How Do I: How and When Do I Inject Suboccipital Muscles in Cervical Dystonia

Cervical dystonia (CD) is characterized by involuntary, sustained or intermittent contractions of neck muscles, leading to abnormal postures, often associated with pain or tremor. Utilizing the COL-CAP framework, the Caput subtype describes the head motion resulting from the action of muscles on the occipito-atlantal (C0-C1) and atlantoaxial (C1-C2) joints; while the Collis subtype describe the neck motion induced by muscle action on the cervical spine (C2-C7). Co-existence of various Caput and Collis subtype combinations in CD is well known. The suboccipital muscles are significant drivers of CD with static and dynamic caput movements. Accurate injections of botulinum toxin into these muscles when required can ensure optimal improvement in CD. This video describes the five suboccipital muscles involved in CD (Obliquus Capitis Inferioris, Semispinalis Capitis, Rectus Capitis Posterior Major, Obliquus Capitis Superioris and Longissimus Capitis), routinely injected at our Centre. With an understanding of the anatomy of the muscles, indications for injection and technique of needle placement for these muscles are also described for movement disorder specialists.