Cervical dystonia is one of the most common dystonic disorders. Cervical dystonia causes sustained muscle contractions of the head and neck region causing the twisting and repetitive movements of head. Initially it may just start with a sensation of head being pulled to one side or the other. It may have a mild head tremor but eventually it may cause the sustained turning of the head to one side. This may lead to significant neck pain.

Cervical dystonia usually worsens with fatigue and emotional stress but it improves with relaxation and usually disappears in sleep. Sensory tricks are the characteristic feature of cervical dystonia in which if a patient touches the side of face or back of their head they can bring their head in the neutral position transiently. Cervical dystonia is also called spasmodic torticollis. It usually affects patients in their adulthood between the ages of 30 to 50. The most common neck muscles involved are sternocleidomastoid, levator scapulae, splenius capitis, trapezius and scalene muscles. The abnormal contractions of the different combination of these muscles  cause the head being turned or tilted to one side. Sometimes the ipsilateral shoulder could be higher than the contralateral shoulder and slightly anteriorly placed. Some patients may have just the sustained turn,  tilt, backward bending or forward beding of their head  whereas other patients may have dystonic head tremor. Some patients with cervical dystonia may have transient periods where dystonia may go away without any treatment, but it usually comes back. The head tremor could be side to side or horizental which is called no-no head tremor or vertical tremor which is called yes-yes head tremor. If the head tremor is mild then the dystonic tremor may be confused with essential tremor affecting head.

DIAGNOSIS: The diagnosis of cervical dystonia is usually clinical and requires examination by a neurologist. The brain scans are usually normal in these patients

TREATMENT: Initially the cervical dystonia may be very mild and patients may not have any botheration or symptoms. If the patient is not bothered by the symptoms, usually is not treated at this stage. Once the patients have neck pain or the symptoms become bothersome, the most effective treatment is botulinum toxin injections. These injections are given in the neck muscles involved. BOTOX injections are started from a low dose and the dose is increased slowly. The effect usually lasts anywhere from 3 to 4 months and these injections have to be repeated once the effect is gone.  Excessive dose of BOTOX may cause excessive weakness of the muscle. Some patients may feel slight swallowing difficulty especially for first 1 to 2 weeks which usually improves. The minority of patients may loose the efficacy of BOTOX injection due to the development of antibodies against BOTOX.

The medications which may be helpful in some cases include trihexyphenidyl, which is an anticholinergic medication. The starting dose is 1 to 2 mg per day then it is increased as needed divided in three doses up to a maximum of 6 mg per day. Side effects include dry mouth, in elderly patients it may cause confusion at times. Other medication used are baclofen and benzodiazepine especially clonazepam.

Surgical procedures such as thalamotomy and pallidotomy may be tried in cervical dystonia and are found to effective. Also surgical resection of the nerve supplying the muscles involved may  helpe in  some patients but usually dystonia comes back after a few years