Journal of Neural Transmission

, Volume 125, Issue 7, pp 1037–1042 | Cite as

A simplified ultrasonography-guided approach for neurotoxin injection into the obliquus capitis inferior muscle in spasmodic torticollis

  • Uwe WalterEmail author
  • Ales Dudesek
  • Urban M. Fietzek
Neurology and Preclinical Neurological Studies - Original Article


The obliquus capitis inferior (OCI) muscle may be crucially involved in generating the tremulous component of spasmodic torticollis. This study was undertaken to evaluate the efficacy of a simplified ultrasonography-guided approach of botulinum neurotoxin injection into the OCI in the management of spasmodic torticollis. Here, a novel off-plane technique of ultrasonography-guided botulinum neurotoxin injection into the OCI is demonstrated on video. We investigated its effect in five patients with tremulous torticollis with only partial response to conventional injection technique not injecting OCI. On ultrasonography the OCI and its neighboring structures (greater occipital nerve, vertebrae C1 and C2) were clearly displayed. Unlike the previously proposed approach with axial OCI imaging and in-plane medio-lateral needle insertion, we applied here an off-plane needle insertion technique. With this, the ultrasonography guidance of needle insertion was easier using the sagittal imaging plane rather than the axial plane. Compared to botulinum neurotoxin injection into more superficial neck muscles only, additional ultrasonography-guided botulinum neurotoxin injection into the OCI led to a higher benefit (self-rated improvement of cervical dystonia, p = 0.026, Mann–Whitney test), especially of the tremulous component (p = 0.007), even though the total botulinum neurotoxin dose was not changed. We conclude that selected patients with tremulous torticollis may benefit from botulinum neurotoxin injection into the OCI.


Ultrasonography Intramuscular injection Neck muscles Cervical dystonia Botulinum toxin 


Compliance with ethical standards

Ethical standards

All procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Conflict of interest

U.W. has received speaker honoraria and travel reimbursement from Merz Pharma, Ipsen Pharma, Allergan, Bristol-Myers Squibb, Daiichi Sankyo, Bayer Vital and Pfizer, and a research grant from Merz Pharma. A.D. has received speaker honoraria and travel reimbursement from Merz Pharma and Ipsen Pharma. U.M.F. has received speaker honoraria and travel reimbursement from Merz Pharma, Ipsen Pharma, Allergan, Bayer Vital and Desitin.

Supplementary material

Video ESM1. The video shows the setting and procedure of ultrasonography- (US-) guidance (combined here with electromyography-guidance) of BoNT injection into the obliquus capitis inferior (OCI) muscle of a patient with spasmodic torticollis. 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 with moving the anterolateral part into upwards direction. Segment 3: For optimal display of the OCI muscle belly on sagittal imaging plane the ultrasound probe is twisted by 90 degree. 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. (MP4 19555 kb)

702_2018_1866_MOESM2_ESM.docx (23 kb)
Table ESM2. Clinical data, treatment protocols and outcome of the patients treated at the department of neurology, University of Rostock. (DOCX 22 kb)


  1. Albanese A, Asmus F, Bhatia KP, Elia AE, Elibol B, Filippini G, Gasser T, Krauss JK, Nardocci N, Newton A, Valls-Solé J (2011) EFNS guidelines on diagnosis and treatment of primary dystonias. Eur J Neurol 18:5–18CrossRefPubMedGoogle Scholar
  2. Bexander CS, Hodges PW (2012) Cervico-ocular coordination during neck rotation is distorted in people with whiplash-associated disorders. Exp Brain Res 217:67–77CrossRefPubMedGoogle Scholar
  3. Brin MF, Fahn S, Moskowitz C, Friedman A, Shale HM, Greene PE, Blitzer A, List T, Lange D, Lovelace RE, McMahon D (1987) Localized injections of botulinum toxin for the treatment of focal dystonia and hemifacial spasm. Mov Disord 2:237–254CrossRefPubMedGoogle Scholar
  4. Cho JC, Haun DW, Kettner NW, Scali F, Clark TB (2010) Sonography of the normal greater occipital nerve and obliquus capitis inferior muscle. J Clin Ultrasound 38:299–304PubMedGoogle Scholar
  5. Consky ES, Basinki A, Belle L, Ranawaya R, Lang AE (1990) The Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS): assessment of validity and inter-rater reliability. Neurology 40(suppl 1):445Google Scholar
  6. Cordivari C, Misra VP, Vincent A, Catania S, Bhatia KP, Lees AJ (2006) Secondary nonresponsiveness to botulinum toxin A in cervical dystonia: the role of electromyogram-guided injections, botulinum toxin A antibody assay, and the extensor digitorum brevis test. Mov Disord 21:1737–1741CrossRefPubMedGoogle Scholar
  7. Dugailly PM, Sobczak S, Moiseev F et al (2011) Musculoskeletal modeling of the suboccipital spine: kinematics analysis, muscle lengths, and muscle moment arms during axial rotation and flexion extension. Spine (Phila Pa 1976) 36:E413–E422CrossRefGoogle Scholar
  8. Fietzek UM, Schroeder AS, Wissel J, Heinen F, Berweck S (2010) Split-screen video demonstration of sonography-guided muscle identification and injection of botulinum toxin. Mov Disord 25:2225–2228CrossRefPubMedGoogle Scholar
  9. Flowers JM, Hicklin LA, Marion MH (2011) Anterior and posterior sagittal shift in cervical dystonia: a clinical and electromyographic study, including a new EMG approach of the longus colli muscle. Mov Disord 26:2409–2414CrossRefPubMedGoogle Scholar
  10. Fujimoto H, Mezaki T, Yokoe M, Mochizuki H (2012) Sonographic guidance provides a low-risk approach to the longus colli muscle. Mov Disord 27:928–929CrossRefPubMedGoogle Scholar
  11. Greher M, Moriggl B, Curatolo M, Kirchmair L, Eichenberger U (2010) Sonographic visualization and ultrasound-guided blockade of the greater occipital nerve: a comparison of two selective techniques confirmed by anatomical dissection. Br J Anaesth 104:637–642CrossRefPubMedGoogle Scholar
  12. Hallgren RC, Andary MT, Wyman AJ, Rowan JJ (2008) A standardized protocol for needle placement in suboccipital muscles. Clin Anat 21:501–508CrossRefPubMedGoogle Scholar
  13. Hong JS, Sathe GG, Niyonkuru C, Munin MC (2012) Elimination of dysphagia using ultrasound guidance for botulinum toxin injections in cervical dystonia. Muscle Nerve 46:535–539CrossRefPubMedGoogle Scholar
  14. Huang L, Chen HX, Ding XD, Xiao HQ, Wang W, Wang H (2015) Efficacy analysis of ultrasound-guided local injection of botulinum toxin type A treatment with orthopedic joint brace in patients with cervical dystonia. Eur Rev Med Pharmacol Sci 19:1989–1993PubMedGoogle Scholar
  15. Kastler A, Onana Y, Comte A, Attyé A, Lajoie JL, Kastler B (2015) A simplified CT-guided approach for greater occipital nerve infiltration in the management of occipital neuralgia. Eur Radiol 25:2512–2518CrossRefPubMedGoogle Scholar
  16. Lee IH, Yoon YC, Sung DH, Kwon JW, Jung JY (2009) Initial experience with imaging-guided intramuscular botulinum toxin injection in patients with idiopathic cervical dystonia. AJR Am J Roentgenol 192:996–1001CrossRefPubMedGoogle Scholar
  17. Macchi V, Porzionato A, Morra A, D’Antoni AV, Tubbs RS, De Caro R (2014) Anatomico-radiologic study of the distribution of the suboccipital artery of Salmon. Clin Neurol Neurosurg 117:80–85CrossRefPubMedGoogle Scholar
  18. Marion MH, Humberstone M, Grunewald R, Wimalaratna S (2016) British Neurotoxin Network recommendations for managing cervical dystonia in patients with a poor response to botulinum toxin. Pract Neurol 16:288–295CrossRefPubMedPubMedCentralGoogle Scholar
  19. Mezaki T (2011) Clinical application of botulinum toxin. Brain Nerve 63:785–794PubMedGoogle Scholar
  20. Misra VP, Ehler E, Zakine B et al (2012) Factors influencing response to Botulinum toxin type A in patients with idiopathic cervical dystonia: results from an international observational study. BMJ Open 2:e000881CrossRefPubMedPubMedCentralGoogle Scholar
  21. Pontell ME, Scali F, Enix DE, Battaglia PJ, Marshall E (2013) Histological examination of the human obliquus capitis inferior myodural bridge. Ann Anat 195:522–526CrossRefPubMedGoogle Scholar
  22. Reichel G (2011) Cervical dystonia: a new phenomenological classification for botulinum toxin therapy. Basal Ganglia 1:5–12CrossRefGoogle Scholar
  23. Schramm A, Bäumer T, Fietzek U, Heitmann S, Walter U, Jost WH (2015) Relevance of sonography for botulinum toxin treatment of cervical dystonia: an expert statement. J Neural Transm (Vienna) 122:1457–1463CrossRefGoogle Scholar
  24. Schramm A, Huber D, Möbius C, Münchau A, Kohl Z, Bäumer T (2017) Involvement of obliquus capitis inferior muscle in dystonic head tremor. Parkinsonism Relat Disord 44:119–123CrossRefPubMedGoogle Scholar
  25. Simpson DM, Hallett M, Ashman EJ, Comella CL, Green MW, Gronseth GS, Armstrong MJ, Gloss D, Potrebic S, Jankovic J, Karp BP, Naumann M, So YT, Yablon SA (2016) Practice guideline update summary: botulinum neurotoxin for the treatment of blepharospasm, cervical dystonia, adult spasticity, and headache: Report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology 86:1818–1826CrossRefPubMedPubMedCentralGoogle Scholar
  26. Tatu L, Jost WH (2017) Anatomy and cervical dystonia: “Dysfunction follows form”. J Neural Transm (Vienna) 124:237–243CrossRefGoogle Scholar
  27. Tsui JK, Eisen A, Stoessl AJ, Calne S, Calne DB (1986) Double-blind study of botulinum toxin in spasmodic torticollis. Lancet 2:245–247CrossRefPubMedGoogle Scholar
  28. Walter U, Dressler D (2014) Ultrasound-guided botulinum toxin injections in neurology: technique, indications and future perspectives. Expert Rev Neurother 14:923–936CrossRefPubMedPubMedCentralGoogle Scholar
  29. Wissel J, Masuhr F, Schelosky L, Ebersbach G, Poewe W (1997) Quantitative assessment of botulinum toxin treatment in 43 patients with head tremor. Mov Disord 12:722–726CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Austria, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of NeurologyUniversity of RostockRostockGermany
  2. 2.Center for Parkinson’s Disease and Movement DisordersSchön Klinik München SchwabingMunichGermany

Personalised recommendations