J Neural Transm
DOI 10.1007/s00702-016-1621-7
HIGH IMPACT REVIEW IN NEUROSCIENCE, NEUROLOGY OR PSYCHIATRY - REVIEW ARTICLE
Anatomy and cervical dystonia
‘‘Dysfunction follows form’’
L. Tatu1,2 • W. H. Jost3
Received: 6 June 2016 / Accepted: 6 September 2016
Ó Springer-Verlag Wien 2016
Abstract At first glance, cervical dystonia might be an
illustration of the well-known proposition ‘‘function fol-
lows form’’. Nevertheless, cervical dystonia is a highly
non-physiological condition, which cannot be reproduced
by healthy subjects and does not respond to the usual
physiological rules. ‘‘Dysfunction follows form’’ might be
the most accurate aphorism to define cervical dystonia.
Taking into account this situation and recent insights, the
anatomic approach needs to be adapted to allow a better
understanding of semiology and to improve botulinum
toxin therapy. In this review dealing with a new approach
to cervical dystonia, we develop some practical anatomical
concepts concerning the head and neck complex. Knowl-
edge of cervical spine and muscular dysfunctions in cer-
vical dystonia is an essential stage in treating cervical
dystonia patients with botulinum toxin.
Keywords Cervical dystonia
Botulinum toxin

Anatomy
Cervical muscles
Muscular function
& L. Tatu
laurent.tatu@univ-fcomte.fr
1
Department of Anatomy, University of Franche-Comté,
Besançon, France
2
Department of Neuromuscular Diseases, CHRU Besançon,
Besançon, France
3
Department of Neurology, University of Freiburg, Freiburg,
Germany
Introduction
There is an age-old question concerning form and function,
anatomy and physiology. The relationships between these
two major branches of medicine are still a matter of debate.
The aphorism ‘‘form follows function’’, a principle asso-
ciated with architecture, is frequently applied to anatomy
(Tubbs 2015). The reverse alliteration ‘‘function follows
form’’ is more accurately used nowadays (Bergman 2015).
Cervical dystonia can be regarded as an example of this
old debate. In the last decade, anatomy has reappeared as a
major point in the management of cervical dystonia,
thereby reopening the discussion between form and func-
tion. The ‘‘collis caput concept’’, a practical semiologic
analysis procedure for cervical dystonia, is, for example,
mainly built on anatomic data and muscle functions (Re-
ichel 2011).
Based on well-known anatomic and biomechanic data,
movements of the head and neck are an interesting example
of the alliteration ‘‘function follows form’’. At first glance,
cervical dystonia might be another illustration of this
condition as well. Nevertheless, cervical dystonia is a
highly non-physiological condition. Numerous postures
and abnormal movements observed in cervical dystonia
cannot be reproduced by healthy subjects and do not
respond to usual physiological rules. Then, ‘‘dysfunction
follows form’’ might be the most accurate aphorism to
define cervical dystonia. Taking into account this situation,
the anatomic approach needs to be adapted to allow a better
understanding of cervical dystonia semiology.
For a long time, botulinum toxin has been the preferred
method in treating cervical dystonia (Wissel et al. 2001).
Nevertheless, failures in botulinum toxin exist and some of
the reasons for these unsatisfactory responses need to be
elucidated (Jinnah et al. 2016). Misunderstanding of
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functional anatomy is undoubtedly one of these factors. To
improve botulinum toxin therapy, in this review, we pro-
pose some practical anatomic data applied to cervical
dystonia.
Functional anatomy of cervical spine applied
to cervical dystonia
Because postures and abnormal movements observed in
cervical dystonia are highly non-physiological conditions,
the question is: do the standard physiological biomechan-
ical data concerning the head and neck movements help us
in cervical dystonia?
Some authors have been working on cervical spine
biomechanics and elaborating theories on head and neck
movements (Kapandji 2008). We can argue that these
biomechanic models are not really helpful in cervical
dystonia. They concern only normal situations and healthy
subjects. Moreover, they are so sophisticated that it is
difficult to use them in clinical practice.
In cervical dystonia patients, we need information to
help us analyze the semiologic patterns of abnormal
movement and to select the involved muscles. The most
practical vision of abnormal movements of the ‘‘head and
neck complex’’ is to consider two different parts in this
complex: the upper level ‘‘head and C1’’ and the lower
‘‘C3–C7’’. The two levels are able to move independently,
the upper one in relation to the lower one and the lower
one in relation to the thoracic spine. In this situation, C2
acts as a kind of ‘‘fixed point’’ due to the numerous
muscles inserted on its spinous process (i.e., obliquus
capitis inferior, rectus capitis major, semispinalis cervicis,
multifidus). This functional division of the ‘‘head and
neck complex’’ is one of the anatomic basics of the
‘‘collis caput complex’’ (Reichel 2011; Jost and Tatu
2015) (Fig. 1).
From a semiologic point of view, the question is to
define in cervical dystonia which level is mainly involved
in the abnormal movement. It may concern only ‘‘the head
and C1’’ level without movements of ‘‘C3–C7’’. On the
other hand, the abnormal movement may concern mainly
‘‘C3–C7’’. In this lower part, some segments (e.g., C3–C4)
can be more involved than the others, depending on the
cervical dystonia type.
Knowledge of topographic anatomy is
fundamental
In cervical dystonia, topographic anatomy is relevant to
two main topics: semiologic analysis and guidance of
botulinum toxin injections.
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L. Tatu, W. H. Jost
Head and C1
C2
C3-C7
Fig. 1 Anatomic organization of ‘‘Head and neck complex’’ applied
to cervical dystonia
With regard to the semiology, anatomical landmarks of
the ventral part of the neck are of major interest. Jugular
notch (Incisura jugularis sternalis), and laryngeal promi-
nence (Adam’s apple) should be considered to define which
part of the ‘‘head and neck complex’’ is involved in the
abnormal movement and posture. In cases of head rotation
or head lateroflexion, these two structures remain aligned.
This condition corresponds to the ‘‘caput’’ status of the
‘‘collis caput complex’’. If these structures are no longer
aligned, the neck is involved in the abnormal movement as
well, corresponding to the ‘‘collis’’ condition of the ‘‘collis
caput complex’’. In this condition, we can claim that the
main muscles involved act on the ‘‘C3–C7 level’’ (Fig. 2a).
In the sagittal plane, the meatus acusticus externus and
the clavicula are useful anatomical landmarks as well. In
case of ante- or retroflexion, if only the ‘‘head and C1
complex’’ is concerned, then meatus acusticus externus
stays in projection of the clavicula. If the ‘‘C3–C7 level’’ is
involved in cervical dystonia, then meatus acusticus
externus’ projection is in front of or behind the clavicular
(Fig. 2b).
Whatever the guidance (electromyography or/and
ultrasonography) of botulinum toxin injections, knowledge
of topographic landmarks of the dorsal and lateral aspects
of the neck is essential. The posterior triangle of the neck is
the key of lateral region of the neck. The triangle is
delimited by the posterior edge of the sternocleidomas-
toideus muscle and the anterior edge of the trapezius
muscle. The base of the triangle is the middle third of the
clavicula, and the apex of the triangle, behind the mastoid
process, is a narrow area where sternocleidomastoideus and
trapezius muscles meet. In this triangle, splenius capitis,
levator scapulae and scalenus medius muscles can be
injected. Nevertheless, the morphology of the posterior
Anatomy and cervical dystonia

(a) (b)

Torticollis Torticaput Antecollis Retrocollis

Laterocollis Laterocaput
Antecaput Retrocaput

Fig. 2 a Collis and caput conditions (rotation and lateroflexion). b Collis and caput conditions (ante- and retroflexion)

triangle of the neck is highly variable. In some cases, the
supraclavicular fossa is very deep and close to the
pulmonary apex. In other cases, the region is fatty and
the muscles can hardly be palpated. The external jugular
vein passes through the triangle and crosses the
SC SCM
sternocleidomastoideus. It should be avoided when inject-
ing muscles (Fig. 3).
Three prominent anatomic landmarks can be palpated on
the posterior aspect of the neck: the external occipital
protuberance (also called inion), the spinous process of C2
and the spinous process of C7. Between C2 and C7, the
spinous processes of C3, C4, C5 and C6 can sometimes be
palpated in thin patients. These three landmarks are of
value to define the vertebral levels and to guide the
injection. In a global manner, it is not recommended to
inject above the C2 level because of the risk of hitting the
vertebral artery (Fig. 4).

1 Cervical muscle dysfunctions

LS
T SM
OH
2 physiological posture. As a consequence, the functions of
Fig. 3 Lateral cervical region. SCM sternocleidomastoideus muscle,
SC splenius capitis muscle, LS levator scapulae muscle, SM scalenus
medius muscle, T trapezius muscle (pars descendens), OH Omohy-
oideus muscle, 1 external jugular vein, 2 common carotid artery
The functions of a cervical muscle depend on the position
of the ‘‘head and neck complex’’. They are usually
described in healthy subjects in a neutral position of the
head and neck (Tabeke et al. 1974; Mayoux Benhamou
et al. 1997). In cervical dystonia, the cervical muscles act
on a ‘‘head and neck complex’’ that is in an abnormal, non-
cervical muscles in cervical dystonia are sometimes not the
physiological ones. Moreover, in cervical dystonia, the
functions of a given muscle may be influenced by other
dystonic cervical muscles.

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I
C2
C7
Fig. 4 Posterior cervical region. I inion (external occipital protuber-
ance), C2 C2 spinous process, C7 C7 spinous process. Red zone risk
of hitting vertebral artery, orange zone risk of hitting pulmonary apex,
green zone no major risk. Blue spots injection sites
From a semiologic point of view, cervical muscles
involved in cervical dystonia can be divided according to
two main classifications. First, considering their insertions,
cervical muscles can be classified into muscles acting
mainly on the head or mainly on the neck. This distinction
corresponds to the anatomical basics of the ‘‘collis caput
complex’’. This approach is very useful to select the
muscles to be injected with botulinum toxin. As an
example, the sternocleidomastoideus muscle, inserted on
the mastoid process, is only able to act on the head, and the
semispinalis cervicis muscle, inserted on the cervico-tho-
racic spine, can only exercise action on the neck.
Second, cervical muscles can also be classified in three
groups: dystonic, ‘‘antagonist’’ and ‘‘compensatory’’,
depending on their type of involvement in cervical dys-
tonia. Dystonic muscles are able to induce abnormal
movement, posture or spasms. Hyperactivity can be
recorded in these muscles with electromyography, and
they are mainly the target of botulinum toxin therapy. The
‘‘antagonist’’ muscles are passively tensed by abnormal
movement or posture. They can sometimes act as real
antagonist muscles inducing opposite movements or tre-
mor. In rare cases, they should also be injected. The
‘‘compensatory’’ muscles may help the patients to correct
their posture and their gaze. As they act as useful muscles
for the patients, they should not be treated by botulinum
toxin (Fig. 5). Moreover, any compensation can mask an
abnormal movement. For example, shoulder elevation can
limit lateroflexion of the head and neck. During clinical
examination, if the shoulder is fixed, then the abnormal
movement becomes obvious.
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L. Tatu, W. H. Jost
2
3
1
Fig. 5 Muscles involved in cervical dystonia. Example of right
lateroflexion. 1 Some of the right paravertebral muscles (splenius and
semispinalis muscles) may act as dystonic muscles, 2 left upper
trapezius muscle should be regarded as an ‘‘antagonist’’ muscle,
passively tensed by the abnormal movement, 3 right levator scapulae
muscle is a compensatory muscle. Right shoulder elevation helps
patient to correct his gaze
Cervical dystonia is a global disease inducing hyperac-
tivity, spasms, tremor in a good number of cervical mus-
cles. Obviously, it is not possible to treat all the hyperactive
muscles with botulinum toxin. We know that a few muscles
are more frequently involved and may be the leading
muscles. They, therefore, have to be injected first. These
key muscles may also be specifically activated during
certain tasks, such as walking, sitting or closing eyes. They
may explain transient worsening of cervical dystonia dur-
ing these tasks.
For decades, splenius capitis and sternocleidomas-
toideus have been considered as the key muscles involved
in cervical dystonia and the main targets of botulinum toxin
injections. The choice of these muscles, both inserted on
the head, was guided by their involvement in rotation in
physiological conditions. Sternocleidomastoideus, as the
most obvious muscle of the region, became an overused
and over-injected muscle in cases of rotation in cervical
dystonia. In fact, sternocleidomastoideus, such as splenius
capitis, are inserted on the head and not on the neck. So, in
cervical dystonia, if the head is not mainly concerned by
the abnormal movement, they are only weakly involved.
Taking into account the new semiologic approaches and
the deep cervical muscles, more frequently used as a target
for botulinum toxin in cervical dystonia, new key muscles
have to be considered: e.g., levator scapulae and obliquus
capitis inferior. These ‘‘non-conventional’’ muscles should
have a stronger role in today’s botulinum toxin therapy.
Obviously, further clinical studies are needed to define the
priorities for the use of these muscles.
Levator scapulae acts mainly on the neck inducing a
homolateral rotation and lateroflexion. In physiological
conditions, participation of levator scapulae in head and
neck motion has been considered as negligible (Bull et al.
Anatomy and cervical dystonia

1984; Mayoux Benhamou et al. 1995). Obliquus capitis

inferior is the biggest suboccipital muscle acting as an
important homolateral rotator of the head in cervical dys-
tonia (Schramm et al. 2014). In physiological conditions,
obliquus capitis inferior is regarded as a powerless rotator
muscle (Kapandji 2008).

A new interest for the deepest layer

of the posterior cervical muscles

Cervical muscles are classified according to their positions

around the cervical spine. The anterior group includes the
platysma and the deep prevertebral muscles: longus capitis
and longus colli muscles. They are mainly involved in the
flexion of the head but are difficult to inject with botulinum
toxin in daily practice (Hefter et al. 2012). The lateral
group includes sternocleidomastoideus, levator scapulae
and scalenus muscles, all inserted on the pectoral girdle.
They are easier to inject using cervical anatomical land-
marks of the lateral part of the neck.
Anatomic organization of posterior cervical muscles is
complex. For some authors, dorsal neck muscles consist of
four muscular layers (Mayoux Benhamou et al. 1997;
Kapandji 2008). From a practical point of view, it seems
more accurate to consider the posterior cervical muscles as
organized in three layers (superficial, middle and deep).
The superficial layer is formed by the upper trapezius
muscle and the middle layer by the splenius capitis, sple-
nius cervicis, longissimus capitis, longissimus cervicis and
semispinalis capitis muscles. The deep layer includes the
suboccipital muscles, the semispinalis cervicis and multi-
fidus muscles. All of these muscles, except the upper
trapezius and the suboccipital muscles, are organized in the
same way: a common paravertebral lower insertion that
gives rise to two components: one to the head and one to
the neck. A fatty layer, including numerous veins, is
inserted between the deep and the middle muscular layers.
When injecting botulinum toxin, hitting a vein in this layer
may lead to bleeding and to post-injection pain.
In the last decade, new attention has been paid to the
deepest muscular layer, which can be divided into two
levels. The upper one (above C2 level) includes four short
suboccipital muscles (rectus capitis major and minor
muscles, obliquus capitis superior and inferior muscles).
The lower one (below C2 level) is made of two muscles:
the semispinalis cervicis muscle lying on the multifidus
muscle. Obliquus capitis inferior appears as a powerful
homolateral rotator of the head in cervical dystonia. The
semispinalis cervicis muscle is involved in the homolateral
rotation of the neck (Fig. 6).
These deepest muscles of the neck, sometimes consid-
ered as too difficult to inject with botulinum toxin, are now
Fig. 6 Deep posterior cervical muscles. 1 Inion (external occipital
protuberance), 2 C2 spinous process, 3 C7 spinous process, 4 obliquus
capitis inferior muscle, 5 semispinalis cervicis muscle
more frequently used in treatment procedures. Injecting
toxin in obliquus capitis inferior or semispinalis cervicis
muscle can be helpful in different types of cervical
dystonia.
Ultrasonography is the most accurate guidance to inject
a given muscle of these posterior muscles. For example, it
allows us to inject selectively splenius capitis muscle or
semispinalis capitis muscle in the middle layer and to reach
safely obliquus capitis inferior in the deepest layer
(Schramm et al. 2015).
The importance of the architecture of cervical
muscles
Muscle architecture definition includes: anatomy of tendi-
nous parts of the muscles, muscular organization and
neuromuscular compartments and, as a consequence,
location of neuromuscular junctions. These data are rarely
taken into account in treating cervical dystonia with
botulinum toxin.
Cervical muscles, as numerous other muscles, are
organized around tendinous parts or include large or long
tendons. The architecture of a given muscle is the major
determinant of its function. The main components of this
architecture are muscle fibers, which are inserted on
intramuscular fibrous structures. The latter form a

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connective tissue network, a ‘‘fibrous skeleton’’ of muscle,
including intramuscular aponeuroses that then densen into
tendons inserted on the bone (Tatu and Parratte 2016).
Tendinous parts are to be avoided when injecting toxin.
They usually participate in dividing the muscle into neu-
romuscular compartments, corresponding to separate
functional subunits formed of morphologically and func-
tionally identical muscle fibers. Each compartment is
innervated by an individual nerve branch and controlled by
a specific spinal neuronal population (Windhorst et al.
1989; Segal et al. 1991). Nevertheless, most of the cervical
muscles’ compartments have to be described. Some of
them are known and sometimes visible in magnetic reso-
nance imaging as in the case of semispinalis capitis muscle.
At least two compartments can be defined in this muscle: a
vertical medial part, traversed by the great occipital nerve
at the C2–C3 level, and a lateral part, semi-circular in
shape. A global unilateral contraction of this muscle
induces homolateral rotation and lateroflexion and partic-
ipates in the retroflexion of the head. Nevertheless, owing
to its insertions, each compartment is involved differently
in these functions.
In some cases, ultrasonography allows us to specify
muscle organization such as in the case of levator scapulae
muscle. This muscle is organized in four bundles inserted
onto the transverse processes of C1, C2, C3 and C4. These
bundles are visible in ultrasonographic images and can be
injected selectively with botulinum toxin to act on a given
vertebral level. The larger part of the muscle, where the
four bundles meet, is located at its insertion into the medial
border of the scapula. Injecting this point leads to a global
action on the muscle but needs a careful approach because
of the risk of hitting the pulmonary apex and causing a
pneumothorax.
Another important question is where the motor endplates
in cervical muscles are. Indeed, botulinum toxin should be
injected near the motor endplates to obtain maximal effi-
ciency and to reduce doses. As a general rule, it is com-
monly accepted that the motor endplates are equidistant
from the poles of their respective muscle fibers (Buchthal
and Schmalbruch 1980). Nevertheless, this question has
strong connections with the muscular compartments and
innervation types (truncular vs metameric). Some muscles,
such as trapezius, have a ‘‘mixed’’ innervation (truncular by
accessory nerve and metameric dorsal branches of cervical
spinal nerves). There is a lack of histochemical studies to
specify the locations of motor endplates in cervical muscles.
An indirect method to study these locations is to practice
intramuscular dissections of motor nerves. The nervous
intramuscular distribution allows the approach to high
density zones of the motor endplates. Using this technique,
the optimal zone in SCM muscle is defined as being in the
upper third of the muscle (Lee et al. 2011). Motor endplates’
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L. Tatu, W. H. Jost
zones can also be approached by 3D surface electromyog-
raphy (Falla et al. 2002; Delnooz et al. 2014). Using this
method in a recent study, this zone was defined at the lower
border of the superior third part of the sternocleidomas-
toideus muscle and at half muscle length of the splenius
capitis muscle (Delnooz et al. 2014). Obviously, this kind of
elaborate process cannot be used in clinical practice.
Moreover, further studies are needed before implementing
data on motor endplates locations in routine botulinum
toxin therapy.
Conclusion
Knowledge of topographic and functional anatomy of
cervical muscles and cervical spine is an essential prereq-
uisite for treating cervical dystonia patients with botulinum
toxin. Recent insights have modified the conventional
anatomical conception of the head and neck complex.
Moreover, some physiological and anatomic data are not
accurate in cervical dystonia, a highly non-physiological
condition. In this review, we have tried to focus on the
more important practical anatomical points that should be
taken into account to improve botulinum toxin efficiency in
cervical dystonia.
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