M u s c u l o s k e l e t a l I m a g i n g • Te c h n i c a l I n n ov a t i o n

Lee et al.
Imaging-Guided Botulinum Toxin Injection for Cervical Dystonia

Musculoskeletal Imaging
Technical Innovation

Initial Experience with Imaging-

Guided Intramuscular Botulinum
Toxin Injection in Patients with
Idiopathic Cervical Dystonia
In Ho Lee1 OBJECTIVE. The objective of our study was to present our initial experiences of imag-
Young Cheol Yoon1 ing-guided intramuscular botulinum toxin (BTX) injection in patients with idiopathic cervi-
Duk Hyun Sung2 cal dystonia.
Jong Won Kwon1 CONCLUSION. Imaging-guided BTX injection is a useful treatment technique in pa-
Jee Young Jung1 tients with idiopathic cervical dystonia when target muscles are located deeply or an injection
must be delivered to a focal muscle area.
Lee IH, Yoon YC, Sung DH, Kwon JW, Jung JY

I
diopathic cervical dystonia is a ing imaging-guided intramuscular BTX in-
most common form of adult-on- jection in a patient with idiopathic cervical
set focal dystonia, which pres- dystonia has been reported [19]. Here we de-
ents with abnormal postures of scribe our experiences with imaging-guided
the neck, neck pain, and muscle hypertrophy intramuscular BTX administration in patients
and tremor [1–5]. Botulinum toxin (BTX) is with idiopathic cervical dystonia.
the first-line treatment of idiopathic cervical
dystonia and produces satisfactory symptom Materials and Methods
relief in more than 85% of cases [6–10]. Nev- Patient and Muscle Selection
ertheless, 15% of patients do not respond to Approval from the institutional review board
the BTX injection, and an abnormal head was obtained to review medical records and
and neck posture is not completely relieved radiologic images for research purposes. In all
in some patients despite partial symptom re- cases, written informed consent was obtained
lief after BTX administration. The most im- from patients or their parents before conducting
portant determinants of a favorable response the procedures.
to BTX treatment are the proper selection of Between October 2005 and April 2008, 14
the muscles involved and an appropriate dos- patients with idiopathic cervical dystonia visited
age [10]. Traditionally, BTX injections have our hospital. They were evaluated by a physician with
Keywords: botulinum toxin, cervical dystonia, PET/CT, been performed by muscle palpation, al- 15 years of experience who performed a clinical
sonography though electromyography (EMG) may be examination, including EMG, and classified dys­
DOI:10.2214/AJR.08.1535
helpful in some patients with obese necks or tonic posture. Additionally, patients underwent
when involved muscles are difficult to iden- PET/CT performed with a Discovery LS PET/CT
Received July 14, 2008; accepted after revision tify by palpation [11]. scanner (GE Healthcare). Whole-body CT from
October 20, 2008. Sometimes, however, even EMG may be head to thigh was performed with a continuous
1 unhelpful when deeply located muscles, such spiral technique on an 8-MDCT helical scanner
Department of Radiology and Center for Imaging
Science, Samsung Medical Center, Sungkyunkwan as the longus colli, are considered for BTX in- with the following parameters: 80 mAs, 140 keV,
University School of Medicine, 50 Ilwon-dong, jection. Therefore, we used PET/CT and clini- 5-mm section width, and table feed rate of 5 mm
Kangnam-ku, Seoul 135-710, Republic of Korea. Address cal physical examination to accurately select per rotation. Next, emission scanning was per­
correspondence to Y. C. Yoon ([email protected]). muscles. In addition, we considered that im- formed from head to thigh at 4 minutes per frame
2
Department of Physical Medicine and Rehabilitation,
aging guidance may be helpful for accurately 45 minutes after the IV administration of 370 MBq
Samsung Medical Center, Sungkyunkwan University and safely administering BTX when target of 18F-FDG. CT data were used for attenuation
School of Medicine, Seoul, Republic of Korea. muscles are deeply located. Imaging-guided correction, and PET images were reconstructed
intramuscular BTX has been previously used with an ordered-subsets expectation maximization
AJR 2009; 192:996–1001
in patients with pyriformis muscle syndrome algorithm (28 subsets, two iterations).
0361–803X/09/1924–996 [12, 13], sialorrhea [14, 15], cerebral palsy Muscles for BTX injection were selected after
[16, 17], and dysphagia [18]. However, to the considering abnormal posture type and EMG and
© American Roentgen Ray Society best of our knowledge, only one case involv- PET/CT findings. A physician delivered the EMG-

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 Imaging-Guided Botulinum Toxin Injection for Cervical Dystonia

guided BTX injections into selected muscles. muscles, they had been treated by EMG-guided and EMG-guided administrations were decided
When the selected muscle was located beyond the BTX injection at a clinician’s outpatient clinic by a clinician. The amount of injected BTX
expected coverage of the EMG-needle near an before performance of the imaging-guided BTX ranged from 20 to 90 IU for each muscle (mean,
important structure, such as the internal carotid injection. These eight patients underwent 27 41 IU). The dosage was intended not to exceed
artery, vertebral artery, pharynx, or spinal canal, sessions (range, 1–7 sessions; mean, 3.4 sessions) 400 IU in total, 50 IU per injection site, and 200
imaging-guided injection was considered. of EMG-guided BTX injections into 25 muscles. IU per large muscle group [20].
Accordingly, eight idiopathic cervical dystonia The number of injections was decided by a
patients (four men and four women; mean age, 36 clinician according to the number of affected Imaging-Guided BTX Injection
years; age range, 21–49 years) were referred to our muscles and the total amount of BTX needed. Imaging-guided injections were performed by a
department of radiology. Because these eight Botox (BTX, Allergan) was used throughout. musculoskeletal radiologist under sonographic
patients also had superficially located affected Total amounts injected for both imaging-guided (HDI 5000 or IU 22, Philips Healthcare) or CT

A B

C D E
Fig. 1—22-year-old woman (patient 5) with right rotatory torticollis and lateral torticollis, which were treated under electromyographic guidance.
A, Transverse PET/CT scan shows increased standardized uptake value (SUV) along course of right obliquus capitis inferior muscle (black arrow) and semispinalis
muscle (white arrow).
B, Sonogram of right superior and posterior neck shows right obliquus capitis inferior muscle (star).
C, Sonographic guidance was used to insert 25-gauge needle into midportion of right obliquus capitis inferior muscle (arrow).
D and E, Coronal reconstructed PET/CT scans obtained before treatment (D) and 4 weeks after sonographically guided botulinum toxin injection (E) at same level show
normalized SUV along course of right obliquus capitis inferior muscle (arrow, D).

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 Lee et al.

(LightSpeed Ultra 16, GE Healthcare) guidance. with 2–3 mL of 1% lidocaine. A 12-cm, 25-gauge of patients (patients 2 and 3) with increased
All treatments were performed as outpatient spinal needle was then introduced into the standardized uptake value (SUV) in the longus
procedures, and written informed consent was midportion of the targeted muscle under colli muscle because of a poor sonic window due
obtained from all patients. Sonographically guided sonographic guidance using a freehand technique. to the pharynx and for exact matching of the
injections were administered during seven sessions Prepared BTX was injected with continuous location of focal increased SUV shown in the
in six patients into the obliquus capitis inferior (six sonographic monitoring after confirming the involved muscles in a patient (patient 6). CT from
injections in six patients) and obliquus capitis location of the needle tip by infusing a small amount the skull base to the thoracic outlet was performed
superior (one injection) muscles (Table 1). In cases of normal saline as contrast material (Fig. 1). using the following parameters: beam width, 10
of the obliquus capitis inferior or obliquus capitis Postinjection sonography was also per­formed for mm; beam pitch, 1.375; and reconstruction
superior, patients were requested to lie prone and to detection of complications. thickness, 2.5 mm at 120 kV and 180 mA. When a
adopt a chin-to-chest position. Sonography exam­ CT-guided injections were performed during BTX injection was required in the longus colli
inations with a 12-MHz linear probe (HDI 5000 or six sessions in three patients into the longus colli muscle, the patient was asked to lie supine and to
IU 22) were performed to identify an adequate (two injections in two patients), oblique capitis rotate the head away from the affected side.
working plane showing the targeted muscle in its inferior (one injection), scalenus anterior (one Needle tracks and skin entry sites were decided
long axis. Subsequently, the predetermined skin injection), scalenus posterior (one injection), and using pretreatment CT images. To avoid injuries
entry site was marked. After shaving and draping levator scapulae (one injection) muscles (Table 1). to the pharynx and thyroid gland, the upper
the suboccipital area, we induced local anesthesia CT-guided injections were preferred in the cases portion of the longus colli was injected at the C-4

A B C
Fig. 2—21-year-old man (patient 2) with right rotatory torticollis, left lateral torticollis, and anterior torticollis, which were treated under electromyographic guidance.
A, Transverse PET/CT scan shows increased standardized uptake value at area of right longus colli muscle (black arrow) and splenius capitis muscle (white arrow), which
were treated under electromyographic guidance.
B, With CT guidance, 25-gauge needle was inserted into right longus colli muscle posterior to carotid space, and location of needle tip was confirmed by infusion of small
amount of contrast material.
C, Transverse CT scan obtained after botulinum toxin (BTX) injection into right longus colli muscle shows that mixture of contrast material, BTX, and small amount of
incidentally injected air are confined within right longus colli muscle.

TABLE 1:  Torticollis Pattern, Targeted Muscles, and the Amount of Botulinum Toxin (BTX) Injected in Eight Patients
Imaging-Guided BTX injection
Patient No. Age (y) Sex Torticollis Pattern Target Amount (IU) Guidance Type
1 27 M RC, right Right OCI 40 Sonography
2 21 M RC, right; LC, left; AC Right OCI; right Lc 40, 50 Sonography, CT; CT
3 43 M RC, left Left Lc, left OCI 20, 60 CT, CT
4 46 F RC, right; LC, right a Right OCI 90 Sonography
5 22 F RC, right; LC, righta Right OCI, left OCS 30, 20 Sonography, sonography
6 36 M LC, right a Left ScA, left ScP, right LS 50, 30, 20 CT, CT, CT
7 42 F RC, right; LC, left Right OCI 55 Sonography
8 49 F RC, right; AC Right OCI 30 Sonography
Note—RC = rotatory torticollis, LC = lateral torticollis, OCI = obliquus capitis inferior, AC = anterior torticollis, Lc = longus colli, OCS = obliquus capitis superior, ScA =
scalenus anterior, ScP = scalenus posterior.
aLC, right indicates that head was tilted to right side and neck was titled to left side relative to trunk.

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 Imaging-Guided Botulinum Toxin Injection for Cervical Dystonia

A B

C D

Fig. 3—36-year-old man (patient 6) with right lateral torticollis (head tilted to right, neck
tilted to left).
A and B, Transverse PET/CT scans show slightly increased standardized uptake value
(SUV) at area of left scalene anterior and posterior muscles (black arrows, A) and right
levator scapulae muscle (black arrow, B), which were considered to be responsible for
neck tilting to left side. Increased SUV along course of right sternocleidomastoideus
muscle (white arrow, A) was treated under electromyographic guidance.
C–E, With CT guidance, 25-gauge needle was inserted accurately into muscles with foci of
increased SUV on PET/CT scans, and botulinum toxin injections were performed.
E

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 Lee et al.

level and the lower portion at the C-6 level. Tracks contralateral lateral torticollis in one patient, ability, pain) scores decreased after injec-
lay posterior to the carotid sheath (Fig. 2). For lateral torticollis in one patient (right), and a tions (Table 2). Two of the eight patients un-
other selected muscles, we tried to place the needle combination (right rotatory torticollis, con- derwent follow-up PET/CT 4 weeks after the
tip precisely in regions of focal high SUV on PET/ tralateral lateral torticollis, and anterior tor- BTX injection, and SUVs in injected muscles
CT under CT guidance (Fig. 3). After draping the ticollis) in one patient. were found to have nearly normalized (Fig.
skin entry site, local anesthesia was induced using Thirteen BTX injections into 13 muscles of 1). A minor complication related to treat-
2–3 mL of 1% lidocaine. A 12-cm, 25-gauge the eight patients were performed under imag- ment occurred in a patient who underwent
spinal needle was introduced very carefully into ing guidance. The most common site of BTX CT-guided BTX injection into the longus
the target muscle under CT guidance and step-by- injection under imaging guidance was the colli muscle, namely, transient dysphagia.
step along the predetermined track. Injection of obliquus capitis inferior muscle (seven ses- However, this condition improved under con-
prepared BTX was performed after confirming sions in seven patients) followed by the longus servative management.
the needle tip location by infusing a small amount colli muscle (two sessions in two patients).
of contrast material. Postinjection CT was also The obliquus capitis superior, scalenus ante- Discussion
performed for detection of complications. rior, scalenus posterior, and levator scapulae BTX is now considered to be the most ef-
Technical success was defined as the injection muscles were injected once each. Five patients fective treatment of symptomatic idiopathic
of BTX into the targeted muscle. Clinical outcome (patients 1, 4, 5, 7, and 8) underwent sono- cervical dystonia [9, 23]. Nonresponsiveness
was assessed using the rating scale of Tsui et al. graphically guided BTX injections; two pa- to BTX treatment has various causes. Initial
[21] and the Toronto Western Spasmodic tients (patients 3 and 6) underwent CT-guided nonresponse can occur in cases of long-stand-
Torticollis Rating Scale (TWSTRS) [22]. Tsui BTX injections; and one patient (patient 2) ing disease, contractures, inadequate BTX
rating scale and TWSTRS scores were evaluated 4 underwent CT-guided and sonographically dose, incorrect targeting, or other artificial
weeks after the last BTX injection regardless of guided BTX injection. For injections into the factors such as improper BTX preparation.
the injection method used. Score reductions longus colli muscle (one session in patient 2 These factors are improved by EMG and thor-
([pretreatment – posttreatment] / pretreatment) and one session in patient 3), the obliquus ough preparation. Nevertheless, patients with
were calculated, and correlations of improvement capitis inferior muscle (one session in patient involvement of inaccessible, deep neck struc-
in Tsui and the three TWSTRS subscales between 3), and the scalenus anterior, scalenus poste- tures do not respond to BTX treatment [24].
pretreatment and posttreatment were evaluated. rior, and levator scapulae muscles (three ses- In addition, secondary nonresponsiveness is
sions in patient 6), CT guidance was chosen. known to be caused by antibody formation
Results Otherwise, sonographic guidance was pre- against BTX [25–30]. Finally, improper eval-
Details of involuntary movements, target- ferred because of its convenience. uations before and after treatment and chang-
ed muscles, and amounts of BTX injected A total of 13 sessions of BTX injection es in muscle patterns may also explain a lack
are listed in Table 1. Predominant directions (seven sonographically guided and six CT of response [24, 31, 32].
of involuntary movements were as follows: guided) were performed in eight patients, After CT-guided or sonographically guided
rotatory torticollis in two patients (right, one; and technical success was achieved in all intramuscular BTX injections, all eight pa-
left, one), rotatory torticollis and lateral tor- cases. After injections, all patients experi- tients included in this study experienced
ticollis in two patients (right, two), rotatory enced a reduction in pain and an improve- marked pain reduction and neck movement
torticollis and anterior torticollis in one pa- ment in neck movement. Therefore, Tsui improvement. Based on Tsui and TWSTRS
tient (right), right rotatory torticollis and score and TWSTRS subscale (severity, dis- subscale (severity, disability, pain) scores, the

TABLE 2:  Tsui Score and TWSTRS Score Before and After BTX Injection
TWSTRS Score
Tsui Score Severity Subscale Disability Subscale Pain Subscale
4-wk Reduction 4-wk Reduction 4-wk Reduction 4-wk Reduction
Patient No. Initial Follow-Up Ratea Initial Follow-Up Ratea Initial Follow-Up Ratea Initial Follow-Up Ratea
1 9 0 1.00 19 0 1.00 21 0 1.00 NA NA NA
2 14 3 0.79 23 3 0.87 20 9 0.55 NA NA NA
3 7 2 0.71 20 8 0.60 17 3 0.82 NA NA NA
4 15 1 0.93 19 6 0.68 24 15 0.38 17 5.5 0.68
5 14 2 0.86 18 6 0.67 23 9 0.61 14 6.5 0.54
6 10 1 0.90 15 3 0.80 9 5 0.44 13.75 8.25 0.4
7 17 2 0.88 28 11 0.61 28 11 0.61 16.75 9.00 0.46
8 8 1 0.88 18 5 0.72 18 4 0.78 4.00 3.25 0.19
Average 11.75 1.50 0.87 20.00 5.25 0.74 20.00 7.00 0.65 13.10 6.50 0.45
SD 3.69 0.93 0.09 3.93 3.37 0.14 5.66 4.87 0.21 4.74 2.04 0.16
Note—TWSTRS indicates Toronto Western Spasmodic Torticollis Rating Scale [22]. NA indicates not available.
aScore reduction rate: (pretreatment score – posttreatment score) / pretreatment score.

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