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Cervical Dystonia and Botulinum Toxin Therapy

Botulinum neurotoxin therapy in spasmodic torticollis.

Written by: Saygı Hospital Health Guide Editorial Board
Last updated:

This content has been compiled by the Saygı Hospital Health Guide Editorial Board and is periodically reviewed by a specialist physician.

References (5)

This content is for informational purposes only and does not constitute medical advice. You can book an appointment at our Nöroloji department. Book Appointment →

What is Cervical Dystonia and Botulinum Toxin Therapy?

Cervical dystonia (CD, spasmodic torticollis - ST) is a focal dystonia characterized by involuntary, sustained or intermittent contractions of cervical muscles, abnormal head-neck position, repetitive movements, and pain. It is the most common focal dystonia (prevalence 1.6/10,000), develops at average age 30-50 years, female:male = 2:1.

Clinical types based on direction: Torticollis (rotation, most common 50%), laterocollis (lateral tilt 15%), retrocollis (backward tilt 10%), anterocollis (forward tilt 10%), mixed type (30%). Head tremor in 60% (dystonic tremor or essential tremor + CD). Geste antagoniste (sensory trick) - touching the chin or face partially corrects posture, characteristic finding (in 70%).

Etiology: idiopathic (95%), genetic (DYT1/TOR1A, DYT6, DYT24/ANO3, DYT25/GNAL), secondary causes (drugs, post-stroke, post-traumatic, post-encephalitis, perinatal). Pathophysiology: imbalance of basal ganglia indirect-direct pathway, dysfunction of cerebellar-thalamic-cortical circuit. Treatment: botulinum neurotoxin injection (BoNT-A: onabotulinum, abobotulinum, incobotulinum; BoNT-B: rimabotulinum) - effect lasts 3-4 months, 70-80% response. Oral drugs (anticholinergic, benzodiazepine, baclofen) are limitedly effective. DBS (GPi) is an option in severe refractory cases.

Symptoms

Involuntary head-neck twisting, tilt, or pulling
Abnormal head posture (rotation, lateral, anterior, posterior)
Sustained or intermittent neck muscle contractions
Neck pain (60-75% - cervical disc, myofascial)
Head tremor (60% - dystonic or essential tremor)
Geste antagoniste (sensory trick, touching chin partially corrects)
Increase with stress and fatigue, decrease with rest
Sleep relieves symptoms (paradox)
Difficulty with daily activities (driving, eating, makeup)
Cervical spondylosis (long-term complication)
Anxiety, depression (psychosocial impact)

Risk Factors

Family history (genetic dystonia, autosomal-dominant)
Genetic mutations: DYT1, DYT6, DYT24, DYT25
Female sex (2:1)
Middle age (30-50)
Post-traumatic (whiplash, neck trauma)
Drug-induced: antiemetics (metoclopramide), antipsychotics
Post-stroke (basal ganglia involvement)
Post-encephalitis (autoimmune)
Anti-NMDA, anti-LGI1 antibodies
Other dystonia history (segmental, generalized progression)

When to See a Doctor?

If you experience any of the following symptoms, seek medical attention promptly:

  • Persistent abnormal neck-head position lasting more than 4 weeks
  • Persistent unexplained neck pain + posture abnormality
  • Sudden onset torticollis after head trauma
  • New onset dystonia after antiemetic-antipsychotic medication
  • Decline in daily life: difficulty driving, eating, working
  • Severe cervical pain + numbness in arm (cervical radiculopathy)
  • Familial cases + new onset dystonia symptoms
  • Loss of effect of botulinum toxin treatment (antibody)

Treatment Methods

01
Detailed neurologic examination + dystonia rating scale (TWSTRS)
02
Cervical MRI (secondary cause exclusion)
03
EMG-guided botulinum neurotoxin (BoNT) injection (gold standard):
04
- BoNT-A onabotulinumtoxin (Botox) 100-300 U total
05
- BoNT-A abobotulinumtoxin (Dysport) 250-1000 U
06
- BoNT-A incobotulinumtoxin (Xeomin)
07
- BoNT-B rimabotulinumtoxin (Myobloc) - if BoNT-A antibody
08
- Target muscles: SCM, splenius capitis, levator scapulae, trapezius, longissimus capitis
09
- Effect: 3-7 days start, peak 2-4 weeks, lasts 3-4 months
10
Oral medications (limited effect):
11
- Trihexyphenidyl 6-30 mg/day (anticholinergic, severe side effects)
12
- Baclofen 30-120 mg/day
13
- Clonazepam 1-6 mg/day
14
- Tetrabenazine (older drugs, limited)
15
Physiotherapy: stretching, posture exercise, biofeedback
16
Pain management: TENS, dry needling, trigger point injection
17
DBS (GPi or STN): severe refractory cases (>2 BoNT injection failure)
18
Selective peripheral denervation (Bertrand procedure - rarely)
19
Psychological support, support group, occupational therapy
20
Long-term follow-up: BoNT every 3-4 months repeat

Which Department to Visit?

You can visit our Nöroloji department for these complaints. Our specialist physicians will create the most suitable treatment plan for you.

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Health Disclaimer: The information on this page is prepared for general informational purposes only. It does not replace medical diagnosis and treatment. Please consult your physician for your complaints. Saygı Hospital does not accept responsibility for actions taken based on the information on this page.