A 50-year-old woman was referred for evaluation of painful spasms of her neck and right shoulder.

The patient presented with marked left torticollis and left shoulder elevation, a set of involuntary, relatively sustained, and patterned muscular contractions producing an abnormal neck posture and referred to as cervical dystonia. In general, dystonia can express as sustained (presenting as fixed posturing or tonic spasms) or intermittent muscle contractions (presenting as spasmodic torticollis or dystonic tremor). Placement of patients’ own hand or fingers on the affected region has the potential of temporarily attenuating the dystonia, a phenomenon referred to as sensory tricks or geste antagonistique, highlighting the disruption of the motor program by a closed-loop sensory feedback. Dystonia may be generalized as is the case with primary, typically inherited, childhood-onset dystonias (such as DYT1 dystonia); focal (as in most secondary or adult-onset dystonias); or segmental (such as in acute dystonic reactions from use of dopamine-blocking drugs). Although secondary dystonias are usually focal or segmental, diffuse brain lesions can lead to generalized dystonia, such in cerebral palsy. Unlike childhood-onset primary dystonias, which affect the lower extremities first and then generalizing, adult-onset primary dystonias most often begin in the neck, face, or arms and rarely generalize. Adult-onset dystonia affecting the feet and childhood-onset dystonia affecting the upper body first should raise suspicion for a secondary rather than primary form of dystonia. In these cases, further diagnostic testing, such as brain imaging, becomes warranted.