Dystonia

INDEX

Retrocollis & Retrocaput

 

                       Retrocollis                                                      Retrocaput                                          Backward Sagittal Shift

 

Retrocollis
The neck is tilted backwards in relation to the thoracic spine; the angle between the neck and head is normal1

Retrocaput
The head is tilted backwards at an angle on the neck; the angle between the cervical and thoracic spine is normal1.

Distinguishing retrocaput and and retrocollis
Analysis of backward flexion (differentiation between retrocollis and retrocaput) can be accomplished by observation from the side of the respective angles between the cervical  and thoracic spine (retrocollis), and between the cervical spine and the base of skull (retrocaput)2.

In cases of severe retrocollis, it is difficult, in practice, to distinguish the extension of the cervical spine (hyperlordosis) from the extension of the head on cervical spine. In that case, it may be more important to choose a high dose of botulinum toxin and an appropriate needle for deeper injection rather than to try to distinguish each muscle of the posterior cervical region during the injections as all the posterior cervical muscles can be involved in the extension3.

Figure 1. Patient with severe retrocollis. 

From: Srinivasan,S. (2019, August,2). Severe retrocollis with trunk dystonia (Video). YouTube. https://www.youtube.com/watch?v=5-tv9pkQ7TA and Cooper IS. Effect of Thalamic Lesions upon Torticollis. N Engl J Med 1964; 270: 967–72.

 

RETROCOLLIS

Figure 2. A patient with retrocollis. 

 

Patient Image

From: Reichel G. Cervical dystonia: A new phenomenological classification for botulinum toxin therapy. Basal Ganglia [Internet] 2011;1(1):5–12. 


TREATMENT

Semispinalis Capitis   2 x 7.5 u; Max 50 u Botox;2 x 30-40; Max 200 u Dysport

And/or splenius capitis    Bilateral 2 x 10-12.5 u; Max 20 u Botox; 2 x 40-50;  Max 2 x 80 u Dysport

Alternative scheme: Bilateral Semispinalis Cervicis (After: Jost WH, Tatu L. Selection of Muscles for Botulinum Toxin Injections in Cervical Dystonia. Mov Disord Clin Pract 2015;2(3):224–6): 

 

 

RETROCAPUT

Figure 3. A patient with retrocaput.

 

Patient Image

From: Reichel G. Cervical dystonia: A new phenomenological classification for botulinum toxin therapy. Basal Ganglia [Internet] 2011;1(1):5–12. 


TREATMENT

Bilateral  (After: Jost WH, Tatu L. Selection of Muscles for Botulinum Toxin Injections in Cervical Dystonia. Mov Disord Clin Pract 2015;2(3):224–6)

1. Obliquus Capitis Inferior
2. Semispinalis Capitis
3. Trapezius (pars descendens)
4. Splenius Capitis

Additional Muscles to consider:

Rectus capitis major
Obliquus capitis superior
Longissimus capitis
Sternocleidomastoid

 

 

 

 

 

 

References

1.          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

2.        Reichel G. Dystonias of the Neck: Clinico-Radiologic Correlations [Internet]. In: Dystonia - The Many Facets. InTech; 2012. Available from: http://www.intechopen.com/books/dystonia-the-many-facets/dystonias-of-the-neck-clinico-radiologic-correlations

3.          Marion MH, Humberstone M, Grunewald R, Wimalaratna S. British neurotoxin network recommendations for managing cervical dystonia in patients with a poor response to botulinum toxin. Pract Neurol 2016;16(4):288–95.