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Dystonia

Deep

8.1.8.1 Anterior
8.1.8.2 Superficial
8.1.8.3 Intermediate

LONGISSIMUS CAPITIS LONGISSIMUS CERVICIS RECTUS CAPITIS POSTERIOR MAJOR SEMISPINALIS CERVICIS SEMISPINALIS CAPITIS

OCI

Origin: posterior spinous process and adjacent lamina of axis.
Insertion: transverse process of atlas
Action: rotates atlas upon axis, thereby rotating head to same side.

The almost horizontal obliquus capitis inferior (OCI) is inserted on the transverse process of the atlas and originates from the spinous process of the axis (C2). It contributes to head movement related to fast visual exploration.
OCI is the biggest suboccipital muscle and is the 2nd strongest head rotator (after the sternocleidomastoid).

The depth from the skin to the superficial fascia of the muscle ranges from about 10 mm to over 35 mm. The muscle thickness also has a wide degree of variability, ranging from 10 to 20 mm, and when it contracts, its thickness increases and the length shortens.

Figure 1. Relationships of the OCI muscle

From: Dr. Joe Muscolino. www.learnmuscles.com – art work Giovanni Rimasti

Lateral view of the termination of the vertebral artery

Figure 2. Trajectory of approach and relationships of the surrounding muscles to OCI

Figure 3. Ultrasound image of the muscles of the neck at the level of the atlas and axis (C1 and C2).

From: Fietzek UM, Nene D, Schramm A, Appel-Cresswell S, Košutzká Z, Walter U, Wissel J, Berweck S, Chouinard S, Bäumer T. The Role of Ultrasound for the Personalized Botulinum Toxin Treatment of Cervical Dystonia. Toxins (Basel). 2021 May 20;13(5):365.

Figure 4. Three different approaches to use of ultrasound for injection of OCI

Three different approaches to injection of OCI
A: In plane technique
B: Out of plane technique
C: Sagittal approach: out of plane approach.

TRA: Trapezius; SPL: Splenius; SSC: Semispinalis capitis; RCPM: Rectus capitis posterior major
White arrows indicate bone; red circle indicates possible site of vertebral artery. Triangle: Greater occipital nerve
Dashed line (E and F) indicates potential path of the needle

From: Walter U, Dudesek A, Fietzek UM. A simplified ultrasonography-guided approach for neurotoxin injection into the obliquus capitis inferior muscle in spasmodic torticollis. J Neural Transm (Vienna). 2018 Jul;125(7):1037-1042.

Video 1. Injection of OCI with ultrasound guidance

(vv)OCI.mp4(tt)

Video 2. Injection of OCI with ultrasound guidance. Sagittal out of plane approach

(vv)OCIfietz.mp4(tt)

Segment 1: The initial positioning of the ultrasound probe at the patient’s neck is demonstrated. After visualization of the processus spinosus of vertebra C4 the ultrasound probe is shifted in cranial direction in order to display the OCI at the level of vertebra C1. Segment 2: For full display of the OCI muscle on axial imaging plane the ultrasound probe is shifted in medio-lateral direction and slightly twisted, moving the anterolateral part in an upwards direction.
Segment 3: For optimal display of the OCI muscle belly on sagittal imaging plane the ultrasound probe is rotated by 90 degrees.
Segment 4: The US-guided insertion of the injection needle (here connected to an electromyography machine) is presented. The needle tip is visible on the screen. Note the electromyography noise demonstrating dystonic activity of the OCI muscle. During the injection of the BoNT the electromyography noise disappears.

From: Walter U, Dudesek A, Fietzek UM. A simplified ultrasonography-guided approach for neurotoxin injection into the obliquus capitis inferior muscle in spasmodic torticollis. J Neural Transm (Vienna). 2018 Jul;125(7):1037-1042.

LONGISSIMUS CAPITIS

Origin: posterior surface of transverse processes of T1 to T6
Insertion: posterior margin of mastoid process and the temporal bone. The insertion is deep to that of the sternocleidomastoid and splenius muscles.
Action: Acting bilaterally, extends and hyperextends head
Acting unilaterally, flexes and rotates the head ipsilaterall (ipsiversion). The rotation is ipsilateral, and rotation of the head takes place at the atlanto-axial joint.

Figure 5. Relationships of the surrounding muscles to Longissimus Capitis

Anatomy: Insertion and Origin of Longissimus capitis muscle

Figure 6. Sequential layers removed from superficial to deep: Trapezius, and then splenius capitis with longissimus capitis lying deep to splenius capitis.

Ultrasound approach for Longissimus capitis muscle

From: Mezaki T. Ultrasoundâ€guided botulinum toxin therapy for deep muscles in cervical dystonia. Neurol Clin Neurosci 2020; 8: 3–10.

Figure 7. Ultrasound image at C4 level

From: Fietzek UM, Nene D, Schramm A, Appel-Cresswell S, Košutzká Z, Walter U, Wissel J, Berweck S, Chouinard S, Bäumer T. The Role of Ultrasound for the Personalized Botulinum Toxin Treatment of Cervical Dystonia. Toxins (Basel). 2021 May 20;13(5):365.

Figure 8. Posterior muscles of the neck, and their relations to longissimus capitis.

Note that in the figure on the right, splenius capitis is transparent, allowing for the longissimus capitis to be seen deep to splenius.

The longissimus capitis lies between the longissimus cervicis (which is directly lateral to it) and the splenius capitis (which is directly medial to it).

LONGISSIMUS CERVICIS

Origin: Transverse processes of the first 5 thoracic vertabrae
The transverse process attachment of the levator scapulae is anterior to the transverse process attachment of the splenius cervicis and directly superficial (posterior) to the transverse process attachment of the scalenes.
Insertion: Posterior tubercles of the transverse processes of C2-C5
Action: Bilateral contraction leads to extension of the neck.
Unilateral contraction causes lateral flexion and rotation of the head ipsilaterally

Figure 9. Ultrasound image at C4 level

From: Fietzek UM, Nene D, Schramm A, Appel-Cresswell S, Košutzká Z, Walter U, Wissel J, Berweck S, Chouinard S, Bäumer T. The Role of Ultrasound for the Personalized Botulinum Toxin Treatment of Cervical Dystonia. Toxins (Basel). 2021 May 20;13(5):365.

RECTUS CAPITIS POSTERIOR MAJOR

Origin: posterior tubercle of atlas.
Insertion: medial portion of occipital bone below inferior nuchal line.
Action: extends head.
Rotates head to same side.

Anatomy: insertion and origin of rectus capitis posterior major

SEMISPINALIS CERVICIS

Origin: Transverse processes of T1-T6
Insertion: Spinous processes of C2-C5
Action: Bilateral contraction leads to extension of the neck.
Unilateral contraction causes lateral flexion ipsilaterally and contralateral rotation

Figure 10. Relationships of the surrounding muscles to Semispinalis cervicis

Figure 11. Ultrasound image of the neck at C4

From: Fietzek UM, Nene D, Schramm A, Appel-Cresswell S, Košutzká Z, Walter U, Wissel J, Berweck S, Chouinard S, Bäumer T. The Role of Ultrasound for the Personalized Botulinum Toxin Treatment of Cervical Dystonia. Toxins (Basel). 2021 May 20;13(5):365.

SEMISPINALIS CAPITIS

Origin: transverse processes of the lower four cervical and upper six or seven thoracic vertebrae (C4–T7).
Insertion: between the superior and inferior nuchal lines of the occipital bone.
Action: Bilateral contraction leads to extension of the neck.
Unilateral contraction causes contralateral rotation

Figure 12. Trajectory of approach and relationships of the surrounding muscles to Semispinalis capitis

Figure 13. Ultrasound image of the neck at C4

From: Fietzek UM, Nene D, Schramm A, Appel-Cresswell S, Košutzká Z, Walter U, Wissel J, Berweck S, Chouinard S, Bäumer T. The Role of Ultrasound for the Personalized Botulinum Toxin Treatment of Cervical Dystonia. Toxins (Basel). 2021 May 20;13(5):365.

Video 2. Ultrasound guided injection of semispinalis

(vv)semispinalis capitis.mp4(tt)

Figure 14 Sequential removal of muscles of the neck

1. Trapezius and sternocleidomastoid muscles removed
2. Splenius removed.
3. Longissimus capitis and cervicis removed.
4. Levator scapulae removed showing semispinalis capitis.

Dystonia

Deep

References