Cervical motion alterations and brain functional connectivity in cervical dystonia

INTRODUCTION

Evaluating the neural correlates of sensorimotor control deficits in cervical dystonia (CD) is fundamental to plan the best treatment. This study aims to assess kinematic and resting-state functional connectivity (RS-FC) characteristics in CD patients relative to healthy controls.

METHODS

Seventeen CD patients and 14 age-/sex-matched healthy controls were recruited. Electromagnetic sensors were used to evaluate dystonic pattern, mean/maximal cervical movement amplitude and joint position error with eyes open and closed, and movement quality during target reaching with the head. RS-fMRI was acquired to compare the FC of brain sensorimotor regions between patients and controls. In patients, correlations between motion analysis and FC data were assessed.

RESULTS

CD patients relative to controls showed reduced mean and maximal cervical range of motion (RoM) in rotation both towards and against dystonia pattern and reduced total RoM in rotation both with eyes open and closed. They had less severe dystonia pattern with eyes open vs eyes closed. CD patients showed an altered movement quality and sensorimotor control during target reaching and a higher joint position error. Compared to controls, CD patients showed reduced FC between supplementary motor area (SMA), occipital and cerebellar areas, which correlated with lower cervical RoM in rotation both with eyes open and closed and with worse movement quality during target reaching.

CONCLUSIONS

FC alterations between SMA and occipital and cerebellar areas may represent the neural basis of cervical sensorimotor control deficits in CD patients. Electromagnetic sensors and RS-fMRI might be promising tools to monitor CD and assess the efficacy of rehabilitative interventions.

Experience with the management of 2599 cases of congenital muscular torticollis and a multicenter epidemiological investigation in 17 hospitals in China

BACKGROUND

Congenital muscular torticollis (CMT) is a common musculoskeletal disease affecting infants and young children. If CMT is not treated correctly and timely, it can lead to limited head and neck movements, head and neck deviation, and abnormal posture. In order to improve patients' symptoms and alleviate the negative impact of the disease on their lives, we are committed to exploring the treatment of CMT.

METHODS

The general clinical and ultrasonographic data of 2599 children with CMT who received standardized treatment at Shenzhen Children's Hospital from 2004 to 2020 were retrospectively reviewed. According to given treatment, children with CMT were divided into the physiotherapy group, physiotherapy combined with glucocorticoid treatment group, and surgical treatment group. We divided children with CMT into local mass, uniform thickening, and atrophy according to ultrasound features. General clinical information, treatment, and ultrasound examination data in each group were compared. Additionally, electronic medical records of 2344 patients admitted due to CMT in 17 tertiary children's hospitals of China's Futang Research Center of Pediatric Development (FRCPD) from 2015 to 2019 were retrospectively analyzed. Data on sex, age, year of admission and discharge, and treatment costs during hospitalization were extracted from the first medical record pages according to the ICD codes. The data were assessed for normality using the Kolmogorov-Smirnov test. Depending on the data distribution, they were analyzed using parametric tests, such as the t-test, or non-parametric tests. Qualitative data are expressed as percentages (%) and analyzed using the chi-square or Fisher's exact probability test, with α = 0.05 as the test level. P < 0.05 was considered to be indicative of a statistically significant difference.

RESULTS

Three types of CMT were defined based on sternocleidomastoid muscle ultrasound examination characteristics: local mass, uniform thickening, and atrophy. Age at first diagnosis was 69.21 ± 108.41 days in local mass type group, 216.85 ± 324.09 days in uniform thickening group, and 417.88 ± 739.05 days in atrophy- type group; while age at first physiotherapy use was 94.06 ± 206.49 days, 255.00 ± 430.62 days, 540.92 ± 1059.29 respectively. The children included in local mass type group have shown a high success rate of conservative treatment, with a rate of 7.5% of children underwent surgery. Age at first diagnosis was 112.44 ± 224.12 days in the physiotherapy group, 115.87 ± 144.86 days in the physiotherapy combined with glucocorticoid treatment subgroup, whereas the age at first physiotherapy use was 137.38 ± 312.11 and 196.91 ± 344.26 days respectively. In the observation period (2015-2019) the mean age at surgery for CMT in 17 tertiary children's hospitals of the FRCPD was 50 months. Overall, 663 children with CMT were 1-2 years of age, accounting for the largest proportion (28.3%). Followed by 417 individuals (17.8%) were 7-14 years of age, indicating that there are still more children with CMT receiving surgical treatment later.

CONCLUSIONS

Early diagnosis and treatment are essential to improve the conservative treatment success rate and achieve good prognosis in children with CMT. Our team's concept for treating CMT is as follows: after diagnosing the children, we will adopt the standardized protocol of treatment, with physiotherapy combined with the injection of glucocorticoid drugs and SCM release surgery, when needed. This program has a high conservative treatment success rate and may facilitate the achievement of better prognosis and reduced teratogenicity rate.

Hypertrophy of the Spinalis Cervicis Muscle in Cervical Dystonia

Background

Botulinum neurotoxin A (BoNT) is the first line treatment for cervical dystonia (CD) and treatment outcome significantly depends on the correct identification of the muscles involved.

Phenomenology shown

In a case with insufficient response to BoNT treatment further work up with magnetic resonance imaging (MRI) of the neck revealed a hypertrophic spinalis cervicis muscle, that is not commonly involved in CD.

Educational value

This highlights the use of MRI for muscle selection in treatment refractory CD cases.

C2 semisegmented hemivertebra - a rare anomaly presenting with torticollis

BACKGROUND

Cervical hemivertebrae are extremely rare anomalies which usually present with restriction of neck movements and torticollis in childhood. Hemivertebrae within the craniovertebral junction have only been reported once previously in the literature. We report a case of semisegmented C2 vertebra presenting in a young adult with cervical pain and torticollis with no other associated anomalies.

CASE DESCRIPTION

A 21-year-old lady presented with a history of neck pain for the past 10 days and longstanding torticollis with head tilt to the left. Computed tomographic scan of the cervical spine revealed a semisegmented hemivertebra located laterally between the C1 lateral mass and C2 on the right side which was not associated with any other bony anomalies, scoliosis or atlantoaxial dislocation. Conservative treatment with physical therapy was the chosen therapeutic strategy.

CONCLUSION

Hemivertebrae within the craniovertebral junction are exceedingly rare anomalies which may present with pain and deformity in childhood and are an important cause of congenital torticollis which may be associated with other spinal, craniofacial, cardiac or renal anomalies.

Neck stiffness and bone osteolytic lesion in a 3-years old child: a case report

BACKGROUND

Neuroblastoma is the most frequent extracranial solid tumor occurring in childhood, representing approximately 28% of all cancers diagnosed in infants. Signs and symptoms of neuroblastoma vary with the site of development of the tumor and can mimic other diseases due to its extreme clinical variability. However, torticollis is not reported in the medical literature as a leading symptom of neuroblastoma.

CASE PRESENTATION

Here we report the case of a 3 years-old girl with fever and neck stiffness. Blood tests revealed a mild anemia and a rise in inflammatory markers. CT-scan showed a solid, heterogeneous, predominantly hypodense surrenal mass with eccentric calcification and extensive inhomogeneity of the vertebral metamers. Blood tests revealed raised serum levels of Neuron-Specific Enolase. At the 24-hours urine collection urinary catecholamines were greatly increased. A course of chemotherapy for neuroblastoma was promptly started with immediate clinical improvement.

CONCLUSIONS

This case shows that the presence of torticollis could be a chief complaint of neuroblastoma. To our knowledge, neuroblastoma is not mentioned among life-threatening underlying conditions of torticollis in most recent literature reviews.

Spontaneous spinal epidural hematoma in a toddler presenting with torticollis: case report and literature review

INTRODUCTION

Spontaneous spinal epidural hematoma (SSEH) is a rare entity, especially in toddlers and infants. The nonspecificity of its presenting symptoms in children may be a source of delayed diagnosis.

CASE DESCRIPTION

We report the case of a 20-month-old young boy without medical history who presented with irreducible torticollis, worsened a few days later by severe tetraplegia and respiratory distress. Spinal magnetic resonance imaging (MRI) showed a posterior epidural hematoma, extending from C3 to T1 and compressing the spinal cord. An urgent decompressive surgery via an extensive laminectomy and evacuation of the clot was performed. The patient demonstrated a partial neurological recovery on follow-up.

CONCLUSION

SSEH is a rare and serious condition that may compromise the functional and vital prognosis of the patient, hence the importance of prompt diagnosis and urgent treatment.

Does Ultrasound Guidance Improve the Effectiveness of Neurotoxin Injections in Patients with Cervical Dystonia? (A Prospective, Partially-Blinded, Clinical Study)

Aim: The aim of this study was to evaluate the efficacy of ultrasound guidance (US) in the treatment of cervical dystonia (CD) with botulinum neurotoxin type A (BoNT-A) injections in comparison to anatomical landmarks (AL). To date, US is routinely used in many centers, but others deny its usefulness. Materials and Methods: Thirty-five patients (12 males, 23 females) with a clinical diagnosis of CD were included in the study. Intramuscular administration of BoNT-A was performed using either US guidance, or with AL, in two separate therapeutic sessions. The efficacy of BoNT-A administration was assessed with the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS), Tsui modified scale, Craniocervical Dystonia Questionnaire (CDQ-24) and Clinical Global Impression—Improvement scale (CGI-I). Additionally, patients at therapeutic sessions were digitally recorded and evaluated by two blinded and independent raters. Results: A significant decrease in total TWSTRS, severity subscale TWSTRS, Tsui score, and CDQ-24 was found in both the AL and US group; however, in the TWSTRS disability and pain subscales, a significant decrease was found only in the US group. Moreover, US guided treatment also resulted in a greater decrease in TWSTRS, Tsui score and CDQ-24 compared to anatomical landmarks use only. Conclusions: US guidance might be helpful in improving the results of BoNT-A injections in cervical dystonia, reducing associated pain and disability; however, more studies are needed to evaluate its clinical efficacy.

A 10-year-old child with acute torticollis due to polymicrobial deep neck infection

Torticollis in children can be a sign of a potentially dangerous disease; the correct diagnosis is not always obvious on history and physical examination. The use of point-of-care ultrasound (POCUS) helps to limit the differential diagnosis and direct appropriate further laboratory and radiology-performed evaluation. We present a case of a 10-year-old child whose deep neck infection (DNI) was timely diagnosed in the paediatric emergency department by early use of POCUS and drained under POCUS guidance after admission to the hospital. The culture from the fluid grew Eikenella corrodens, Streptococcus constellatus and Prevotella buccae This case demonstrates that DNIs occur in children with acute acquired torticollis, even without fever and demonstrates the importance of early use of POCUS in cases where DNI is a potential diagnosis. Moreover, this case emphasises the importance of microbiological identification of DNIs that can be the key to successful treatment.

Sternocleidomastoid size and upper trapezius muscle thickness in congenital torticollis patients: A retrospective observational study

The purpose of this study was to investigate the upper trapezius muscle thickness (UTMT) in congenital muscular torticollis (CMT) patients and determine the correlation among sternocleidomastoid muscle thickness (SCMT), accessory nerve (AN) cross-sectional area (CSA), and UTMT in CMT.This retrospective study consisted of 2 participant groups: Group 1 (SCM mass CMT, n = 20) and Group 2 (Postural CMT, n = 22). For both groups, B-mode ultrasound was performed by a physiatrist to measure the SCMT and UTMT and calculate the CSA of the AN. The correlation among SCMT, CSA of the AN, and UTMT in both groups was evaluated.The between-group comparison revealed that Group 1 had significantly greater SCMT, UTMT, and CSA of the AN on the affected side than Group 2 (P < .05). The intragroup comparison between the affected and unaffected sides also revealed that, in Group 1, the SCMT, UTMT, and CSA of the AN were significantly higher on the affected side than on the unaffected side (P < .05), whereas no significant differences were observed in Group 2. In Group 1, a positive correlation (r = 0.55) was observed between the UTMT and CSA of the AN on the affected side, but not observed between the SCMT and CSA of the AN.The findings of the study indicate that sternocleidomastoid muscle size may impact the thickness of the upper trapezius muscle via the accessory nerve in patients with congenital torticollis.

Traumatic atlanto-axial rotatory subluxation and dens fracture with subaxial SCIWORA of Brown-Sequard syndrome: A case report

RATIONALE

A case of traumatic atlanto-axial rotatory subluxation (AARS), dens fracture, rupture of transverse atlantal ligament (TAL), and subaxial spinal cord injury without radiographic abnormality (SCIWORA) of Brown-Sequard syndrome has never been reported in a child.

PATIENT CONCERNS

A 7-year-old boy presented to hospital with torticollis, neck pain, and limited neck rotation after a seat-belt injury sustained during a car accident. Neurologic examination revealed right-side motor weakness and left-side sensory abnormality, known as Brown-Sequard syndrome.

DIAGNOSIS

Radiologic examinations revealed type II AARS (Fielding and Hawkins classification), increased atlanto-dental interval (ADI) of 4.5 mm due to a type 1B TAL rupture (Dickman classification), a displaced transverse dens fracture along with an ossiculum terminale, and an intramedullary hemorrhage on the right side of the spinal cord at C3-4.

INTERVENTIONS

The patient immediately received methylprednisolone, and his motor weakness and sensory abnormality gradually improved. At the same time, the patient underwent initial halter traction for 2 weeks, but he failed to achieve successful reduction and required manual reduction under general anesthesia.

OUTCOMES

At the 7-month follow-up visit, radiologic examinations showed a corrected type II AARS that was well maintained and normalization of the ADI to 2 mm. The reduced transverse dens fracture was well maintained but still not united. All clinical symptoms were significantly improved, except the remaining motor weakness of the right upper extremity.

LESSONS

To the best of our knowledge, this is the first report of traumatic AARS, dens fracture, TAL rupture, and subaxial SCIWORA of Brown-Sequard syndrome in a child. Appropriate diagnosis and careful treatment strategy are required for successful management of complex cervical injuries in a child.

Botulinum toxin injection changes resting state cerebellar connectivity in cervical dystonia

In cervical dystonia, functional MRI (fMRI) evidence indicates changes in several resting state networks, which revert in part following the botulinum neurotoxin A (BoNT) therapy. Recently, the involvement of the cerebellum in dystonia has gained attention. The aim of our study was to compare connectivity between cerebellar subdivisions and the rest of the brain before and after BoNT treatment. Seventeen patients with cervical dystonia indicated for treatment with BoNT were enrolled (14 female, aged 50.2 ± 8.5 years, range 38-63 years). Clinical and fMRI examinations were carried out before and 4 weeks after BoNT injection. Clinical severity was evaluated using TWSTRS. Functional MRI data were acquired on a 1.5 T scanner during 8 min rest. Seed-based functional connectivity analysis was performed using data extracted from atlas-defined cerebellar areas in both datasets. Clinical scores demonstrated satisfactory BoNT effect. After treatment, connectivity decreased between the vermis lobule VIIIa and the left dorsal mesial frontal cortex. Positive correlations between the connectivity differences and the clinical improvement were detected for the right lobule VI, right crus II, vermis VIIIb and the right lobule IX. Our data provide evidence for modulation of cerebello-cortical connectivity resulting from successful treatment by botulinum neurotoxin.

A Rare Case of Nontraumatic Atlantoaxial Rotatory Fixation in an Adult Patient Treated by a Closed Reduction: A Case Report

CASE

A 42-year-old woman presented with a severe neck pain and torticollis due to uncertain etiology. Because her radiographs and computed tomography revealed atlantoaxial rotatory fixation (AARF) that is an extremely rare condition in the adult population, a nonsurgical treatment was initially applied. Because 3 weeks of indirect traction failed, closed reduction was performed under general anesthesia at 2 months after onset, and her symptoms markedly improved without any complications and recurrence.

CONCLUSION

Closed reduction under general anesthesia for nontraumatic AARF in adult patients might be an effective treatment option, even for chronic cases or intractable cases by traction treatment.

Quantitative imaging of tongue kinematics during infant feeding and adult swallowing reveals highly conserved patterns

Tongue motility is an essential physiological component of human feeding from infancy through adulthood. At present, it is a challenge to distinguish among the many pathologies of swallowing due to the absence of quantitative tools. We objectively quantified tongue kinematics from ultrasound imaging during infant and adult feeding. The functional advantage of this method is presented in several subjects with swallowing difficulties. We demonstrated for the first time the differences in tongue kinematics during breast- and bottle-feeding, showing the arrhythmic sucking pattern during bottle-feeding as compared with breastfeeding in the same infant with torticollis. The method clearly displayed the improvement of tongue motility after frenotomy in infants with either tongue-tie or restrictive labial frenulum. The analysis also revealed the absence of posterior tongue peristalsis required for safe swallowing in an infant with dysphagia. We also analyzed for the first time the tongue kinematics in an adult during water bolus swallowing demonstrating tongue peristaltic-like movements in both anterior and posterior segments. First, the anterior segment undulates to close off the oral cavity and the posterior segment held the bolus, and then, the posterior tongue propelled the bolus to the pharynx. The present methodology of quantitative imaging revealed highly conserved patterns of tongue kinematics that can differentiate between swallowing pathologies and evaluate treatment interventions. The method is novel and objective and has the potential to advance knowledge about the normal swallowing and management of feeding disorders.

Management of Anterocapitis and Anterocollis: A Novel Ultrasound Guided Approach Combined with Electromyography for Botulinum Toxin Injection of Longus Colli and Longus Capitis

Chemodenervation of cervical musculature using botulinum neurotoxin (BoNT) is established as the gold standard or treatment of choice for management of Cervical Dystonia (CD). The success of BoNT procedures is measured by improved symptomology while minimizing side effects and is dependent upon many factors including: clinical pattern recognition, identifying contributory muscles, BoNT dosage, and locating and safely injecting target muscles. In patients with CD, treatment of anterocollis (forward flexion of the neck) and anterocaput (anterocapitis) (forward flexion of the head) are inarguably challenging. The longus Colli (LoCol) and longus capitis (LoCap) muscles, two deep cervical spine and head flexor muscles, frequently contribute to these patterns. Localizing and safely injecting these muscles is particularly challenging owing to their deep location and the complex regional anatomy which includes critical neurovascular and other structures. Ultrasound (US) guidance provides direct visualization of the LoCol, LoCap, other cervical muscles and adjacent structures reducing the risks and side effects while improving the clinical outcome of BoNT for these conditions. The addition of electromyography (EMG) provides confirmation of muscle activity within the target muscle. Within this manuscript, we present a technical description of a novel US guided approach (combined with EMG) for BoNT injection into the LoCol and LoCap muscles for the management of anterocollis and anterocaput in patients with CD.

A Study of the Midbrain Network for Covert Attentional Orienting in Cervical Dystonia Patients using Dynamic Causal Modelling

Understanding the neuronal network dynamics underlying the third most common movement disorder, cervical dystonia, can be achieved using dynamic causal modelling. Current literature establishes structures of the midbrain network for covert attentional orienting as dysfunctional in patients with cervical dystonia. One of these structures is the superior colliculus, for which it is hypothesised that deficient GABAergic activity therein causes cervical dystonia. To understand the role that this node plays in cervical dystonia, various connectivity models of the midbrain network were compared under the influence of a loom-recede visual stimulus fMRI paradigm. These models included the thalamus and striatum, crucial nodes in the direct/indirect pathways for motor movement and inhibition. The parametric empirical Bayes approach was used to quantify the difference in connection strengths across the winning models between patients and controls. Our findings demonstrated greater modulation by a looming stimulus event on the strength of connection from the striatum to the superior colliculus in patients. These results offer new means to understanding the pathophysiology of cervical dystonia.

Objective Analysis of Neck Muscle Boundaries for Cervical Dystonia Using Ultrasound Imaging and Deep Learning

OBJECTIVE

To provide objective visualization and pattern analysis of neck muscle boundaries to inform and monitor treatment of cervical dystonia.

METHODS

We recorded transverse cervical ultrasound (US) images and whole-body motion analysis of sixty-one standing participants (35 cervical dystonia, 26 age matched controls). We manually annotated 3,272 US images sampling posture and the functional range of pitch, yaw, and roll head movements. Using previously validated methods, we used 60-fold cross validation to train, validate and test a deep neural network (U-net) to classify pixels to 13 categories (five paired neck muscles, skin, ligamentum nuchae, vertebra). For all participants for their normal standing posture, we segmented US images and classified condition (Dystonia/Control), sex and age (higher/lower) from segment boundaries. We performed an explanatory, visualization analysis of dystonia muscle-boundaries.

RESULTS

For all segments, agreement with manual labels was Dice Coefficient (64 ± 21%) and Hausdorff Distance (5.7 ± 4 mm). For deep muscle layers, boundaries predicted central injection sites with average precision 94 ± 3%. Using leave-one-out cross-validation, a support-vector-machine classified condition, sex, and age from predicted muscle boundaries at accuracy 70.5%, 67.2%, 52.4% respectively, exceeding classification by manual labels. From muscle boundaries, Dystonia clustered optimally into three sub-groups. These sub-groups are visualized and explained by three eigen-patterns which correlate significantly with truncal and head posture.

CONCLUSION

Using US, neck muscle shape alone discriminates dystonia from healthy controls.

SIGNIFICANCE

Using deep learning, US imaging allows online, automated visualization, and diagnostic analysis of cervical dystonia and segmentation of individual muscles for targeted injection.

Two-Dimensional Ultrasound and Shear Wave Elastography in Infants With Late-Referral Congenital Muscular Torticollis

OBJECTIVES

To investigate the feasibility of using 2-dimensional ultrasound (US) and shear wave elastography (SWE) to evaluate infants with late-referral congenital muscular torticollis (CMT).

METHODS

A total of 46 infants with late-referral CMT were enrolled and divided into 4 groups according to the degree of the passive range of motion (PROM) deficit in neck rotation. We introduced 6 metrics to represent the US features of the sternocleidomastoid muscle detected by 2-dimensional US and SWE studies.

RESULTS

There were no significant differences in the age at referral, sex, weight, or side of involvement between the 4 groups (P > .05). The thickness and shear modulus of the involved sternocleidomastoid muscle were positively correlated with the degree of the PROM deficit in neck rotation in late-referral infants with CMT (r = 0.71 and 0.82, respectively; P < .01). However, the difference in the shear modulus between adjacent PROM-limited groups of late-referral infants was not as significant as that of early-referral infants.

CONCLUSIONS

The shear modulus ratio may be one of the best diagnostic indicators of CMT available. However, more effective differential diagnostic SWE indicators late-referral infants with CMT need to be further explored.

Pilot feasibility study of a semi-automated three-dimensional scoring system for cervical dystonia

The objective of this study is to test the feasibility of a semi-automated scoring system for the Toronto Western Spasmodic Torticollis Scale (TWSTRS) severity scale in patients with cervical dystonia. The TWSTRS requires training and experience. We previously developed a system to measure neck angle by analyzing three-dimensional position, obtained using Kinect, a marker-less three-dimensional depth sensor. The system can track patients’ faces and bodies, automatically analyze neck angles, and semi-automatically calculate the TWSTRS severity scale score. We compared the TWSTRS severity scale scores calculated by the system with the video-based scores calculated by a neurologist trained in movement disorders. A correlation coefficient analysis was then conducted. Absolute accuracy was measured using intra-class correlation (ICC) (3,1), with 95% limits of agreement. To analyze the subscales, Cohen's kappa coefficient (κ) was calculated. A p-value of < .05 was considered statistically significant. Thirty patients were enrolled. Their average age was 52.3±16.0 years, and the male to female ratio was 3:2. The average disease duration was 11.3±12.7 years. Total score measurements by the system were significantly correlated with those rated by the movement disorder-trained neurologist (r = .596, p < .05). There was a significant correlation (r = .655, p < .05) with regard to the automated part of the scale. An adequate ICC (3,1) of .562 was obtained for total severity score (p < .001, 95% confidence interval [CI]: .259–.765), while the equivalent score was .617 for the total automated part (p < .001, 95% CI .336–.798). Our three-dimensional motion capture system, which can measure head angles and semi-automatically calculate the TWSTRS severity scale score utilizing a single-depth camera, demonstrated adequate validity and reliability. This low-cost and portable system could be applied by general practitioners treating cervical dystonia to obtain objective measurements.

Cause or effect: Altered brain and network activity in cervical dystonia is partially normalized by botulinum toxin treatment

Background

Idiopathic cervical dystonia (CD) is a chronic movement disorder characterized by impressive clinical symptoms and the lack of clear pathological findings in clinical diagnostics and imaging. At present, the injection of botulinum toxin (BNT) in dystonic muscles is an effective therapy to control motor symptoms and pain in CD.

Objectives

We hypothesized that, although it is locally injected to dystonic muscles, BNT application leads to changes in brain and network activity towards normal brain function.

Methods

Using 3 T functional MR imaging along with advanced analysis techniques (functional connectivity, Granger causality, and regional homogeneity), we aimed to characterize brain activity in CD (17 CD patients vs. 17 controls) and to uncover the effects of BNT treatment (at 6 months).

Results

In CD, we observed an increased information flow within the basal ganglia, the thalamus, and the sensorimotor cortex. In parallel, some of these structures became less responsive to regulating inputs. Furthermore, our results suggested an altered somatosensory integration. Following BNT administration, we noted a shift towards normal brain function in the CD patients, especially within the motor cortex, the somatosensory cortex, and the basal ganglia.

Conclusion

The changes in brain function and network activity in CD can be interpreted as related to the underlying cause, the effort to compensate or a mixture of both. Although BNT is applied in the last stage of the cortico-neuromuscular pathway, brain patterns are shifted towards those of healthy controls.

•

we characterized brain activity in CD and the effects of BNT using 3T fMR imaging and network analysis techniques

•

following treatment with botulinum toxin (BNT), abnormal brain activity patterns in primary dystonia are attenuated

•

critical key regions for both the pathophysiology and BNT-induced improvement in cervical dystonia are the BG

Unique finding in congenital muscular torticollis: Clinic screening on the neck of one day old neonate and ultrasonographic imaging from birth through 3 years of follow-up

Congenital muscular torticollis (CMT) is a common musculoskeletal abnormality in children, which has been characterized by unclarified pathological changes in the sternocleidomastoid muscle (SCM) and various hypothetical etiologies. There are 2 main hypothetical etiologies for CMT in the literature: 1 infers that CMT may represent the sequela of an intrauterine or perinatal compartment syndrome, and the other regard CMT as a maldevelopment of the fetal SCM.To better understand the etiopathogenesis of CMT, we screened the necks of 1-day-old newborns that may potentially have CMT for evidence of SCM trauma or tumor.A convenience sample of 2564 full-term (>37 weeks) Chinese neonates were included in this study. All neonates were screened for CMT by physical examination at birth. If CMT was suspected, further ultrasonic and physical examinations were performed. When CMT was confirmed, we provided appropriate interventions and follow-up. The progress and changes in patients with CMT were recorded.Following physical examination, 44 of 2564 neonates were diagnosed with suspected CMT based on obvious facial asymmetry or palpable swelling or mass in the SCM. Among these, ultrasound examination showed 81.8% (36/44) had asymmetry in the thickness of the bilateral SCM. The 36 neonates were followed-up for 6 months; among them, 1 infant developed CMT and 35 showed normal development in bilateral SCM. The 1 patient with CMT underwent regular physiotherapy and recovered with no evidence of recurrence after the final 3 years of follow-up. No neonates suffered from signs of neck trauma, such as hematoma or subcutaneous ecchymosis.There was no evidence of neck trauma in this 1 day old newborn. The pseudotumor of SCM that developed after birth underwent differentiation, maturation, and disappeared as the baby grew. The SCM asymmetry did exist in some of the newborn babies, and became symmetric with the baby's growth. Data from this clinical study and our previous ultra-structural pathological studies suggested that both prenatal and postnatal factors play important roles in CMT. We hypothesized that CMT might be a developmental disease.

Changes in sensorimotor network activation after botulinum toxin type A injections in patients with cervical dystonia: a functional MRI study

Botulinum toxin type A (BoNT) is considered an effective therapeutic option in cervical dystonia (CD). The pathophysiology of CD and other focal dystonias has not yet been fully explained. Results from neurophysiological and imaging studies suggest a significant involvement of the basal ganglia and thalamus, and functional abnormalities in premotor and primary sensorimotor cortical areas are considered a crucial factor in the development of focal dystonias. Twelve BoNT-naïve patients with CD were examined with functional MRI during a skilled hand motor task; the examination was repeated 4 weeks after the first BoNT injection to the dystonic neck muscles. Twelve age- and gender-matched healthy controls were examined using the same functional MRI paradigm without BoNT injection. In BoNT-naïve patients with CD, BoNT treatment was associated with a significant increase of activation in finger movement-induced fMRI activation of several brain areas, especially in the bilateral primary and secondary somatosensory cortex, bilateral superior and inferior parietal lobule, bilateral SMA and premotor cortex, predominantly contralateral primary motor cortex, bilateral anterior cingulate cortex, ipsilateral thalamus, insula, putamen, and in the central part of cerebellum, close to the vermis. The results of the study support observations that the BoNT effect may have a correlate in the central nervous system level, and this effect may not be limited to cortical and subcortical representations of the treated muscles. The results show that abnormalities in sensorimotor activation extend beyond circuits controlling the affected body parts in CD even the first BoNT injection is associated with changes in sensorimotor activation. The differences in activation between patients with CD after treatment and healthy controls at baseline were no longer present.

Pedunculopontine Nucleus Cholinergic Deficiency in Cervical Dystonia

BACKGROUND

The etiology of cervical dystonia is unknown. Cholinergic abnormalities have been identified in dystonia animal models and human imaging studies. Some animal models have cholinergic neuronal loss in the striatum and increased acetylcholinesterase activity in the pedunculopontine nucleus.

OBJECTIVES

The objective of this study was to determine the presence of cholinergic abnormalities in the putamen and pedunculopontine nucleus in cervical dystonia human brain donors.

METHODS

Formalin-fixed brain tissues were obtained from 8 cervical dystonia and 7 age-matched control brains (controls). Pedunculopontine nucleus was available in only 6 cervical dystonia and 5 controls. Neurodegeneration was evaluated pathologically in the putamen, pedunculopontine nucleus, and other regions. Cholinergic neurons were detected using choline acetyltransferase immunohistochemistry in the putamen and pedunculopontine nucleus. Putaminal cholinergic neurons were quantified. A total of 6 cervical dystonia patients and 6 age-matched healthy controls underwent diffusion tensor imaging to determine if there were white matter microstructural abnormalities around the pedunculopontine nucleus.

RESULTS

Decreased or absent choline acetyltransferase staining was identified in all 6 pedunculopontine nucleus samples in cervical dystonia. In contrast, strong choline acetyltransferase staining was present in 4 of 5 pedunculopontine nucleus controls. There were no differences in pedunculopontine nucleus diffusion tensor imaging between cervical dystonia and healthy controls. There was no difference in numbers of putaminal cholinergic neurons between cervical dystonia and controls.

CONCLUSIONS

Our findings suggest that pedunculopontine nucleus choline acetyltransferase deficiency represents a functional cholinergic deficit in cervical dystonia. Structural lesions and confounding neurodegenerative processes were excluded by absence of neuronal loss, gliosis, diffusion tensor imaging abnormalities, and beta-amyloid, tau, and alpha-synuclein pathologies. © 2018 International Parkinson and Movement Disorder Society.

Functional activity of the sensorimotor cortex and cerebellum relates to cervical dystonia symptoms

Cervical dystonia (CD) is the most common type of focal dystonia, causing abnormal movements of the neck and head. In this study, we used noninvasive imaging to investigate the motor system of patients with CD and uncover the neural correlates of dystonic symptoms. Furthermore, we examined whether a commonly prescribed anticholinergic medication in CD has an effect on the dystonia-related brain abnormalities. Participants included 16 patients with CD and 16 healthy age-matched controls. We collected functional MRI scans during a force task previously shown to extensively engage the motor system, and diffusion and T1-weighted MRI scans from which we calculated free-water and brain tissue densities. The dystonia group was also scanned ca. 2 h after a 2-mg dose of trihexyphenidyl. Severity of dystonia was assessed pre- and post-drug using the Burke-Fahn-Marsden Dystonia Rating Scale. Motor-related activity in CD was altered relative to controls in the primary somatosensory cortex, cerebellum, dorsal premotor and posterior parietal cortices, and occipital cortex. Most importantly, a regression model showed that increased severity of symptoms was associated with decreased functional activity of the somatosensory cortex and increased activity of the cerebellum. Structural imaging measures did not differ between CD and controls. The single dose of trihexyphenidyl altered the fMRI signal in the somatosensory cortex but not in the cerebellum. Symptom severity was not significantly reduced post-treatment. Findings show widespread changes in functional brain activity in CD and most importantly that dystonic symptoms relate to disrupted activity in the somatosensory cortex and cerebellum. Hum Brain Mapp 38:4563-4573, 2017. © 2017 Wiley Periodicals, Inc.

The relationship between the dopaminergic system and depressive symptoms in cervical dystonia

PURPOSE

Cervical dystonia (CD) is associated with tremor/jerks (50%) and psychiatric complaints (17-70%). The dopaminergic system has been implicated in the pathophysiology of CD in animal and imaging studies. Dopamine may be related to the motor as well as non-motor symptoms of CD. CD is associated with reduced striatal dopamine D_2/3 (D2/3) receptor and increased dopamine transporter (DAT) binding. There are differences in the dopamine system between CD patients with and without jerks/tremor and psychiatric symptoms.

METHODS

Patients with CD and healthy controls underwent neurological and psychiatric examinations. Striatal DAT and D2/3 receptor binding were assessed using [¹²³I]FP-CIT and [¹²³I]IBZM SPECT, respectively. The ratio of specific striatal to non-specific binding (binding potential; BP_ND) was the outcome measure.

RESULTS

Twenty-seven patients with CD and 15 matched controls were included. Nineteen percent of patients fulfilled the criteria for a depression. Striatal DAT BP_ND was significantly lower in depressed versus non-depressed CD patients. Higher DAT BP_ND correlated significantly with higher scores on the Unified Myoclonus Rating Scale (UMRS). The striatal D2/3 receptor BP_ND in CD patients showed a trend towards lower binding compared to controls. The D2/3 BP_ND was significantly lower in depressed versus non-depressed CD patients. A significant correlation between DAT and D2/3R BP_ND was found in both in patients and controls.

CONCLUSIONS

Alterations of striatal DAT and D2/3 receptor binding in CD patients are related mainly to depression. DAT BP_ND correlates significantly with scores on the UMRS, suggesting a role for dopamine in the pathophysiology of tremor/jerks in CD.

Longitudinal follow-up of muscle echotexture in infants with congenital muscular torticollis

Unilateral fibrous contracture of the sternocleidomastoid (SCM) muscle is the major pathophysiology in infants with congenital muscular torticollis (CMT). Physical examination is not always sufficient to detect minimal muscle fibrosis in involved SCM muscles.A prospective study for SCM muscle fibrosis in CMT infants by quantifying echotexture and muscle thickness during the course of treatment is highlighted in the study.Convenience samples of 21 female and 29 male infants with CMT, who were 1 to 12 months old, underwent physiotherapy for at least 3 months and were followed for 4.7 ± 0.4 months. All infants had at least 2 clinical assessments and ultrasonographic examinations for bilateral SCM muscles during follow-up. The K value, derived from the difference in echo intensities between the involved and uninvolved SCM muscles on longitudinal sonograms, was used to represent the severity of muscle fibrosis. Bilateral SCM muscle thickness and ratio of involved to uninvolved muscle thickness (Ratio I/U) were obtained simultaneously. Clinical outcome was also recorded.No subjects underwent surgical intervention during follow-up. The K value decreased from 6.85 ± 0.58 to 1.30 ± 0.36 at the end of follow-up (P < 0.001), which reflected the decrease of muscle fibrosis. The Ratio I/U decreased from 1.11 ± 0.04 to 0.97 ± 0.02 during treatment, which was possibly related to the increased uninvolved SCM muscle thickness.In conclusion, echotexture is an efficient indicator for reflecting a wide degree of muscle fibrosis in infants with CMT and is informative during the treatment course.

Relevance of sonography for botulinum toxin treatment of cervical dystonia: an expert statement

Botulinum neurotoxin A (BoNT A) is the first-line treatment for cervical dystonia. However, although BoNT A has a favorable safety profile and is effective in the majority of patients, in some cases the treatment outcome is disappointing or side effects occur when higher doses are used. It is likely that in such cases either the target muscles were not injected accurately or unintended weakness of non-target muscles occurred. It has been demonstrated in clinical trials for spastic movement disorders that sonography-guided BoNT A injections could improve treatment outcome. As the published evidence for a benefit of sonography-guided BoNT injection in patients with cervical dystonia is scarce, it is the aim of this review to discuss the relevance of sonography in this indication and provide a statement from clinical experts for its use. The clear advantage of sonography-guided injections is non-invasive, real-time visualization of the targeted muscle, thus improving the precision of injections and potentially the treatment outcomes as well as avoiding adverse effects. Other imaging techniques are of limited value due to high costs, radiation exposure or non-availability in clinical routine. In the hands of a trained injector, sonography is a quick and non-invasive imaging technique. Novel treatment concepts of cervical dystonia considering the differential contributions of distinct cranial and cervical muscles can reliably be implemented only by use of imaging-guided injection protocols.

Efficacy analysis of ultrasound-guided local injection of botulinum toxin type A treatment with orthopedic joint brace in patients with cervical dystonia

OBJECTIVE

To study the efficacy of ultrasound-guided local injection of botulinum toxin type A (BTX-A) treatment with orthopedic joint brace in patients with cervical dystonia (CD).

PATIENTS AND METHODS

A total of 105 patients with cervical dystonia were selected and randomly divided into medication treatment group (A group), botulinum toxin treatment group under the guidance of ultrasound treatment (B group) and botulinum toxin under the guidance of ultrasound treatment combined with orthopedic joint brace treatment group (C group). Tsui scale and Spitzer quality of life index was applied to evaluate the spasm and quality of life. The scores of Tsui scale and Spitzer quality of life index were compared after ultrasound-guided local treatment for one month, three months and six months.

RESULTS

The difference in Tsui and Spitzer scores before and after the treatment of oral medications were not statistically significant (p > 0.05). Whereas, the differences in Tsui and Spitzer scores before and after the treatment between local injection of BTX-A treatment group and orthopedic joint brace combined with BTX-A injection group were statistically significant (p < 0.05). Also, the difference in Tsui and Spitzer scores of orthopedic joint brace combined with BTX-A injection group at 3 months, and 6 months were statistically significant compared to local injection of BTX-A treatment group (p < 0.05).

CONCLUSIONS

Ultrasound-guided local injection of BTX-A combined with orthopedic brace could significantly reduce muscle tension and improve quality of life.

Not your typical torticollis: a case of atlantoaxial rotatory subluxation

A 9-year-old boy was pushed while carrying a heavy backpack. He had no fall or direct trauma to his neck. After a few hours from the incident, he presented with neck pain and torticollis. However, somewhat atypical for torticollis, he was not able to rotate his face to the neutral position. There were no neurological deficits. Concerned by his inability to rotate his neck, the clinician suggested CT of the upper cervical spine, which demonstrated rotary subluxation of the atlantoaxial junction. The patient was taken to the operating theatre. Reduction was performed under general anaesthesia. He did well and was back to school in the following days.

Distinctive spine abnormalities in patients with Goldenhar syndrome: tomographic assessment

PURPOSE

Goldenhar syndrome consists of a combination of unilateral auricular appendages, auricular fistulas, and ocular epibulbar dermoids combined with a unilateral underdevelopment of the craniofacial structures and vertebral abnormalities. We aimed to elicit the underlying spine pathology in a group of patients via tomographic assessment.

MATERIALS AND METHODS

Hemifacial microsomia, cranial asymmetry, multiple ear tags, skin tags around the mouth and microtia were the most prominent facial features encountered in six patients with Goldenhar syndrome. Torticollis and cervico-thoracic scoliosis were the major deformities encountered in all patients. Thoraco-lumbar scoliosis and kyphoscoliosis were of lesser occurrence. Tomographic studies have been applied to all patients to delineate the underlying pathology.

RESULTS

Diverse spectrum of distinctive spine anomalies has been identified. Malsegmentation of the skull base associated with diffuse fusion with the upper cervical vertebrae was the most common spine pathology. Bilateral failure of segmentation, unilateral unsegmented bar and failure of vertebral formation were of lesser occurrence. Strikingly, we observed that the side of the hemifacial microsomia is strongly correlated with that of the craniocervical and the cervical vertebral abnormalities.

CONCLUSION

The importance of this paper is threefold; first, little information is available in the literature regarding the magnitude and the diversity of spine pathology in patients with Goldenhar syndrome. Second, is to alert spine specialists that conventional radiographic assessment of the craniocervical area is an insufficient modality to assess children with syndromic associations. Third, a rotation and flexion deformity of the neck associated with facial asymmetry and/or plagiocephaly should be considered as a syndromic entity rather than a simple physiological deformation.

Diagnostic value of real-time sonoelastography in congenital muscular torticollis

OBJECTIVES

The purpose of this study was to evaluate the possible use of real-time sonoelastography in infants with congenital muscular torticollis for predicting treatment outcomes.

METHODS

The study included 20 infants with a sternocleidomastoid muscle thickness of greater than 10 mm, a sonoelastographic score of 4, and involvement of the entire length of the muscle (group 1) and 30 infants with a sternocleidomastoid muscle thickness of less than 10 mm, a sonoelastographic score of 3, and involvement of only part of the muscle (group 2). A physiatrist performed B-mode sonography and sonoelastography together, measured the thickness of the sternocleidomastoid muscle, and calculated the cross-sectional area of the involved muscle in both groups. On color scale sonoelastography, the sonoelastographic score of the sternocleidomastoid muscle was graded from 1 (purple to green: soft) to 4 (red: stiff), and the color histogram of the muscle was subsequently analyzed.

RESULTS

The thickness and cross-sectional area of the sternocleidomastoid muscles in group 1 were significantly greater than those in group 2 (P = .001). On the color histograms, the median red pixel values in group 1 were significantly greater than those in group 2 (P = .001). In group 1, the mass in the affected muscle completely disappeared in 16 infants (80%), and a residual mass was detected in 4 (20%) on B-mode sonography at the final outcome. However, in group 2, the mass in the affected sternocleidomastoid muscle completely disappeared in all of the infants.

CONCLUSIONS

These findings suggest that real-time sonoelastography, although an ancillary technique to conventional sonography, may predict treatment outcomes of congenital muscular torticollis.

[Cervical dystonia: clinical-radiological correlations and recommendations for the correction of botulinum therapy]

Seventy-eight patients with confirmed primary cervical dystonia CD were studied. All patients underwent CT of the soft tissues of the neck using slices at cervical vertebrae and MRI images of the cervical spine and of soft tissues. MRI images of 50 patients who did not have CD were used for comparison. This was followed by measuring the largest diameter along with the description of the shape of all observable muscles including the small muscles of the occipital area. In lateral flexion and rotation, 19% of patients showed disorders of muscles acting on head joints (laterocaput/torticaput). Muscles that act on the cervical spine were affected (laterocollis/torticollis) in 20% of patients. Both types of the disorder, but with various degrees of the caput- and collis- involvement, were presented in 61% of patients. Consequently, the ratio for these forms was approximately estimated as 1:1:3. The following conclusions have been made: In lateral flexion, clinical differentiation between laterocollis and laterocaput is possible. Lateral shift is always a result of laterocollis on one side and laterocaput on the opposite side. In rotation, clinical differentiation between torticollis and torticaput is not always possible. CT slices at levels C1 and C2 are advisable in these cases. Comparing the positions of vertebrae on both levels will provide a safe differentiation between torticollis and torticaput. Analysis of forward flexion (differentiation between antecollis and antecaput) can be accomplished by lateral observation of the angles between the cervical spine and the thoracic spine, respectively, and between the cervical spine and the base of skull. The same applies to the analysis of backward flexion (differentiation between retrocollis and retrocaput). Sagittal shift forwards usually does not require further diagnosis: it is almost always caused by bilateral dystonic activities of the Mm. sternocleidomastoidei.

The aetiology behind torticollis and variable spine defects in patients with Müllerian duct/renal aplasia-cervicothoracic somite dysplasia syndrome: 3D CT scan analysis

The aim of the article is fourfold; firstly, to detect the aetiology of torticollis in patients with Müllerian duct/renal aplasia-cervicothoracic somite dysplasia syndrome; secondly, spine pathology in Müllerian duct/renal aplasia-cervicothoracic somite dysplasia syndrome varies considerably from one patient to another and there are remarkable differences in severity and localization; thirdly, mismanagement of congenital spine pathology is a frequent cause of morbid/fatal outcome; and fourthly, the application of prophylactic surgical treatment to balance the growth of the spine at an early stage is mandatory. Reformatted CT scans helped in exploring the craniocervical and the entire spine in these patients. The reason behind torticollis ranged between aplasia of the posterior arch of the atlas, assimilation of the atlas and extensive fusion of the lower cervical vertebrae (bilateral failure of segmentation) in four patients; in one patient, in addition to the hypoplastic posterior arch of the atlas, we observed ossification of the anterior and the posterior longitudinal spinal ligaments giving rise to a block vertebrae-like suggestive of early senile ankylosing vertebral hyperostosis (Forestier disease). Scoliosis at different spine levels was attributable to variable spine defects. Pelvic ultrasound showed the classical renal agenesis in four patients; whereas in one patient, the MRI showed pelvic cake kidney (renal fused ectopia) associated with ovarian, uterine and vaginal abnormalities. This is the first exploratory study on the craniocervical and the entire spine in a group of patients with MURCS association.

Cervical myelopathy with retroodontoid pseudotumor caused by atlantoaxial rotatory fixation and senile tremor

OBJECTIVE

A rare case of retroodontoid pseudotumor caused by the combination of atlantoaxial rotatory fixation and senile tremor is reported.

METHOD

A 63-year-old man was treated for cervical myelopathy with retroodontoid pseudotumor caused by atlantoaxial rotatory fixation and senile tremor. He had an 18-year history of torticollis and a 7-year history of tremor. Magnetic resonance imaging revealed a retroodontoid pseudotumor compressing the spinal cord. Computed tomography showed an atlantoaxial rotatory fixation and osteoarthritis of the lateral facets. Resection of the posterior arch of the atlas and a posterior occiput-to-axis arthrodesis were performed with an autologous bone graft. His neurological condition improved, and the retroodontoid pseudotumor disappeared at 3-year follow up.

CONCLUSIONS

Frequent rotation of the head by the senile tremor caused friction of the lateral atlantoaxial facet with the development of osteoarthritis. This long-term mechanical stress was thought to cause the soft tissue hypertrophy around the lateral facet. Although spontaneous resolution of the pseudotumor after fixation of the unstable segment has been reported as the treatment of choice, decompression with occipitoaxial fusion was selected in the current case because the patient's neurological deficit was severe and progressive because of a remarkable canal stenosis at level C1/2.

Motor and cognitive development at one-year follow-up in infants with torticollis

BACKGROUND

Clinical experience suggests infants with torticollis are at risk for developmental delay.

AIMS

To examine gross motor (GM) skills at presentation in infants with torticollis; report first-year GM and cognitive outcomes; examine relationship between types of torticollis and above outcomes.

STUDY DESIGN

Prospective follow-up study.

SUBJECTS

Infants referred to 2 regional child development centers from April 2001-December 2002 with torticollis/head tilt and no perinatal complications syndromes were studied.

OUTCOME MEASURES

GM function was measured using the Alberta Infant Motor Scale and classified as normal (>10%), suspect (5-10% inclusive), or abnormal (<5%). Cognitive function was measured at follow-up using CAT-CLAMS-r Developmental Assessment. Follow-up data obtained between 8 and 15 months of age.

RESULTS

One hundred and one infants with torticollis were seen for initial assessment at mean age 2.9 (SD 1.5) months. Eighteen had sternomastoid tumor, 47 muscular torticollis and 36 postural torticollis. At presentation, 35 (35%) of the 101 infants had suspect or abnormal GM function. 19/66 children with normal GM and 17/35 with suspect or abnormal GM function had postural torticollis (p=0.054). All children received physical therapy. Follow-up assessment of 83 participants, mean age 12.8 (SD 3.6) months, showed 75 had normal GM function and 8 had suspect or abnormal GM function; 11/83 still had torticollis. Cognitive assessment on 66 infants, mean age 14.4 (SD 4.8) months, revealed 57 (87%) had normal cognitive function and 9 (13%) were either delayed or significantly delayed.

CONCLUSIONS

Infants with torticollis are at increased risk for early GM delay but most normalize by one year. Torticollis is not associated with delays in early cognitive function.

Atlantoaxial rotatory subluxation: realignment and discharge within 48???h

Atlantoaxial rotatory fixation is a rare disorder in which the atlas gets fixed in a position normally achieved during rotation. Patients present with painful torticollis and a typical 'cock robin' position of the head: rotation, slight flexion and head tilting contralateral to the direction of rotation. During childhood, laxity of the ligamentous apparatus and joint cups allows a wider range of motion and rotation within these joints. Traumatic effects contribute to subluxation at relevant degree (Fiedling type 2 and higher) for which skeletal traction is necessary. Duration of skeletal traction can be reduced to a minimum (24 h), as seen in this patient, when diagnosis is set as early as possible.

Suspected atlantoaxial rotatory fixation-subluxation: the value of multidetector computed tomography scanning under general anesthesia

STUDY DESIGN

Clinical case reports and radiologic study.

OBJECTIVES

To emphasize the value of computed tomography (CT) scan under general anesthesia in order to prevent misdiagnosing atlantoaxial rotatory fixation-subluxation in children with acute torticollis.

SUMMARY OF BACKGROUND DATA

A "cock-robin" posture clinically characterizes painful rotatory fixation of the atlantoaxial joint in children. Classically, the observation of persistent displacement of the dens between the lateral mass of the atlas and asymmetry of the atlantoaxial joint on radiography confirmed the diagnosis. More recently, (dynamic) CT scanning or magnetic resonance imaging is used to confirm the diagnosis. However, when a CT scan is performed with the head of the patient in the "cock-robin" position, there is a serious chance of misinterpretation due to the abnormal anatomic position of the atlantoaxial joint.

METHODS

Four consecutive cases of children presenting with an acute torticollis were analyzed. All were neurologically intact. A conventional single-slice CT scan made with the head rotated in the "cock-robin" position confined rotatory dislocation of the atlantoaxial joint. Subsequently, the patients were referred to our hospital for further treatment. To confirm the diagnosis before potential treatment, a multidetector CT scan under general anesthesia was performed in all 4.

RESULTS

The multidetector CT scans under general anesthesia did not show any abnormalities. All patients were treated conservatively and recovered completely within 4 weeks of being referred to our hospital.

CONCLUSIONS

Multidetector CT scanning under general anesthesia is recommended in children when there is suspicion for a spontaneously developed atlantoaxial rotatory fixation-subluxation.

Limited value of plain radiographs in infant torticollis

OBJECTIVE

The purpose of this work was to assess the frequency of clinically relevant findings from plain films of infants evaluated for torticollis.

PATIENTS AND METHODS

After institutional review board approval, radiology records were searched for infants 0 to 12 months of age who underwent plain film study for torticollis or "head tilt." Infants evaluated for trauma or Down syndrome were excluded. All of the studies were reviewed, demographic data was recorded, and any additional imaging studies were examined.

RESULTS

A total of 502 patients (189 girls and 313 boys) were identified with an average age of 0.37 +/- 0.2 years. Head tilt was to the left in two thirds of patients. Ten patients had abnormal findings reported. Six of these proved normal on subsequent studies (3 suspected occipital-C1 fusions, 2 suspected cervical fusions, and 1 suspected hemivertebra). Four patients had true bony vertebral abnormalities including absent left C7 pedicle, multiple fusion anomalies from C4 to T2, C3 hemivertebra and thoracic spine anomalies, and C4 hypoplasia. This last patient had abnormal kyphosis on physical examination and demonstrated instability with dynamic testing. Twenty-five additional patients with normal plain films underwent spine computed tomography or magnetic resonance imaging; all were normal.

CONCLUSIONS

The true-positive yield of plain films in nontraumatic infant torticollis was low (4 of 502). There were more false-positive than true-positive results. A common rationale for imaging is to exclude craniocervical or other unstable abnormalities that might contraindicate physical therapy, seen in only 1 of the 502 cases. Close physical examination could safely eliminate most patients sent for radiography.

Dynamic motion analysis of fetuses with central nervous system disorders by cine magnetic resonance imaging using fast imaging employing steady-state acquisition and parallel imaging: a preliminary result

OBJECT

The authors present a novel cine magnetic resonance (MR) imaging, two-dimensional (2D) fast imaging employing steady-state acquisition (FIESTA) technique with parallel imaging. It achieves temporal resolution at less than half a second as well as high spatial resolution cine imaging free of motion artifacts for evaluating the dynamic motion of fetuses in utero. The information obtained is used to predict postnatal outcome.

METHODS

Twenty-five fetuses with anomalies were studied. Ultrasonography demonstrated severe abnormalities in five of the fetuses; the other 20 fetuses constituted a control group. The cine fetal MR imaging demonstrated fetal head, neck, trunk, extremity, and finger as well as swallowing motions. Imaging findings were evaluated and compared in fetuses with major central nervous system (CNS) anomalies in five cases and minor CNS, non-CNS, or no anomalies in 20 cases. Normal motility was observed in the latter group. For fetuses in the former group, those with abnormal motility failed to survive after delivery, whereas those with normal motility survived with functioning preserved. The power deposition of radiofrequency, presented as specific absorption rate (SAR), was calculated. The SAR of FIESTA was approximately 13 times lower than that of conventional MR imaging of fetuses obtained using single-shot fast spin echo sequences.

CONCLUSIONS

The following conclusions are drawn: 1) Fetal motion is no longer a limitation for prenatal imaging after the implementation of parallel imaging with 2D FIESTA, 2) Cine MR imaging illustrates fetal motion in utero with high clinical reliability, 3) For cases involving major CNS anomalies, cine MR imaging provides information on extremity motility in fetuses and serves as a prognostic indicator of postnatal outcome, and 4) The cine MR used to observe fetal activity is technically 2D and conceptually three-dimensional. It provides four-dimensional information for making proper and timely obstetrical and/or postnatal management decisions.

The Coconut Condyle: Occipital Condylar Dysplasia Causing Torticollis and Leading to C1 Fracture

In this report we discuss the case of a child who was initially diagnosed at 1 month of age with congenital muscular torticollis. After falling off a slide at 22 months of age, the patient had onset of pain and an abrupt worsening of his torticollis. After a full workup, it was found that the patient had a C1 fracture and a disproportionately large ipsilateral occipital "coconut" condyle. We believe this congenital anomaly to be the cause of his original head tilt and also predisposed him to C1 fracture and worsening head tilt.