: On observation, there were a mild left-sided head tilt and what was then interpreted as a severe left torticollis. A geste antagoniste was present. An etiological investigation was negative for secondary causes of dystonia. A diagnosis of idiopathic CD was assumed. Clonazepan and biperidene had been ineffective. Treatment with abobotulinumtoxinA of the right sternocleidomastoideus (up to 200U), left splenius capitis (up to 500U) and left trapezius muscles (up to 200U) resulted in no benefit and no adverse events. Efficacy of botulinum toxin was confirmed by testing one of the frontalis muscles. A referral for deep brain stimulation (DBS) surgery was considered, but on a subsequent reassessment a pattern of predominant torticaput was identified. Additional injections into the left obliquus capitis inferior muscle under ultrasound (US) guidance resulted in major improvement in dystonia. Pain improved significantly with injections to the left levator scapulae. These changes enabled a reduction of the amount of toxin administered to other injected muscles. Functional improvement after dose optimization was 70% (as reported by patient); a complete remission of cervical pain was achieved. There were no adverse events.

Conclusions: The present case illustrates the importance of a correct evaluation of the pattern of CD, as well as the usefulness of US guidance for targeting short, deep-seated muscles of the cranio-cervical junction which may play a major role in dystonic postures. Ultimately, the need for invasive procedures such as DBS may be avoided.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/usefulness-of-ultrasound-guided-botulinum-toxin-injections-in-a-case-of-cervical-dystonia/