Neck on Lockdown: Using Botulinum Toxin to Break Free from Cervical Dystonia Acquired Post-Infection- A Case Report

Case Diagnosis: A 68 year old male with acquired cervical dystonia due to post-infectious cervical ankylosis.

Case Description or Program Description: The patient presented with chronic cervical paraspinal pain and progressive range of motion (ROM) restriction worsening since his initial osteomyelitis infection nine years ago. Symptoms were treated non-surgically and were refractory to multiple courses of physical therapy. Physical examination was significant for cervical protraction with exaggerated lordosis. ROM was severely limited in all cervical planes with hypertonicity in the bilateral sternocleidomastoid, scalene and trapezius musculature. Imaging of the cervical spine was significant for cervical vertebrae ankylosis as well as atrophy and fatty infiltration of bilateral paraspinal musculature. In conjunction with physical therapy, 200 units of botulinum toxin was administered to bilateral splenius capitus, trapezius, and cervical paraspinals musculature with hopes of improving pain and ROM.

Setting: outpatient spine clinic

Assessment/Results: One month after botulinum toxin injections, the patient reported an 80% reduction in overall pain in the muscles injected. While his ROM improved minimally, the patient’s overall comfort level significantly improved. He continues with physical therapy in conjunction with recurrent botulinum toxin injections to further improve mobility throughout the cervical spine over time.

Discussion (relevance): Although cervical osteomyelitis is uncommon, its incidence has increased in recent decades, which could allow for post-infectious complications to become more prevalent. While both cervical dystonia and cervical ankylosis have been reported to occur after a spine infection, cases are rare and management options have not been well discussed. To our knowledge, this is the first reported case of using botulinum toxin to manage acquired cervical dystonia that developed in the context of post-infectious cervical ankylosis.

Conclusions: In an acquired cervical dystonia secondary to post-infectious cervical ankylosis, botulinum toxin may aid in pain relief, and, over time, improve cervical ROM.