What are the treatment options for cervical dystonia?

Treatment Options for Cervical Dystonia

Botulinum toxin injections are the first-line treatment of choice for cervical dystonia, with established efficacy and safety even after long-term use. 1, 2

First-Line Treatment: Botulinum Toxin

Botulinum Toxin Options

• OnabotulinumtoxinA (Botox): Recommended dose of 135 units every 84 days, not to exceed 400 units 2
• IncobotulinumtoxinA (Xeomin): FDA-approved with demonstrated efficacy at doses of 120-240 units 3
• AbobotulinumtoxinA (Dysport): Recommended starting dose of 500 units, with option to increase to 1000 units if necessary 4

Administration Considerations

• Injection sites should be customized to the specific muscles involved in the dystonic posture
• Common muscles injected include:
  • Splenius capitis/semispinalis (median 48 units of Xeomin)
  • Sternocleidomastoid (median 25 units of Xeomin)
  • Trapezius (median 25 units of Xeomin)
  • Levator scapulae (median 25 units of Xeomin)
  • Scalene muscles (median 20 units of Xeomin) 3

Efficacy and Duration

• Botulinum toxin provides significant improvement in dystonia severity as measured by the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) 3
• Treatment effects typically last 3-4 months 5
• Recent long-term follow-up data shows sustained efficacy even after 25 years of repeated treatments 6

Safety Considerations

• Common side effects: Neck muscle weakness, dysphagia, voice changes 3, 4
• Serious but rare side effects: Severe dysphagia, breathing difficulties, spread of toxin effect 3
• Contraindications: Allergy to botulinum toxin 1
• Risk factors for complications include:
  • Smaller neck muscle mass
  • Bilateral sternocleidomastoid injections
  • Pre-existing swallowing or breathing difficulties 3

Adjunctive Treatments

Physical Therapy

• Should be offered alongside botulinum toxin injections to maximize functional outcomes 2, 7
• Beneficial components include:
  • EMG biofeedback training
  • Muscle elongation exercises
  • Postural training
  • Range of motion exercises 7

Preventive Measures

• Adequate hydration
• Voice rest to prevent strain
• Use of amplification in noisy environments
• Indoor air humidification
• Avoiding excessive throat clearing and coughing 1

Treatment Algorithm

1. Initial Assessment: Determine the specific pattern of dystonia (rotational, laterocollis, anterocollis, retrocollis)
2. First-Line Treatment: Botulinum toxin injection to affected muscles
   • Start with recommended doses (e.g., 120-135 units of Xeomin/Botox or 500 units of Dysport)
   • Target the most involved muscles based on clinical examination
3. Follow-up: Assess response at 4-6 weeks post-injection
4. Dose Adjustment: If inadequate response, consider increasing dose at next injection session
5. Maintenance: Continue injections every 12-16 weeks as needed
6. Adjunctive Care: Refer for physical therapy to improve range of motion and functional capacity

Special Considerations

• Early intervention with botulinum toxin may prevent long-term complications such as contractures and radiculopathy 5
• EMG guidance may allow for more precise injections, particularly in complex cases 8
• To maintain responsiveness over time, use the lowest effective dose at the longest tolerable interval 8

Botulinum toxin treatment has transformed the management of cervical dystonia from a difficult-to-treat condition to one with reliable, effective therapy that significantly improves quality of life, pain, and function.