{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,2]],"date-time":"2026-09-02T22:02:38Z","timestamp":1788386558173,"version":"build-2803163510"},"reference-count":41,"publisher":"MDPI AG","issue":"5","license":[{"start":{"date-parts":[[2021,5,20]],"date-time":"2021-05-20T00:00:00Z","timestamp":1621468800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Toxins"],"abstract":"<jats:p>The visualization of the human body has frequently been groundbreaking in medicine. In the last few years, the use of ultrasound (US) imaging has become a well-established procedure for botulinum toxin therapy in people with cervical dystonia (CD). It is now undisputed among experts that some of the most relevant muscles in this indication can be safely injected under visual US guidance. This review will explore the method from basic technical considerations, current evidence to conceptual developments of the phenomenology of cervical dystonia. We will review the implications of introducing US to our understanding of muscle function and anatomy of common cervical dystonic patterns. We suggest a flow chart for the use of US to achieve a personalized treatment of people with CD. Thus, we hope to contribute a resource that is useful in clinical practice and that stimulates the ongoing development of this valuable technique.<\/jats:p>","DOI":"10.3390\/toxins13050365","type":"journal-article","created":{"date-parts":[[2021,5,20]],"date-time":"2021-05-20T11:45:57Z","timestamp":1621511157000},"page":"365","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":27,"title":["The Role of Ultrasound for the Personalized Botulinum Toxin Treatment of Cervical Dystonia"],"prefix":"10.3390","volume":"13","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-4323-9930","authenticated-orcid":false,"given":"Urban M.","family":"Fietzek","sequence":"first","affiliation":[{"name":"Department of Neurology, Ludwig-Maximilians-University, 81377 Munich, Germany"},{"name":"Department of Neurology and Clinical Neurophysiology, Sch\u00f6n Klinik M\u00fcnchen Schwabing, 80804 Munich, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3707-0067","authenticated-orcid":false,"given":"Devavrat","family":"Nene","sequence":"additional","affiliation":[{"name":"Djavad Mowafaghian Centre for Brain Health, Division of Neurology, University of British Columbia Vancouver, Vancouver, BC V6T 1Z3, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Axel","family":"Schramm","sequence":"additional","affiliation":[{"name":"NeuroPraxis F\u00fcrth, 90762 F\u00fcrth, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Silke","family":"Appel-Cresswell","sequence":"additional","affiliation":[{"name":"Djavad Mowafaghian Centre for Brain Health, Division of Neurology, University of British Columbia Vancouver, Vancouver, BC V6T 1Z3, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Zuzana","family":"Ko\u0161utzk\u00e1","sequence":"additional","affiliation":[{"name":"2nd Department of Neurology, Comenius University, 83305 Bratislava, Slovakia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6280-785X","authenticated-orcid":false,"given":"Uwe","family":"Walter","sequence":"additional","affiliation":[{"name":"Department of Neurology, University of Rostock, 18147 Rostock, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"J\u00f6rg","family":"Wissel","sequence":"additional","affiliation":[{"name":"Neurorehabilitation, Vivantes Klinikum Spandau, 13585 Berlin, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Steffen","family":"Berweck","sequence":"additional","affiliation":[{"name":"Department of Paediatric Neurology, Ludwig-Maximilians-University, 80337 Munich, Germany"},{"name":"Sch\u00f6n Klinik Vogtareuth, 83569 Vogtareuth, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sylvain","family":"Chouinard","sequence":"additional","affiliation":[{"name":"Centre hospitalier de l\u2019Universit\u00e9 de Montr\u00e9al, Montr\u00e9al, QC H2X 3E4, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tobias","family":"B\u00e4umer","sequence":"additional","affiliation":[{"name":"Institute of Systems Motor Science, University of L\u00fcbeck, 23562 L\u00fcbeck, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2021,5,20]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"1818","DOI":"10.1212\/WNL.0000000000002560","article-title":"Practice Guideline Update Summary: Botulinum Neurotoxin for the Treatment of Blepharospasm, Cervical Dystonia, Adult Spasticity, and Headache: Report of the Guideline Development Subcommittee of the American Academy of Neurology","volume":"86","author":"Simpson","year":"2016","journal-title":"Neurology"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"783","DOI":"10.1002\/mds.20403","article-title":"Efficacy and Safety of Botulinum Type A Toxin (Dysport) in Cervical Dystonia: Results of the First US Randomized, Double-Blind, Placebo-Controlled Study","volume":"20","author":"Truong","year":"2005","journal-title":"Mov. Disord."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"633","DOI":"10.1136\/jnnp.53.8.633","article-title":"Botulinum Toxin Treatment of Cranial-Cervical Dystonia, Spasmodic Dysphonia, Other Focal Dystonias and Hemifacial Spasm","volume":"53","author":"Jankovic","year":"1990","journal-title":"J. Neurol. Neurosurg. Psychiatry"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"1949","DOI":"10.1212\/01.WNL.0000163767.99354.C3","article-title":"A New Botulinum Toxin Type A Free of Complexing Proteins for Treatment of Cervical Dystonia","volume":"64","author":"Benecke","year":"2005","journal-title":"Neurology"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"245","DOI":"10.1016\/S0140-6736(86)92070-2","article-title":"Double-Blind Study of Botulinum Toxin in Spasmodic Torticollis","volume":"2","author":"Tsui","year":"1986","journal-title":"Lancet"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"37","DOI":"10.1016\/j.jns.2015.06.015","article-title":"Collum-Caput (COL-CAP) Concept for Conceptual Anterocollis, Anterocaput, and Forward Sagittal Shift","volume":"355","author":"Finsterer","year":"2015","journal-title":"J. Neurol. Sci."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"272","DOI":"10.1055\/s-0028-1109416","article-title":"The phenomenology of cervical dystonia","volume":"77","author":"Reichel","year":"2009","journal-title":"Fortschr. Neurol. Psychiatr."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"996","DOI":"10.2214\/AJR.08.1535","article-title":"Initial Experience with Imaging-Guided Intramuscular Botulinum Toxin Injection in Patients with Idiopathic Cervical Dystonia","volume":"192","author":"Lee","year":"2009","journal-title":"Am. J. Roentgenol."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"221","DOI":"10.1055\/s-2002-34500","article-title":"Sonography-Guided Injection of Botulinum Toxin A in Children with Cerebral Palsy","volume":"33","author":"Berweck","year":"2002","journal-title":"Neuropediatrics"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"249","DOI":"10.1016\/S0140-6736(03)15351-2","article-title":"Sonography-Guided Injection of Botulinum Toxin in Children with Cerebral Palsy","volume":"363","author":"Berweck","year":"2004","journal-title":"Lancet"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"477","DOI":"10.1213\/00000539-200108000-00047","article-title":"A Study of the Paravertebral Anatomy for Ultrasound-Guided Posterior Lumbar Plexus Block","volume":"93","author":"Kirchmair","year":"2001","journal-title":"Anesth. Analg."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"45","DOI":"10.1016\/j.ejpn.2009.09.005","article-title":"The Updated European Consensus 2009 on the Use of Botulinum Toxin for Children with Cerebral Palsy","volume":"14","author":"Heinen","year":"2010","journal-title":"Eur. J. Paediatr. Neurol."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"368","DOI":"10.1097\/00000542-200602000-00024","article-title":"Ultrasound-Guided Regional Anesthesia: Current State of the Art","volume":"104","author":"Gray","year":"2006","journal-title":"Anesthesiology"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"1457","DOI":"10.1007\/s00702-014-1356-2","article-title":"Relevance of Sonography for Botulinum Toxin Treatment of Cervical Dystonia: An Expert Statement","volume":"122","author":"Schramm","year":"2015","journal-title":"J. Neural Transm."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"923","DOI":"10.1586\/14737175.2014.936387","article-title":"Ultrasound-Guided Botulinum Toxin Injections in Neurology: Technique, Indications and Future Perspectives","volume":"14","author":"Walter","year":"2014","journal-title":"Expert Rev. Neurother."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"1016","DOI":"10.1179\/1743132811Y.0000000010","article-title":"Skeletal Muscle Ultrasound","volume":"33","author":"Pillen","year":"2011","journal-title":"Neurol. Res."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"1894","DOI":"10.1007\/s00415-020-10365-w","article-title":"Accuracy of Non-Guided versus Ultrasound-Guided Injections in Cervical Muscles: A Cadaver Study","volume":"268","author":"Kreisler","year":"2021","journal-title":"J. Neurol."},{"key":"ref_18","doi-asserted-by":"crossref","unstructured":"Kim, B.S., Kim, D.S., Kang, S., Kim, J.Y., Kang, B., Rhyu, I.J., and Yoon, J.S. (2020). Ultrasound-Guided Injection of the Sternocleidomastoid Muscle: A Cadaveric Study with Implications for Chemodenervation. PM&R.","DOI":"10.1002\/pmrj.12463"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"370","DOI":"10.5535\/arm.19211","article-title":"Accuracy of Ultrasound-Guided and Non-Guided Botulinum Toxin Injection Into Neck Muscles Involved in Cervical Dystonia: A Cadaveric Study","volume":"44","author":"Ko","year":"2020","journal-title":"Ann. Rehabil. Med."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"535","DOI":"10.1002\/mus.23409","article-title":"Elimination of Dysphagia Using Ultrasound Guidance for Botulinum Toxin Injections in Cervical Dystonia","volume":"46","author":"Hong","year":"2012","journal-title":"Muscle Nerve"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"1161","DOI":"10.1007\/s00702-020-02220-z","article-title":"Dysphagia in Cervical Dystonia Patients Receiving Optimised Botulinum Toxin Therapy: A Single-Center Retrospective Cohort Study","volume":"127","author":"Kutschenko","year":"2020","journal-title":"J. Neural Transm."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"e000196","DOI":"10.1136\/bmjopen-2011-000196","article-title":"Dysport Cervical Dystonia Study Group A Botulinum Toxin A Treatment Algorithm for de Novo Management of Torticollis and Laterocollis","volume":"1","author":"Hefter","year":"2011","journal-title":"BMJ Open"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"2409","DOI":"10.1002\/mds.23905","article-title":"Anterior and Posterior Sagittal Shift in Cervical Dystonia: A Clinical and Electromyographic Study, Including a New EMG Approach of the Longus Colli Muscle","volume":"26","author":"Flowers","year":"2011","journal-title":"Mov. Disord. Off. J. Mov. Disord. Soc."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"1016","DOI":"10.1109\/JBHI.2020.2964098","article-title":"Objective Analysis of Neck Muscle Boundaries for Cervical Dystonia Using Ultrasound Imaging and Deep Learning","volume":"24","author":"Loram","year":"2020","journal-title":"IEEE J. Biomed. Health Inform."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"662","DOI":"10.21037\/qims.2019.04.08","article-title":"Application of Real-Time Shear Wave Elastography in the Assessment of Torsional Cervical Dystonia","volume":"9","author":"Song","year":"2019","journal-title":"Quant. Imaging Med. Surg."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"1037","DOI":"10.1007\/s00702-018-1866-4","article-title":"A Simplified Ultrasonography-Guided Approach for Neurotoxin Injection into the Obliquus Capitis Inferior Muscle in Spasmodic Torticollis","volume":"125","author":"Walter","year":"2018","journal-title":"J. Neural Transm."},{"key":"ref_27","doi-asserted-by":"crossref","unstructured":"Lagnau, P., Lo, A., Sandarage, R., Alter, K., Picelli, A., Wissel, J., Verduzco-Gutierrez, M., Suputtitada, A., Munin, M.C., and Carda, S. (2021). Ergonomic Recommendations in Ultrasound-Guided Botulinum Neurotoxin Chemodenervation for Spasticity: An International Expert Group Opinion. Toxins, 13.","DOI":"10.3390\/toxins13040249"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"76","DOI":"10.1016\/j.jns.2014.06.028","article-title":"Intramuscular Distribution of Botulinum Toxin\u2014Visualized by MRI","volume":"344","author":"Elwischger","year":"2014","journal-title":"J. Neurol. Sci."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"9","DOI":"10.1016\/j.apmr.2008.04.030","article-title":"Botulinum Toxin Dilution and Endplate Targeting in Spasticity: A Double-Blind Controlled Study","volume":"90","author":"Gracies","year":"2009","journal-title":"Arch. Phys. Med. Rehabil."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"1486-e98","DOI":"10.1111\/ene.12517","article-title":"The Clinical Utility of Botulinum Toxin Injections Targeted at the Motor Endplate Zone in Cervical Dystonia","volume":"21","author":"Delnooz","year":"2014","journal-title":"Eur. J. Neurol."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"878","DOI":"10.1212\/WNL.42.4.878","article-title":"Botulinum Toxin Injection for Spasmodic Torticollis: Increased Magnitude of Benefit with Electromyographic Assistance","volume":"42","author":"Comella","year":"1992","journal-title":"Neurology"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"2305","DOI":"10.1016\/j.clinph.2011.04.012","article-title":"The Utility of EMG Interference Pattern Analysis in Botulinum Toxin Treatment of Torticollis: A Randomised, Controlled and Blinded Study","volume":"122","author":"Werdelin","year":"2011","journal-title":"Clin. Neurophysiol. Off. J. Int. Fed. Clin. Neurophysiol."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"167","DOI":"10.1016\/j.jns.2014.09.041","article-title":"EMG Coherence and Spectral Analysis in Cervical Dystonia: Discriminative Tools to Identify Dystonic Muscles?","volume":"347","author":"Nijmeijer","year":"2014","journal-title":"J. Neurol. Sci."},{"key":"ref_34","doi-asserted-by":"crossref","unstructured":"Nijmeijer, S.W.R., de Bruijn, E., Verhagen, R., Forbes, P.A., Kamphuis, D.J., Happee, R., Tijssen, M.A.J., and Koelman, J.H.T.M. (2017). Spectral EMG Changes in Cervical Dystonia Patients and the Influence of Botulinum Toxin Treatment. Toxins, 9.","DOI":"10.3390\/toxins9090256"},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"119","DOI":"10.1016\/j.parkreldis.2017.07.034","article-title":"Involvement of Obliquus Capitis Inferior Muscle in Dystonic Head Tremor","volume":"44","author":"Schramm","year":"2017","journal-title":"Parkinsonism Relat. Disord."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"e563","DOI":"10.1212\/WNL.0000000000011049","article-title":"Dystonia and Tremor: A Cross-Sectional Study of the Dystonia Coalition Cohort","volume":"96","author":"Shaikh","year":"2021","journal-title":"Neurology"},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"928","DOI":"10.1002\/mds.25024","article-title":"Sonographic Guidance Provides a Low-Risk Approach to the Longus Colli Muscle","volume":"27","author":"Fujimoto","year":"2012","journal-title":"Mov. Disord. Off. J. Mov. Disord. Soc."},{"key":"ref_38","first-page":"1989","article-title":"Efficacy Analysis of Ultrasound-Guided Local Injection of Botulinum Toxin Type A Treatment with Orthopedic Joint Brace in Patients with Cervical Dystonia","volume":"19","author":"Huang","year":"2015","journal-title":"Eur. Rev. Med. Pharmacol. Sci."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"302","DOI":"10.1097\/RUQ.0000000000000226","article-title":"Ultrasound and Electromyography Guidance for Injection of the Longus Colli With Botulinum Toxin for the Treatment of Cervical Dystonia","volume":"32","author":"Allison","year":"2016","journal-title":"Ultrasound Q."},{"key":"ref_40","doi-asserted-by":"crossref","unstructured":"Ty\u015blerowicz, M., and Jost, W.H. (2019). Injection into the Longus Colli Muscle via the Thyroid Gland. Tremor Hyperkinetic Mov., 9.","DOI":"10.5334\/tohm.489"},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"237","DOI":"10.1007\/s00702-016-1621-7","article-title":"Anatomy and Cervical Dystonia: \u201cDysfunction Follows Form\u201d","volume":"124","author":"Tatu","year":"2017","journal-title":"J. Neural Transm."}],"container-title":["Toxins"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2072-6651\/13\/5\/365\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,11]],"date-time":"2025-10-11T06:04:56Z","timestamp":1760162696000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2072-6651\/13\/5\/365"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2021,5,20]]},"references-count":41,"journal-issue":{"issue":"5","published-online":{"date-parts":[[2021,5]]}},"alternative-id":["toxins13050365"],"URL":"https:\/\/doi.org\/10.3390\/toxins13050365","relation":{},"ISSN":["2072-6651"],"issn-type":[{"value":"2072-6651","type":"electronic"}],"subject":[],"published":{"date-parts":[[2021,5,20]]}}}