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

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rtesyo

f G. R

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l

anterocaputanterocollis retrocollis retrocaput

Neck foldArticulatio atlantooccipitalis

Double chin

with

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personal photo by W. Jost with the approval of the patientwith courtesy of G. Reichel

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onal photo

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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.

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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

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M = stern

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= scalen

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A = trap

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L = sp

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CI = o

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= lon

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colli, LC

a= lo

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itisp

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Ma

= rectus cap

itisp

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S = o

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= carotid

artery, BP

= brach

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lexus, V

C5

= vertebra C

5, R

C5

= roo

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, 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

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personal ultrasound pictures by W. Jost

Lev

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personal ultrasound videos by W. Jost

Lev

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personal photo by W. Jost with the approval of the proband

personal ultrasound pictures by W. Jost

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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

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© Heitmann&Jost

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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