Neurology, Neuropsychiatry, Psychosomatics

Advanced search

Novel approaches to the treatment of cervical dystonia. The concept of dual navigation control

Full Text:


Сervical dystonia (CD) is the most common type of focal dystonia (up to 50% of all dystonia cases). Botulinum neurotoxin (BoNT) injections is the treatment choice for CD. However, the effectiveness and tolerability of botulinum therapy in CD depends on the correct choice of target muscles and the accuracy of the BoNT injection. The publication presents literature data and our own clinical experience regarding the use of navigation in BoNT injections in CD.
According to the majority of authors, the use of navigation equipment, such as ultrasound (US) and electromyography (EMG), definitely increases the effectiveness of CD treatment and reduces the likelihood of adverse events. For the first time, an algorithm for the diagnosis and treatment of CD is proposed, based on the use of the method of «double- (EMG and US) guided navigation», a variant for determining the comparative activity of muscles by the intensity of the EMG signal and the design of an individual «passport» of the CD. The possibilities of analyzing the US of muscles, drawing up an accurate treatment regimen, targeted administration of BoNT, and using a non-injectable EMG electrode are shown. We present 4 clinical cases demonstrating the advantages of the double- (EMG+US) guided navigation method over the EMG-guided navigation for injection. The proposed algorithm for the diagnosis and treatment of CD makes it possible to increase the effectiveness of treatment, optimize the costs of BoNT and diagnostic equipment (injection EMG needle).

About the Authors

A. P. Kovalenko
S.M. Kirov Military Medical Academy
Russian Federation

 6, Academician Lebedev St., Saint Petersburg 194044, Russia 

Z. A. Zalyalova
Kazan State Medical University, Ministry of Health of Russia
Russian Federation

 49, Butlerov St., Kazan 420012, Russia 

A. F. Ivolgin
A.A. Vishnevsky 3rd Central Military Clinical Hospital, Ministry of Defense of Russia
Russian Federation

  1, p. Noviy, Krasnogorsk 143420, Moscow region, Russia 


1. Zalialova ZA. Current classifications of dystonies, treatment strategy. Zhurnal nevrologii i psikhiatrii imeni S.S. Korsakova. 2013;113(3):85-9 (In Russ.).

2. Comella C, Bhatia K. An international survey of patients with cervical dystonia. J Neurol. 2015;262(4):837-48. doi: 10.1007/s00415-014-7586-2. Epub 2015 Jan 22.

3. Albanese A, Asmus F, Bhatia K, et al. EFNS guidelines on diagnosis and treatment of primary dystonias. Eur J Neurol. 2011 Jan;18(1):5-18. doi: 10.1111/j.1468-1331.2010.03042.x

4. Timerbayeva SL, editor. Azbuka botulinoterapii [The alphabet of botulinum therapy]. Moscow; 2014 (In Russ.).

5. Sethi K, Rodriguez R, Olayinka B. Satisfaction with botulinum toxin treatment: a cross-sectional survey of patients with cervical dystonia. J Med Econom. 2012;15(3):419-23. doi: 10.3111/13696998.2011.653726. Epub 2012 Jan 18.

6. Ivolgin AF, Avseitseva TYu. Cervical dystonia: ways to improve the effectiveness of botulinum therapy. Zhurnal nevrologii i psikhiatrii imeni S.S. Korsakova. 2020;120(6):137-43. doi: 10.17116/jnevro2020120061137 (In Russ.).

7. Zalyalova ZA, Iusupova ER. Rehabilitation approaches in cervical dystonia. Nevrologiya, neiropsikhiatriya, psikhosomatika = Neurology, Neuropsychiatry, Psychosomatics. 2021;13(4):103-8. doi: 10.14412/2074-2711-2021-4-103-108 (In Russ.).

8. Reichel G, Stenner A, Jahn A. The Phenomenology of Cervical Dystonia. Fortschr Neurol Psychiatr. 2009 May;77(5):272-7. doi: 10.1055/s-0028-1109416. Epub 2009 May 5.

9. Schnitzler A, Roche N, Denormandie P, et al. Manual Needle Placement: Accuracy of Botulinum Toxin A Injections. Muscle Nerve. 2012 Oct;46(4):531-4. doi: 10.1002/mus.23410

10. Santamato A, Micello MF, Panza F, et al. Can Botulinum Toxin Type A Injection Technique Influence the Clinical Outcome of Patients with Post-Stroke Upper Limb Spasticity? A Randomized Controlled Trial Comparing Manual Needle Placement and Ultrasound-Guided Injection Techniques. J Neurol Sci. 2014 Dec 15;347(1-2):39-43. doi: 10.1016/j.jns.2014.09.016. Epub 2014 Sep 19.

11. Castagna A, Albanese A. Management of cervical dystonia with botulinum neurotoxins and EMG/ultrasound guidance. Neurol Clin Pract. 2019 Feb;9(1):64-73. doi: 10.1212/CPJ.0000000000000568

12. O’Brien CF. Injection Techniques for Botulinum Toxin Using Electromyography and Electrical Stimulation. Muscle Nerve. 1997;6:S176-80. doi: 10.1002/(SICI)1097-4598(1997)6+<176::AID-MUS12>3.0.CO;2-4

13. Lee LH, Chang WN, Chang CT. The Finding and Evaluation of EMG-Guided BOTOX Injection in Cervical Dystonia. Acta Neurol Taiwan. 2004 Jun;13(2):71-6.

14. Werdelin L, Dalager T, FuglsangFrederiksen A, et al. The Utility of EMG Interference Pattern Analysis in Botulinum Toxin Treatment of Torticollis: A Randomised, Controlled and Blinded Study. Clin Neurophysiol. 2011 Nov;122(11):2305-9. doi: 10.1016/j.clinph.2011.04.012. Epub 2011 Jun 1.

15. Gelb DJ, Yoshimura DM, Olney RK, et al. Change in Pattern of Muscle Activity Following Botulinum Toxin Injections for Torticollis. Ann Neurol. 1991 Apr;29(4):370-6. doi: 10.1002/ana.410290407

16. Picelli A, Roncari L, Baldessarelli S, et al. Accuracy of Botulinum Toxin Type A Injection into the Forearm Muscles of Chronic Stroke Patients with Spastic Flexed Wrist and Clenched Fist: Manual Needle Placement Evaluated Using Ultrasonography. J Rehabil Med. 2014 Nov;46(10):1042-5. doi: 10.2340/16501977-1871

17. Ko YD, Yun SI, Ryoo D, et al. Accuracy of Ultrasound-Guided and Non-Guided Botulinum Toxin Injection into Neck Muscles Involved in Cervical Dystonia: A Cadaveric Study. Ann Rehabil Med. 2020 Oct;44(5):370-7. doi: 10.5535/arm.19211. Epub 2020 Sep 28.

18. Picelli A, Bonetti P, Fontana C, et al. Accuracy of Botulinum Toxin Type A Injection into the Gastrocnemius Muscle of Adults with Spastic Equinus: Manual Needle Placement and Electrical Stimulation Guidance Compared Using Ultrasonography. J Rehabil Med. 2012 May;44(5):450-2. doi: 10.2340/16501977-0970

19. Stenner A, Reiche G. A New Classification of Cervical Dystonia for Botulinum Toxin Therapy: The Col Cap Concept. Movement Disord. 2015;357:e288. doi: 10.1016/j.jns.2015.08.1006

20. Tsui JK. Cervical Dystonia. In: Tsui JK, Calne D, editors. Handbook of Dystonia. New York: Marcel Dekker, Inc.; 1995. P. 115-27.

21. Walter U, Dressler D. Ultrasound-Guided Botulinum Toxin Injections in Neurology: Technique, Indications and Future Perspectives. Expert Rev Neurother. 2014 Aug;14(8):923-36. doi: 10.1586/14737175.2014.936387. Epub 2014 Jul 21.

22. Kovalenko AP, Misikov VK. Atlas ul'trazvukovoy vizualizatsii myshts dlya botulinoterapii. Spastichnost'. Diagnostika i lecheniye: Metodicheskoye rukovodstvo [Atlas of ultrasound imaging of muscles for botulinum toxin therapy. Spasticity. Diagnosis and treatment: Methodological guidance]. Мoscow – St. Petersburg; 2020. 264 p. ISBN 978-5-9909968-0-9 (In Russ.).

23. Reimers K, Reimers CD, Wagner S, et al. Skeletal Muscle Sonography: A Correlative Study of Echogenicity and Morphology. J Ultrasound Med. 1993 Feb;12(2):73-7. doi: 10.7863/jum.1993.12.2.73

24. Pillen S, Tak RO, Zwarts MJ, et al. Skeletal Muscle Ultrasound: Correlation between Fibrous Tissue and Echo Intensity. Ultrasound Med Biol. 2009 Mar;35(3):443-6. doi: 10.1016/j.ultrasmedbio.2008.09.016. Epub 2008 Dec 10.

25. Reimers CD, Schlotter B, Eicke BM, Witt TN. Calf Enlargement in Neuromuscular Diseases: A Quantitative Ultrasound Study in 350 Patients and Review of the Literature. J Neurol Sci. 1996 Nov;143(1-2):46-56. doi: 10.1016/s0022-510x(96)00037-8

26. Franchi MV, Longo S, Mallinson J, et al. Muscle Thickness Correlates to Muscle CrossSectional Area in the Assessment of Strength Training-Induced Hypertrophy. Scand J Med Sci Sports. 2018 Mar;28(3):846-53. doi: 10.1111/sms.12961. Epub 2017 Sep 21.

27. Watanabe Y, Yamada Y, Fukumoto Y, et al. Echo Intensity Obtained from Ultrasonography Images Reflecting Muscle Strength in Elderly Men. Clin Interv Aging. 2013;8:993-8. doi: 10.2147/CIA.S47263. Epub 2013 Jul 25.

28. Gusev EI, Gekht AB, editors. Klinicheskiye rekomendatsii po diagnostike i lecheniyu distonii. Utverzhdeny resheniyem Prezidiuma Vserossiyskogo obshchestva nevrologov 17.06.2014 g. [Clinical practice guidelines for the diagnosis and treatment of dystonia. Approved by the decision of the Presidium of the All-Russian Society of Neurologists on June 17, 2014]. Moscow; 2014. 26 p. (In Russ.).

29. Allison SK, Odderson IR. Ultrasound and Electromyography Guidance for Injection of the Longus Colli With Botulinum Toxin for the Treatment of Cervical Dystonia. Ultrasound Q. 2016 Sep;32(3):302-6. doi: 10.1097/RUQ.0000000000000226

30. Farrell M, Karp BI, Kassavetis P, et al. Alter Management of Anterocapitis and Anterocollis: A Novel Ultrasound Guided Approach Combined with Electromyography for Botulinum Toxin Injection of Longus Colli and Longus Capitis. Toxins. 2020 Sep 30;12(10):626. doi: 10.3390/toxins12100626

31. Salazar G, Ferreiro S, Fragoso M, et al. Ultrasound and Electromyography as Guidance Tools for the Botulinum Toxin Therapy in Cervical Dystonia. J Behav Brain Sci. 2021 Feb;11(2):49-57. doi: 10.4236/jbbs.2021.112004

32. Trosch RM, Misra VP, Maisonobe P, Om S. Impact of abobotulinumtoxinA on the clinical features of cervical dystonia in routine practice. Clin Park Relat Disord. 2020 Jun 15;3:100063. doi: 10.1016/j.prdoa.2020.100063. eCollection 2020.

For citation:

Kovalenko A.P., Zalyalova Z.A., Ivolgin A.F. Novel approaches to the treatment of cervical dystonia. The concept of dual navigation control. Neurology, Neuropsychiatry, Psychosomatics. 2021;13(6):124-131.

Views: 61

Creative Commons License
This work is licensed under a Creative Commons Attribution 4.0 License.

ISSN 2074-2711 (Print)
ISSN 2310-1342 (Online)