Techniques for Bont Injection- EMG Vs US Vs Palpation

Techniques for BoNT injection- EMG vs US vs Palpation

Wolfgang Jost, Dept. of Neurology, University of Freiburg, Parkinson-Klinik Ortenau, Wolfach Disclosure: WH Jost is consultant and speaker for Allergan/Abbvie, Ipsen and Merz Col-Cap – Classification of cervical dystonia Head and neck movements: old school

Transverse plane Coronal plane Sagittal plane Rotation Lateroflexion Ante-retro flexion

Jost W. Atlas of Botulinum Toxin Injection. KVM-Verlag, Berlin, 2019 Tatu L, Jost W. Anatomy and cervical dystonia: “Dysfunction follows form” J Neural Transm 2017; 124: 237-243 Head and neck movements: „new“ school The head-neck complex

Anatomic basics of the Col-Cap concept

Tatu L, Jost W. Anatomy and cervical dystonia: “Dysfunction follows form” J Neural Transm 2017; 124: 237-243 Laterocollis: Anterocollis: ipsilateral bilateral M. levator scapulae (M) M. scalenus medius (M) M. semispinalis cervicis (M) M. levator scapulae (M) M. scalenus medius (S) M. longus colli (S) M. longissimus cervicis (S)

Torticollis: Lateral shift: ipsilateral Combination of laterocollis to M. semispinalis cervicis (M) one side and laterocaput to M. levator scapulae (M) the opposite site M. splenius cervicis (S) Correspondent muscles M. longissimus cervicis (S)

Retrocoliis: bilateral M. semispinalis cervicis (M)

Laterocaput: Torticaput: Anterocaput: Retrocaput: Anterior shift: ipsilateral contralateral bilateral bilateral Combination of anterocollis M. sternocleidomastoideus (M) M. trapezius pars descendens (M) M. longus capitis (M) M. obliquus capitis inferior (M) and retrocaput M. trapezius pars descendens (M) M. sternocleidomastoideus (M) M. levator scapulae (M) M. semispinalis capitis (M) Correspondent muscles M. splenius capitis (M) M. semispinalis capitis pars med. (S) M. sternocleidomastoideus (S) M. trapezius pars descendens (M) M. semispinalis capitis (S) ipsilateral M. splenius capitis (S) M. longissimus capitis (S) M. obliquus capitis inferior (M) M. levator scapulae (S) M. longissimus capitis (S) M. splenius capitis (S) Jost WH, Tatu L. MDCP 2015 N=306 N=150 Torticaput

Torticaput

Torticaput Torticollis Latrocaput Torticollis Laterocaput Laterocollis Laterocollis Retrocaput Retrocollis Retrocaput Retrocollis Antecaput Antecaput Antecollis Shift Antecollis

Antecaput Antecollis Laterocaput Laterocollis Retrocaput Retrocollis Torticaput Torticollis Shift 1.6% (5) 2.6% (8) 16.7% (51) 9.8% (30) 4.6% (14) 2.9% (9) 49% (150) 8.8% (27) 3.9 (12)

Frequency of different subtypes of cervical dystonia Jost WH et al. J Neural Transm 2020; 127: 45-50 Clinical Approaches

- Clinical examination - Landmarks - Sonography - Electromyography 1. Active group Dystonic muscles Abnormal movements Posture

2. AntagonistAAgroup Passively stretched muscles « Tremor »

3. Compensatory group

Muscles in CD: general considerations

Tatu L, Jost W. Anatomy and cervical dystonia: “Dysfunction follows form” J Neural Transm 2017; 124: 237-243 with courtesy of G. Reichel Torticaput

Larynx

Torticollis

Torticollis Torticaput personal photo by W. Jost with the approval of the patient

Example of rotation Sternocleidomastoideus

with

courtesy of G. Reichel G. of

Laterocaput Laterocollis

with

courtesy of G. Reichel G. of

anterocollis anterocaput retrocollis retrocaput

Double chin Neck fold Articulatio atlantooccipitalis personal photo by W. Jost with the approval of the patient with courtesy of G. Reichel personal photo by W. Jost with the approval of the patient personal photo by W. Jost with the approval of the patient with courtesy of G. Reichel Retrocaput , Torticaput , Laterocollis Main subtype torticaput (n=150)

Antecaput Antecollis Laterocaput Laterocollis Retrocaput Retrocollis Torticaput Torticollis 4.7% 6.7% 46.0% 12.7% 20.7% 3.3% Ø 18.7%

Main subtype laterocaput (n=51)

Antecaput Antecollis Laterocaput Laterocollis Retrocaput Retrocollis Torticaput Torticollis 5.9% 15.7% Ø 33.3% 23.5% 0 45.1% 0

Main subtype laterocollis (n=30)

Antecaput Antecollis Laterocaput Laterocollis Retrocaput Retrocollis Torticaput Torticollis 3.3% 16.7% 67.7% Ø 16.7% 6.7% 46.7% 3.3%

Main subtype torticollis (n=27)

Antecaput Antecollis Laterocaput Laterocollis Retrocaput Retrocollis Torticaput Torticollis 7.4% 11.1% 22.2% 14.8% 7.4% 7.4% 51.8% Ø

Combinations of the main subtype with secondary and third subtype Jost WH et al. J Neural Transm 2020; 127: 45-50 SCM SM LS SsCap SsCer SCap SCer OCI Trap Long 79.1 11.1 48.7 38.2 22.9 83.0 6.9% 35.3 58.5 16.7 % % % % % % % % %

Frequency of injections (all patients) SCM: Sternocleidomastoideus; SM: Scalene muscles; LS: Levator scapulae; SsCap: Semispinalis capitis; SsCer: Semispinalis cervicis; SCap: Splenius capitis; SCer: Splenius cervicis; OCI: Obliquus capitis Inferior; Trap: Trapezius; Long: Longissimus All others: 20.1%

Involved muscles: frequency of injections

Jost WH et al. Neurol Neurochir Polska 2020

https://doi.org/10.5334/tohm.63 Hyperkinetic Botulinum 293 patients with idiopathic CD who were all treated with botulinum toxin (BTX). Pandey S, et al. in Tremor

Results: The dystonic head tremor (DHT+) was present in 57.6 % of CD patients and Toxin Toxin Treatment they had a significantly longer duration of symptoms than patients without head Movements tremor (DHT–).

In DHT+ patients torticaput was the most common subtype and the majority

. 2020; 10(1): 13, pp. 1 13, 10(1): 2020; . Idiopathic (63.3%) had one or two subtypes only. There was no significant difference between Considering

the number of unilateral injections for any of the muscles in the DHT+ and DHT– Cervical

groups, while the number of patients receiving bilateral injections were the Col

significantly more in the DHT+ group. The mean doses of all three types of BTX/A Dystonia

Cap –

were not significantly different between the two groups. 8. DOI:

Classification – Conclusions: The frequency of head tremor was 57.6% in our CD Possible and torticaput was the most common subtype associated with tremor.

patients Implications . Tremor and Other Simple forms of CD seemed more likely associated with head tremor, than complex forms of CD. Most of the DHT+ patients received bilateral injections. The use of ‘ColCap’ classification was helpful in the identification of muscles likely to be for involved in tremor in CD patients. Anatomic landmarks

C2 level: Close to the midline

C4-C5 level: 2-3 cm near to the midline

Improves the precision of injection - Accuracy of placement - Improves thereby safety and efficacy - Allows standardization - Teaching

Peter Hall on twitter

Schramm A, et al. Relevance of sonography for botulinum toxin treatment of cervical dystonia an expert recommendation. J Neural Transm 2015; 122: 1457-63 Muscles: IH = infrahyoid, SCM = sternocleidomastoideus, , SA = scalenus anterior, SMP = scalenus medius posterior, LEV = levator scapulae, TRA = trapezius, SEM = semispinalis capitis, SPL = splenius capitis, OCI = obliquus capitis inferior, LC = longissimus capitis, LCo = longus colli, LCa = longus capitis, RMi = rectus capitis posterior minor, RMa = rectus capitis posterior major, OCS = obliquus capitis superior. Other: CA = carotid artery, BP = brachial plexus, VC5 = vertebra C5, RC5 = root C5, VN = vagus nerve 63 - 2015; 122: 1457 122: 2015; Transm Relevance of sonography for botulinum toxin treatment of cervical dystonia an expert recommendation. J Neural J Neural recommendation. expert an cervical dystonia of treatment toxin botulinum for sonography of Relevance Schramm A, et al. al. et A, Schramm Sternocleidomastoideus

Levator scapulae

personal ultrasound pictures by W. Jost

Levator scapulae

personal ultrasound videos by W. Jost M. obliquus capitis inf.

personal ultrasound pictures by W. Jost

Verlag, Berlin, 2019 Berlin, Verlag, -

personal photo by W. Jost with the approval of the proband Jost W. Atlas of Botulinum Toxin Injection. KVM Injection. Toxin Botulinumof Atlas W. Jost Longissimus capitis

personal ultrasound picture by W. Jost Electromyography Improves the precision of injection - accuracy of placement - Improves thereby safety and efficacy Identification of the target and the most active muscles EMG is well adapted in neurology - May differentiate between dystonic and non dystonic muscles

Tyślerowicz M, et al. Cervical dystonia - improving the effectiveness of botulinum toxin therapy. Neurol Neurochir Pol 2020; 54: 232-242 Wu C, Xue F, Chang W, et al. Botulinum toxin type A with or without needle electromyographic guidance in patients with cervical dystonia. Springerplus. 2016; 5(1): 1292, doi: 10.1186/s40064-016-2967-x Electromyography

© Heitmann&Jost personal photos by W. Jost with the approval of the patient personal photo by W. Jost with the approval of the patient • It is important to distinguish between neck and head types (–collis and –caput) because different groups of muscles are affected) • Visual observation and proper examination of the patient is usually sufficient • Sonography is indispensable • Electromyography is useful in complicated cases and in combination with sonography • Techniques for BoNT injection are EMG and US and Palpation

Reichel G. Cervical dystonia: A new phenomenological classification for botulinum toxin therapy. Basal Ganglia 2011; 1: 5-12 Jost WH, Tatu L. Selection of muscles for botulinum toxin injections in cervical dystonia. Mov Disord Clin Pract 2015; 224-226 Tatu L, Jost W. Anatomy and cervical dystonia: “Dysfunction follows form” J Neural Transm 2017; 124: 237-243 Tyślerowicz M, et al. Cervical dystonia - improving the effectiveness of botulinum toxin therapy. Neurol Neurochir Pol 2020; 54: 232-242