Botulinum Toxin (Botox) Treatment of Cervical Torticollis

In addition to the negative impacts mentioned above, dystonia of the neck, if untreated, can potentially spread to other contiguous regions of the body (regions neighbouring the neck). While there is no cure for torticollis, its symptoms can be managed or alleviated by relaxing the dystonic neck muscles to prevent involuntary contraction, or by wearing a corrective neck brace (cervical collar).

Symptoms of cervical torticollis

Patients suffering from cervical torticollis typically experience:

• Neck pain or neck stiffness that may radiate into the shoulders
• Uneven shoulders (one shoulder is higher or lower than the other)
• Swollen neck muscles
  Involuntary muscle spasms
• Sudden twitching/jerking of the neck muscles
• Uncontrollable tightening of the neck muscles, causing them to feel hard
• Abnormal positioning of the neck muscles
• Head tremor: uncontrollably, jerky, and irregular shaking of the neck and head that may worsen when the patient attempts to turn or tilt their head into a normal position

Treatment procedure – Botulinum toxin injection

While treatment of cervical torticollis is symptomatic and optional, torticollis can significantly diminish the patient’s quality of life and potentially worsen if left unchecked.

Botulinum Toxin-A, also known as botulinum neurotoxin (BoNT), is a paralysing agent and muscle relaxant derived from the Clostridium botulinum bacteria that is commonly used to relieve chronic or painful muscle contractions like cervical torticollis. BoNT is often regarded as the first-line therapy of choice for cervical dystonia due to its exceptional symptom relief properties with minimal side effects.

Botox injections can be used to manage the symptoms of cervical torticollis as wells as other abnormal postures caused by cervical dystonia. However, please note that Botox injections are not a permanent cure for cervical torticollis/ cervical dystonia but can provide excellent temporary symptom relief. Botox injections are recommended to be performed quarterly as repeated injections can ensure the patient enjoys sustained benefit frm the symptom relieving properties of BoNT.

What to expect during the procedure

Botox injection treatment is quick, taking around 10 to 30 minutes to complete, and can be done over your lunchtime. This treatment also has little to no downtime; following treatment, you are free to immediately resume regular daily activities.

Prior to the treatment procedure, our clinic’s doctor(s) will first assess your neck muscles to determine which muscle groups/muscles (such as the trapezius) are causing the pain and involuntary contractions.

Once the affected muscle groups are identified, our doctor(s) will access the affected area and mark out specific points on the muscles, making sure that the points are well spaced to ensure that BoNT overdose does not occur in any part of the treatment area, where Botox units will be carefully injected to minimise discomfort.

The injections partially paralyse and reduce tension in the targeted muscles, alleviating the involuntary contractions, straightening the neck, and relieving pain. Immediate relief is sometimes felt after the first injection, but most patients start to notice the effect of BoNT around a week after the treatment.

Common postures associated with dystonia of the neck

Involuntary contraction/spams of the neck muscles can affect posture by causing the head to rotate or tilt. Dystonia of the neck can cause torticollis in addition to multiple other abnormal postures. However, the direction of the tilt/rotation is usually inconsistent as it may change as different muscles become affected by the condition.

If you find that your posture resembles any of the postures described below, we recommend consulting a medical practitioner to get a professional diagnosis.

Torticollis
Rotation of the head and neck relative to the upper trunk of the body; the head rotating in a way that can be described as the chin moving/pointing towards either shoulder.

Torticaput
Rotation of just the head while the neck remains in a vertical position; similar to torticollis, the head rotates such that the chin moves/points towards either shoulder.

Laterocollis
Sideways tilting of the head and neck; the head and neck tilt in the same plane such that the ear “moves” closer/towards either shoulder.

Laterocaput
Sideways tilting of just the head while the neck remains in a vertical position; similar to laterocollis, the head tilts in a way that makes the ear “move” closer/towards either shoulder.

Anterocollis
Forward tilting of the neck relative to the spine while the angle between the neck and head remains normal.

Anterocaput
Forward tilting of the head at too great an angle while the angle between the neck and spine remains normal.

Retrocollis
Backwards tilting of the neck relative to the spine while the angle between the neck and head remains normal.

Retrocaput
Backwards tilting of the head at too great an angle while the angle between the neck and spine remains normal.

Most patients with dystonia of the neck suffer from a combination of postures

Lateral shift
A combination of laterocollis towards one shoulder and laterocaput towards the other shoulder (laterocollis and laterocaput in opposite directions), causing the head to appear vertical but displaced towards the left or the right.

Forward sagittal shift (“Goose-neck”)
A combination of anterocollis forward tilting of the neck and retrocaput backwards tilting of the head, causing the head to protrude forward relative to the cervical spine with the chin poking outwards, resulting in the patient having an abnormal “goose like” posture.

Backward sagittal shift (“Double-chin posture”)

A combination of retrocollis backwards tilting of the neck with anterocaput forward tilting of the head, causing the patient’s neck to flex downwards with their chin “pressing” against the neck, resulting in an exaggerated ”double-chin”.

Causes and risk factors

Although the exact cause of cervical torticollis/cervical dystonia is largely unknown, medical research has identified some possible triggers and risk factors, including:

Gender: Women are more likely to develop cervical torticollis/cervical dystonia compared to men.

Age: cervical torticollis/cervical dystonia is more likely to develop during late adulthood, typically developing after the patient is 30 years old.

Genetics: Patients with close family members suffering from cervical torticollis/cervical dystonia are more likely to develop the condition themselves.

History of neck-related injury or disease: cervical torticollis/cervical dystonia may be a sequela of a previous injury or disease that affected the neck muscles; the impact of the injury/condition persisting for years even after the initial injury/condition has recovered.