101
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Gimeno H, Lumsden D, Gordon A, Tustin K, Ashkan K, Selway R, Lin JP. Improvement in upper limb function in children with dystonia following deep brain stimulation. Eur J Paediatr Neurol 2013; 17:353-60. [PMID: 23332134 DOI: 10.1016/j.ejpn.2012.12.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2012] [Revised: 12/10/2012] [Accepted: 12/17/2012] [Indexed: 11/18/2022]
Abstract
BACKGROUND Childhood dystonia can severely impact upper limb function. Deep brain stimulation (DBS) has been shown to be effective in reducing dystonic symptoms in childhood. Functional recovery following DBS is however not well understood. AIMS To explore changes in upper limb function following DBS in paediatric dystonia. METHODS Upper limb outcomes, using the Melbourne Assessment of Unilateral Upper Limb Function, are reported in 20 cases of childhood dystonia (unilateral n = 1, four limb n = 19) at 6 and 12 months following DBS. RESULTS Improvement in at least in one upper limb was seen in the majority of cases (n = 17, 85%) at 12 months following DBS. Deterioration of scores in both upper limbs was seen in 3 children with progressive disorders. Grouping the children aetiologically, a significant improvement in the dominant hand was obtained for the primary dystonia/dystonia-plus group at both six (p = 0.018) and twelve months (p = 0.012). In secondary dystonia due to a static disorder, improvement was also seen at 6 (p = 0.043) and 12 months (p = 0.046) in the non-dominant hand. No significant change was found in the group of children with progressive disorders. CONCLUSIONS DBS has the potential to alter upper limb function in children with primary and secondary dystonia. The dominant hand improved most in children with primary dystonias, with greater improvement in the non-dominant hand in secondary-static cases.
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Affiliation(s)
- Hortensia Gimeno
- Complex Motor Disorders Service, Evelina Children's Hospital, Guy's & St Thomas' NHS Foundation Trust, London, UK.
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102
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Lumsden DE, Kaminska M, Gimeno H, Tustin K, Baker L, Perides S, Ashkan K, Selway R, Lin JP. Proportion of life lived with dystonia inversely correlates with response to pallidal deep brain stimulation in both primary and secondary childhood dystonia. Dev Med Child Neurol 2013; 55:567-74. [PMID: 23452222 DOI: 10.1111/dmcn.12117] [Citation(s) in RCA: 112] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/20/2012] [Indexed: 12/20/2022]
Abstract
AIM The aim of this study was to examine the impact of dystonia aetiology and duration, contracture, and age at deep brain stimulation (DBS) surgery on outcome in a cohort of children with medically refractory, disabling primary, secondary-static, or secondary-progressive dystonias, including neurodegeneration with brain iron accumulation (NBIA). METHOD Dystonia severity was assessed using the Burke-Fahn-Marsden Dystonia Rating Scale (BFMDRS) motor score at baseline and 6 and 12 months postoperatively in a cohort of 70 consecutive children undergoing DBS between June 2005 and July 2011. RESULTS Two children (3%) received unilateral DBS for hemidystonia and were excluded and five (7%) developed infections requiring part-DBS removal within 6 months, leaving 63 children (90%) undergoing bilateral DBS for follow-up (34 males, 29 females; mean age at surgery for the whole group 10y 4mo, SD 4y 2mo, range 1-14y). Seventeen children were classified with primary dystonia: mean age 12 years 11 months, SD 4 years 6 months range 4 years 6 months to 17 years 3 months; 28 as having secondary-static dystonia: mean age 10 years 2 months, SD 4 years 9 months (range 3y 3mo-20y); five as having secondary-progressive dystonia: mean age 8 years 11 months, SD 3 years 9 months (range 5y 5mo-13y 1mo); and 13 as having NBIA dystonia: mean age 10 years 2 months, SD 3 years 11 months (range 1-14y). Children with primary dystonias demonstrated greater improvements in BFMDRS motor score than those in the other aetiological categories (Kruskal-Wallis test, p<0.001), which correlated negatively with dystonia duration and more strongly still against the ratio of dystonia duration normalized to age at surgery (DD/AS ratio) at 1 year (Spearman's rank correlation coefficient 0.4752 and -0.599 respectively). A similar significant negative correlation was found in the secondary-static dystonia group between outcome at 1 year and DD/AS ratio (-0.461). Poorer outcome in secondary dystonia coincided with the absence of a period of normal motor development in comparison with the primary dystonia group. A significant improvement in BFMDRS motor score was seen in the NBIA group at 6, but not 12 months (Wilcoxon signed rank test p=0.028, p=0.85 respectively). No reduction in efficacy was seen in children with a musculoskeletal deformity at the time of surgery. CONCLUSION Response to pallidal DBS in the treatment of dystonia declines with the proportion of life lived with dystonia in primary and secondary dystonia. Other intrinsic factors reduce the median magnitude of reduction in secondary dystonia after DBS. DBS should be offered early, preferably within 5 years of onset, to maximize benefits and reduce the childhood experience of dystonia, including musculoskeletal deformity. Other multidimensional assessments are required to understand how DBS improves the lives of children with dystonia.
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Affiliation(s)
- Daniel E Lumsden
- Complex Motor Disorders Service, Evelina Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
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103
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Lumsden DE, Ashmore J, Charles-Edwards G, Lin JP, Ashkan K, Selway R. Accuracy of stimulating electrode placement in paediatric pallidal deep brain stimulation for primary and secondary dystonia. Acta Neurochir (Wien) 2013; 155:823-36. [PMID: 23430231 DOI: 10.1007/s00701-013-1629-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2012] [Accepted: 01/24/2013] [Indexed: 12/14/2022]
Abstract
BACKGROUND Accuracy of electrode placement is an important determinant of outcome following deep brain stimulation (DBS) surgery. Data on accuracy of electrode placement into the globus pallidum interna (GPi) in paediatric patients is limited, particularly those with non-primary dystonia who often have smaller GPi. Pallidal DBS is known to be more effective in the treatment of primary dystonia compared with secondary dystonia. OBJECTIVES We aimed to determine if accuracy of pallidal electrode placement differed between primary, secondary and NBIA (neuronal degeneration and brain iron accumulation) associated dystonia and how this related to motor outcome following surgery. METHODS A retrospective review of a consecutive cohort of children and young people undergoing DBS surgery in a single centre. Fused in frame preoperative planning magnetic resonance imaging (MRI) and postoperative computed tomography (CT) brain scans were used to determine the accuracy of placement of DBS electrode tip in Leskell stereotactic system compared with the planned target. The differences along X, Y, and Z coordinates were calculated, as was the Euclidean distance of electrode tip from the target. The relationship between proximity to target and change in Burke-Fahn-Marsden Dystonia Rating Scale at 1 year was also measured. RESULTS Data were collected from 88 electrodes placed in 42 patients (14 primary dystonia, 18 secondary dystonia and 10 NBIA associated dystonia). Median differences between planned target and actual position were: left-side X-axis 1.05 mm, Y-axis 0.85 mm, Z-axis 0.94 mm and Euclidean difference 2.04 mm; right-side X-axis 1.28 mm, Y-axis 0.70 mm, Z-axis 0.70 mm and Euclidean difference 2.45 mm. Accuracy did not differ between left and right-sided electrodes. No difference in accuracy was seen between primary, secondary or NBIA associated dystonia. Dystonia reduction at 1 year post surgery did not appear to relate to proximity of implanted electrode to surgical target across the cohort. CONCLUSIONS Accuracy of surgical placement did not differ between primary, secondary or NBIA associated dystonia. Decreased efficacy of pallidal DBS in secondary and NBIA associated dystonia is unlikely to be related to difficulties in achieving the planned electrode placement.
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Affiliation(s)
- Daniel E Lumsden
- Complex Motor Disorders Service, Evelina Children's Hospital, Guy's & St Thomas' NHS Foundation Trust, Lambeth Palace Road, London, SE1 7EH, UK.
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104
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Ashkan K, Shotbolt P, David AS, Samuel M. Deep brain stimulation: a return journey from psychiatry to neurology. Postgrad Med J 2013; 89:323-8. [PMID: 23503892 DOI: 10.1136/postgradmedj-2012-131520] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Deep brain stimulation (DBS) has emerged as an effective neurosurgical tool to treat a range of conditions. Its use in movement disorders such as Parkinson's disease, tremor and dystonia is now well established and has been approved by the National Institute of Clinical Excellence (NICE). The NICE does, however, emphasise the need for a multidisciplinary team to manage these patients. Such a team is traditionally composed of neurologists, neurosurgeons and neuropsychologists. Neuropsychiatrists, however, are increasingly recognised as essential members given many psychiatric considerations that may arise in patients undergoing DBS. Patient selection, assessment of competence to consent and treatment of postoperative psychiatric disease are just a few areas where neuropsychiatric input is invaluable. Partly driven by this close team working and partly based on the early history of DBS for psychiatric disorders, there is increasing interest in re-exploring the potential of neurosurgery to treat patients with psychiatric disease, such as depression and obsessive-compulsive disorder. Although the clinical experience and evidence with DBS in this group of patients are steadily increasing, many questions remain unanswered. Yet, the characteristics of optimal surgical candidates, the best choice of DBS target, the most effective stimulating parameters and the extent of postoperative improvement are not clear for most psychiatric conditions. Further research is therefore required to define how DBS can be best utilised to improve the quality of life of patients with psychiatric disease.
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Affiliation(s)
- Keyoumars Ashkan
- Department of Neurosurgery, King's College Hospital, Denmark Hill, London SE5 9RS, UK.
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105
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Koy A, Hellmich M, Pauls KAM, Marks W, Lin JP, Fricke O, Timmermann L. Effects of deep brain stimulation in dyskinetic cerebral palsy: A meta-analysis. Mov Disord 2013; 28:647-54. [DOI: 10.1002/mds.25339] [Citation(s) in RCA: 122] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2012] [Revised: 11/27/2012] [Accepted: 12/03/2012] [Indexed: 01/26/2023] Open
Affiliation(s)
| | - Martin Hellmich
- Institute of Medical Statistics, Informatics and Epidemiology; University of Cologne; Germany
| | | | - Warren Marks
- Department of Pediatric Neurology; Cook Children's Medical Center; Fort Worth; Texas; United States of America
| | - Jean-Pierre Lin
- Complex Motor Disorders Service, Pediatric Neuroscience; Guy's & St Thomas' Hospitals Foundation Trust & King's College Hospital Foundation Trust, King's Health Partners; London; United Kingdom
| | - Oliver Fricke
- Department of Pediatric Neurology; University Hospital; Cologne; Germany
| | - Lars Timmermann
- Department of Neurology; University Hospital Cologne; Germany
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106
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Fuller J, Prescott IA, Moro E, Toda H, Lozano A, Hutchison WD. Pallidal Deep Brain Stimulation for a Case of Hemidystonia Secondary to a Striatal Stroke. Stereotact Funct Neurosurg 2013; 91:190-7. [DOI: 10.1159/000345113] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2011] [Accepted: 09/28/2012] [Indexed: 11/19/2022]
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107
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Harries AM, Sandhu M, Spacey SD, Aly MM, Honey CR. Unilateral Pallidal Deep Brain Stimulation in a Patient with Dystonia Secondary to Episodic Ataxia Type 2. Stereotact Funct Neurosurg 2013; 91:233-5. [DOI: 10.1159/000345265] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2011] [Accepted: 10/15/2012] [Indexed: 11/19/2022]
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108
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Vidailhet M, Jutras MF, Roze E, Grabli D. Deep brain stimulation for dystonia. HANDBOOK OF CLINICAL NEUROLOGY 2013; 116:167-187. [PMID: 24112893 DOI: 10.1016/b978-0-444-53497-2.00014-0] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
The few reported controlled studies show that bilateral stimulation of the globus pallidus interna (GPi) is a safe and effective long-term treatment for hyperkinetic disorders. However, the recently published data on deep brain stimulation (DBS) applied to different targets or patients (especially those with secondary dystonia) are mainly uncontrolled case reports, precluding a clear determination of its efficacy, and providing little guidance as to the choice of a "good" target in a "good" patient. This chapter reviews the literature on DBS in primary dystonia, paying particular attention to the risk:benefit ratio in focal and segmental dystonias (cervical dystonia, cranial dystonia) and to the predictive factors for a good outcome. The chapter also highlights recent data on the marked benefits of the technique in myoclonus dystonia (in which pallidal, as opposed to thalamic, stimulation is more effective) and in tardive dystonia-dyskinesia. Although, the decision to treat appears relatively straightforward in patients with primary dystonia, myoclonus-dystonia, and tardive dystonia who have a normal findings on magnetic resonance imaging and normal cognitive function, there are still no reliable tools to help predict the timescale of postoperative benefit. This chapter provides a comprehensive analysis of the use of the treatment in various types of secondary dystonia, with little to moderate benefit in most cases, based on single cases or small series. Beyond the reduction in the severity of dystonia, the global motor and functional outcome is difficult to determine owing to the paucity of adequate evaluation tools. Because of the large interpatient variability, different targets may be effective depending on the symptoms in each individual.
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Affiliation(s)
- Marie Vidailhet
- Department of Neurology, Groupe Hospitalier Pitié-Salpêtrière, Paris, France; Research Center of the Brain and Spinal Cord Institute, Université Paris 6/Inserm UMR S975, Paris, France; Pierre et Marie Curie Paris-6 University, Paris, France
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109
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Martinez JAE, Vidarte OAE, Uribe GA. Functional neurosurgery for secondary dystonia: indications and long-term results. ACTA NEUROCHIRURGICA. SUPPLEMENT 2013; 117:61-6. [PMID: 23652658 DOI: 10.1007/978-3-7091-1482-7_10] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
Dystonia is a movement disorder characterized by patterned, repetitive, phasic, or tonic sustained muscle contractions that produce abnormal, often twisting, postures or repetitive movements. When the disorder is genetic or the cause is unknown and dystonia is the sole feature, the disease is called primary or idiopathic, conversely secondary dystonia (SD) may be caused by various brain insults. Both primary dystonia and SD have been notorious for their poor response to medical treatment. Today, stereotactic neurosurgical procedures are offered to improve the disability and quality of life of patients who do not respond to medical therapy. However, SD shows less and more variable results than primary dystonia to neurosurgical procedures, the benefits of ablative or deep brain stimulation (DBS) procedures in basal structures being still subject to debate and much harder to fully appreciate. In this work, the authors show a 33-patient series with secondary dystonia, separating the statistic and clinical analysis into several etiology groups: perinatal insults, tardive syndromes, genetic syndromes, and posttraumatic. In these groups, we show the mean BFM score improvement in the different patient series, comparing our results with world literature, and finally propose a classification system for bettering the clinical approach in surgery decision when this is indicated.
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110
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Witt J, Starr PA, Ostrem JL. Use of Pallidal Deep Brain Stimulation in Postinfarct Hemidystonia. Stereotact Funct Neurosurg 2013; 91:243-7. [DOI: 10.1159/000345262] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2012] [Accepted: 10/13/2012] [Indexed: 11/19/2022]
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111
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Tierney TS, Lozano AM. Surgical treatment for secondary dystonia. Mov Disord 2012; 27:1598-605. [PMID: 23037556 DOI: 10.1002/mds.25204] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2012] [Revised: 08/15/2012] [Accepted: 08/22/2012] [Indexed: 12/16/2022] Open
Abstract
Surgical therapy for the secondary dystonias is generally perceived to be less effective than for primary disease. However, a number of case reports and small open series have recently appeared describing quite favorable outcomes following surgery for some nonprimary dystonias. We discuss surgical treatment options for this group of diverse conditions, including tardive dystonia, dystonic cerebral palsy, and certain heredodegenerative diseases in which deep brain stimulation and ablative lesions of the posteroventral pallidum have been shown to be effective. Other types of secondary dystonia respond less well to pallidal surgery, particularly when anatomical lesions of the basal ganglia are prominent on preoperative imaging. For these conditions, central baclofen delivery and botulinum toxin denervation may be considered. With optimal medical and surgical care, some patients with secondary dystonia have achieved reductions in disability and pain that approach those documented for primary dystonia.
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Affiliation(s)
- Travis S Tierney
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
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112
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DiFrancesco MF, Halpern CH, Hurtig HH, Baltuch GH, Heuer GG. Pediatric indications for deep brain stimulation. Childs Nerv Syst 2012; 28:1701-14. [PMID: 22828866 DOI: 10.1007/s00381-012-1861-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2012] [Accepted: 07/10/2012] [Indexed: 12/16/2022]
Abstract
PURPOSE Based on the success of deep brain stimulation (DBS) in the treatment of adult disorders, it is reasonable to assume that the application of DBS in the pediatric population is an emerging area worthy of study. The purpose of this paper is to outline the current movement disorder indications for DBS in the pediatric population, and to describe areas of investigation, including possible medically refractory psychiatric indications. METHODS We performed a structured review of the English language literature from 1990 to 2011 related to studies of DBS in pediatrics using Medline and PubMed search results. RESULTS Twenty-four reports of DBS in the pediatric population were found. Based on published data on the use of DBS for pediatric indications, there is a spectrum of clinical evidence for the use of DBS to treat different disorders. Dystonia, a disease associated with a low rate of remission and significant disability, is routinely treated with DBS and is currently the most promising pediatric application of DBS. We caution the application of DBS to conditions associated with a high remission rate later in adulthood, like obsessive-compulsive disorder and Tourette's syndrome. Moreover, epilepsy and obesity are currently being investigated as indications for DBS in the adult population; however, both are associated with significant morbidity in pediatrics. CONCLUSION While currently dystonia is the most promising application of DBS in the pediatric population, multiple conditions currently being investigated in adults also afflict children and adolescents, and thus warrant further research.
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Affiliation(s)
- Matthew F DiFrancesco
- Center for Functional and Restorative Neurosurgery, Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA 19104-4399, USA
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113
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Gimeno H, Tustin K, Selway R, Lin JP. Beyond the Burke-Fahn-Marsden Dystonia Rating Scale: deep brain stimulation in childhood secondary dystonia. Eur J Paediatr Neurol 2012; 16:501-8. [PMID: 22258088 DOI: 10.1016/j.ejpn.2011.12.014] [Citation(s) in RCA: 89] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2011] [Revised: 12/22/2011] [Accepted: 12/27/2011] [Indexed: 11/30/2022]
Abstract
PURPOSE Deep brain stimulation is now widely accepted as an effective treatment for children with primary generalized dystonia. More variable results are reported in secondary dystonias and its efficacy in this heterogeneous group has not been fully elucidated. Deep brain stimulation outcomes are typically reported using impairment-focused measures, such as the Burke-Fahn-Marsden Dystonia Rating Scale, which provide little information about function and participation outcomes or changes in non-motor areas. The aim is to demonstrate that in some cases of secondary dystonia, the sole use of impairment level measures, such as the Burke-Fahn-Marsden Dystonia Rating Scale, may be insufficient to fully evaluate outcome following deep brain stimulation. METHODS Six paediatric cases who underwent deep brain stimulation surgery with a minimum of one year follow up were selected on the basis of apparent non-response to deep brain stimulation, defined as a clinically insignificant change in the Burke-Fahn-Marsden Dystonia Movement Scale (<20%), but where other evaluation measures demonstrated clinical efficacy across several domains. RESULTS Despite no significant change in Burke-Fahn-Marsden Dystonia Rating Scale scores following deep brain stimulation, parallel outcome measures demonstrated significant benefit in a range of child and family-centred goal areas including: pain and comfort, school attendance, seating tolerance, access to assistive technology and in some cases carer burden. CONCLUSIONS Sole use of impairment-focused measures, are limited in scope to evaluate outcome following deep brain stimulation, particularly in secondary dystonias. Systematic study of effects across multiple dimensions of disability is needed to determine what deep brain stimulation offers patients in terms of function, participation, care, comfort and quality of life. Deep brain stimulation may offer meaningful change across multiple domains of functioning, disability and health even in the absence of significant change in dystonia rating scales.
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Affiliation(s)
- Hortensia Gimeno
- Complex Motor Disorders Service, Evelina Children's Hospital, Guy's & St Thomas' NHS Foundation Trust, London, UK.
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114
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Movimenti anomali secondari (distonie, mioclonie, tremori, discinesie). Neurologia 2012. [DOI: 10.1016/s1634-7072(12)62644-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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115
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Kim JP, Chang WS, Cho SR, Chang JW. The effect of bilateral globus pallidus internus deep brain stimulation plus ventralis oralis thalamotomy on patients with cerebral palsy. Stereotact Funct Neurosurg 2012; 90:292-9. [PMID: 22797720 DOI: 10.1159/000338093] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2011] [Accepted: 02/28/2012] [Indexed: 12/14/2022]
Abstract
OBJECTIVE We compared bilateral globus pallidus internus (GPi) deep brain stimulation (DBS) with bilateral GPi DBS plus ventralis oralis (Vo) thalamotomy to analyze the effect of the combined Vo thalamotomy. METHODS Between March 2003 and December 2008, 10 patients underwent DBS and/or Vo thalamotomy for treatment of cerebral palsy in our institute of neurosurgery and rehabilitation medicine. Four patients received bilateral posteroventral GPi DBS as group I and 6 patients received GPi DBS plus unilateral thalamotomy as group II. RESULTS The movement and disability scores of group I improved by 32 and 14.3%, respectively, at the last follow-up compared with baseline. The movement and disability scores of group II improved by 31.5 and 0.18%. The BFMDRS-movement subscores of group II demonstrated statistically significant improvement in the contralateral arm compared to group I (p = 0.042). Body pain, vitality and mental health seemed to improve in group II, in terms of health-related quality of life. CONCLUSIONS Contrary to our expectations, we were unable to demonstrate clear improvements in overall BFMDRS scores between group I and group II. However, movements of the contralateral upper extremities improved and health-related quality of life in group II showed satisfactory results.
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Affiliation(s)
- Joo Pyung Kim
- Department of Neurosurgery, Severance Hospital, Brain Korea 21 Project for Medical Science, Brain Research Institute, Yonsei University College of Medicine, Seoul, South Korea
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116
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Pelzer E, Pauls AK, Binder E, Brunn A, Fink GR, Timmermann L. Deep brain stimulation in rapidly progressive parkinson-dystonia syndrome due to mitochondrial disorder. Parkinsonism Relat Disord 2012; 18:672-4. [DOI: 10.1016/j.parkreldis.2011.10.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2011] [Revised: 10/16/2011] [Accepted: 10/25/2011] [Indexed: 11/28/2022]
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117
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The long-term surgical outcomes of secondary hemidystonia associated with post-traumatic brain injury. Acta Neurochir (Wien) 2012; 154:823-30. [PMID: 22367408 DOI: 10.1007/s00701-012-1306-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2011] [Accepted: 02/07/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND The aim was to assess the effect of deep brain stimulation for secondary hemidystonias associated with focal post-traumatic brain injuries. METHODS Four patients underwent deep brain stimulation for the treatment of medically refractory secondary hemidystonia associated with post-traumatic brain injury. Clinical outcome assessments were based on Burke-Fahn-Marsden Dystonia Rating Scale movement and disability scores. Health-related quality of life was assessed using a 36-item short-form general health survey questionnaire administered preoperatively and at the last follow-up visit. RESULTS Burke-Fahn-Marsden Dystonia Rating Scale movement scores had improved by 73.2% (range, 38.1-94.1) and disability scores had improved by 75% (range, 60-100) at the 2-year follow-up visit. The health-related quality of life assessment revealed satisfactory results at follow-up, such that body pain, general health, vitality, social functioning, as well as emotional and mental health improved significantly. CONCLUSIONS Globus pallidus internus deep brain stimulation can be used to modulate and ameliorate secondary hemidystonia associated with focal post-traumatic brain injury.
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118
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Viallet F, Vercueil L, Gayraud D, Bonnefoi B, Renie L. Mouvements anormaux secondaires (dystonies, myoclonies, tremblements, dyskinésies). ACTA ACUST UNITED AC 2012. [DOI: 10.1016/s0246-0378(12)57571-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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119
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Walcott BP, Nahed BV, Kahle KT, Duhaime AC, Sharma N, Eskandar EN. Deep brain stimulation for medically refractory life-threatening status dystonicus in children. J Neurosurg Pediatr 2012; 9:99-102. [PMID: 22208329 PMCID: PMC3734533 DOI: 10.3171/2011.10.peds11360] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Generalized dystonic syndromes may escalate into persistent episodes of generalized dystonia known as status dystonicus that can be life-threatening due to dystonia-induced rhabdomyolysis and/or respiratory compromise. Treatment of these conditions usually entails parenteral infusion of antispasmodic agents and sedatives and occasionally necessitates a medically induced coma for symptom control. The authors report a series of 3 children who presented with medically intractable, life-threatening status dystonicus and were successfully treated with bilateral pallidal deep brain stimulation. Bilateral globus pallidus internus stimulation appears to be effective in the urgent treatment of medically refractory and life-threatening movement disorders.
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Affiliation(s)
- Brian P. Walcott
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Brian V. Nahed
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Kristopher T. Kahle
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Ann-Christine Duhaime
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Nutan Sharma
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Emad N. Eskandar
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
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120
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Oluigbo CO, Salma A, Rezai AR. Deep Brain Stimulation for Neurological Disorders. IEEE Rev Biomed Eng 2012; 5:88-99. [DOI: 10.1109/rbme.2012.2197745] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Treatment of secondary dystonia with a combined stereotactic procedure: long-term surgical outcomes. Acta Neurochir (Wien) 2011; 153:2319-27; discussion 2328. [PMID: 21909834 DOI: 10.1007/s00701-011-1147-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2011] [Accepted: 08/24/2011] [Indexed: 12/18/2022]
Abstract
OBJECTIVE There is some debate about the effects of pallidal deep brain stimulation (DBS) or lesioning on secondary dystonia. We applied a multimodal method to maximize the treatment effects of deep brain stimulation in patients with secondary dystonia. METHODS Between March 2003 and January 2009, four patients underwent bilateral globus pallidus internus (GPi) DBS and six patients underwent bilateral GPi DBS plus unilateral thalamotomy for treatment of cerebral palsy (CP). Among the patients with secondary dystonia without CP, five were also treated by DBS. We classified patients with generalized secondary dystonia with cerebral palsy into group I and patients with focal dystonia without CP into group II. Clinical outcome assessments were based on Burke-Fahn-Marsden Dystonia Rating Scale movement and disability scores. Heath-related quality of life was assessed with a 36-item short-form general health survey questionnaire preoperatively and at the last follow-up. RESULTS The movement and disability scores of group I-A had improved by 32.0% (P = 0.285) and 14.3% (P = 0.593), respectively, at the last follow-up compared with baseline. The movement and disability scores of group I-B had improved by 31.5% and 0.18% at the last follow-up compared with baseline, respectively. In comparison with patients in group I-A, patients in group I-B showed a significant improvement in movement scores for the contralateral arm (P = 0.042). Group II patients showed a marked improvement in movement and disability scores of 77.7% (P = 0.039) and 80.0% (P = 0.041), respectively. CONCLUSIONS We demonstrated that DBS plus unilateral ventralis oralis thalamotomy for CP patients with fixed states in the upper extremities is useful not only to treat secondary dystonic movement but also to improve quality of life. In group II patients with post-traumatic dystonia and tardive dyskinesia, we achieved excellent clinical outcomes using a stereotactic procedure.
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Schiefer TK, Matsumoto JY, Lee KH. Moving forward: advances in the treatment of movement disorders with deep brain stimulation. Front Integr Neurosci 2011; 5:69. [PMID: 22084629 PMCID: PMC3211039 DOI: 10.3389/fnint.2011.00069] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2011] [Accepted: 10/07/2011] [Indexed: 11/13/2022] Open
Abstract
The modern era of stereotactic and functional neurosurgery has ushered in state of the art technologies for the treatment of movement disorders, particularly Parkinson's disease (PD), tremor, and dystonia. After years of experience with various surgical therapies, the eventual shortcomings of both medical and surgical treatments, and several serendipitous discoveries, deep brain stimulation (DBS) has risen to the forefront as a highly effective, safe, and reversible treatment for these conditions. Idiopathic advanced PD can be treated with thalamic, globus pallidus internus (GPi), or subthalamic nucleus (STN) DBS. Thalamic DBS primarily relieves tremor while GPi and STN DBS alleviate a wide range of Parkinsonian symptoms. Thalamic DBS is also used in the treatment of other types of tremor, particularly essential tremor, with excellent results. Both primary and various types of secondary dystonia can be treated very effectively with GPi DBS. The variety of anatomical targets for these movement disorders is indicative of the network-level dysfunction mediating these movement disturbances. Despite an increasing understanding of the clinical benefits of DBS, little is known about how DBS can create such wide sweeping neuromodulatory effects. The key to improving this therapeutic modality and discovering new ways to treat these and other neurologic conditions lies in better understanding the intricacies of DBS. Here we review the history and pertinent clinical data for DBS treatment of PD, tremor, and dystonia. While multiple regions of the brain have been targeted for DBS in the treatment of these movement disorders, this review article focuses on those that are most commonly used in current clinical practice. Our search criteria for PubMed included combinations of the following terms: DBS, neuromodulation, movement disorders, PD, tremor, dystonia, and history. Dates were not restricted.
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Affiliation(s)
| | | | - Kendall H. Lee
- Department of Neurologic Surgery, Mayo ClinicRochester, MN, USA
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Kupsch A, Tagliati M, Vidailhet M, Aziz T, Krack P, Moro E, Krauss JK. Early postoperative management of DBS in dystonia: programming, response to stimulation, adverse events, medication changes, evaluations, and troubleshooting. Mov Disord 2011; 26 Suppl 1:S37-53. [PMID: 21692111 DOI: 10.1002/mds.23624] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Early postoperative management in deep brain stimulation-treated patients with dystonia differs from that of patients with essential tremor and Parkinson's disease, mainly due to the usually delayed effects of deep brain stimulation and the heterogenous clinical manifestation and etiologies of dystonia. The present chapter summarizes the available data about and concentrates on practical clinical aspects of early postoperative management in deep brain stimulation-treated patients with dystonia.
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Affiliation(s)
- Andreas Kupsch
- Division of Neurology, Charité, Campus Virchow, Berlin, Germany.
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Tagliati M, Krack P, Volkmann J, Aziz T, Krauss JK, Kupsch A, Vidailhet AM. Long-Term management of DBS in dystonia: response to stimulation, adverse events, battery changes, and special considerations. Mov Disord 2011; 26 Suppl 1:S54-62. [PMID: 21692113 DOI: 10.1002/mds.23535] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Multiple independent case series have documented sustained benefit of bilateral pallidal deep brain stimulation (DBS) up to 3 years in patients with primary dystonia. Growing evidence exists for positive outcomes extending up to 10 years. The beneficial effects from DBS are usually reported to be stable, thus requiring little long-term modifications of the parameters of stimulation. Speech and swallowing abnormalities are less responsive than other dystonic symptoms. Symptom exacerbation after initial benefit has been reported in a few cases. It is not known whether this is related to potential tolerance or habituation to stimulation or to progression of the underlying disease. Failures of pallidal DBS, at least in primary dystonia patients, should not be accepted without further re-evaluation of each individual case, including possible revisions of the electrode location. Both hardware- and stimulation-related adverse effects, including insufficient relief of speech function, have been reported in the long-term. Despite early reports suggesting that hardware problems might be more frequent in dystonia, more recent studies did not confirm these observations. In patients with severe segmental (e.g., axial) or generalized dystonia, sudden cessation of stimulation may become a medical emergency and should be anticipated changing the neurostimulator before its natural end of life.
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Affiliation(s)
- Michele Tagliati
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, California 90048, USA.
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125
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Bronte-Stewart H, Taira T, Valldeoriola F, Merello M, Marks WJ, Albanese A, Bressman S, Moro E. Inclusion and exclusion criteria for DBS in dystonia. Mov Disord 2011; 26 Suppl 1:S5-16. [PMID: 21692112 DOI: 10.1002/mds.23482] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
When considering a patient with dystonia for deep brain stimulation (DBS) surgery several factors need to be considered. Level B evidence has shown that all motor features and associated pain in primary generalized and segmental dystonia are potentially responsive to globus pallidus internus (GPi) DBS. However, improvements in clinical series of ≥ 90% may reflect methods that need improvement, and larger prospective studies are needed to address these factors. Nevertheless, to date the selection criteria for DBS-specifically in terms of patient features (severity and nature of symptoms, age, time of evolution, or any other demographic or disease aspects)--have not been assessed in a systematic fashion. In general, dystonia patients are not considered for DBS unless medical therapies have been previously and extensively tested. The vast majority of reported patients have had DBS surgery when the disease was provoking important disability, with loss of independence and impaired quality of life. There does not appear to be an upper age limit or a minimum age limit, although there are no published data regarding the outcome of GPi DBS for dystonia in children younger than 7 years of age. There is currently no enough evidence to prove that subjects with primary--generalized dystonia who undergo DBS at an early age and sooner rather than later after disease onset may gain more benefit from DBS than those undergoing DBS after the development of fixed skeletal deformities. There is no enough evidence to refuse or support consideration of DBS in patients with previous ablative procedures.
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Affiliation(s)
- Helen Bronte-Stewart
- Department of Neurology and Neurological Sciences, Stanford University, Stanford, California 94305, USA.
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McClelland V, Mills K, Siddiqui A, Selway R, Lin JP. Central motor conduction studies and diagnostic magnetic resonance imaging in children with severe primary and secondary dystonia. Dev Med Child Neurol 2011; 53:757-63. [PMID: 21707595 DOI: 10.1111/j.1469-8749.2011.03981.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
AIM Dystonia in childhood has many causes. Imaging may suggest corticospinal tract dysfunction with or without coexistent basal ganglia damage. There are very few published neurophysiological studies on children with dystonia; one previous study has focused on primary dystonia. We investigated central motor conduction in 62 children (34 males, 28 females; age range 3-19y, mean age 10y 8mo, SD 4y 8mo) with severe dystonia to evaluate corticospinal tract integrity before consideration for deep brain stimulation. METHOD Distal motor and F-wave latencies were measured in the ulnar and/or posterior tibial nerves. Transcranial magnetic stimulation was applied over the motor cortex and motor-evoked potentials were recorded in the activated abductor digiti minimi and/or abductor hallucis muscles. Central motor conduction time (CMCT) was calculated using the F-wave method. RESULTS CMCT was normal in 50 out of 62 patients; 12 patients showed prolonged CMCT to upper and/or lower limbs. Most children with severe primary and secondary dystonia had normal CMCT, indicating corticospinal tract integrity despite abnormal imaging in 42 out of 50 patients. Abnormal CMCT was found in two out of 12 patients with normal imaging. INTERPRETATION This study provides new CMCT data for children with severe primary and secondary dystonia. Over 50% of children with evidence of periventricular white-matter damage from magnetic resonance imaging had normal CMCT, challenging traditional pathophysiological models. This is consistent with recent diffusion tensor imaging in children with periventricular white-matter damage, showing disruption of sensory connections rather than corticospinal tract damage. CMCT helps refine our understanding of imaging changes in complex motor disorders of childhood.
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Affiliation(s)
- Verity McClelland
- Department of Clinical Neurophysiology, King's College Hospital, London, UK
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Sobstyl M, Ząbek M. Głęboka stymulacja mózgu w leczeniu kręczu karku i zespołu Meige'a. Neurol Neurochir Pol 2011; 45:590-9. [DOI: 10.1016/s0028-3843(14)60127-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Michał Sobstyl
- Klinika Neurochirurgii, Centrum Medycznego Kształcenia Podyplomowego, Warszawa.
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Aydin S, Abuzayed B, Varlibas F, Apaydin H, Mengi M, Kucukyuruk B, Hanimoglu H, Yagci S, Kizilkilic O, Hanci M. Treatment of Homocystinuria-Related Dystonia with Deep Brain Stimulation: A Case Report. Stereotact Funct Neurosurg 2011; 89:210-3. [DOI: 10.1159/000325703] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2010] [Accepted: 02/12/2011] [Indexed: 11/19/2022]
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Capelle HH, Blahak C, Schrader C, Baezner H, Kinfe TM, Herzog J, Dengler R, Krauss JK. Chronic deep brain stimulation in patients with tardive dystonia without a history of major psychosis. Mov Disord 2010; 25:1477-81. [PMID: 20629157 DOI: 10.1002/mds.23123] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Tardive dystonia usually occurs with a delay after neuroleptic exposure in patients with major psychosis. A subgroup of patients, however, is given such medication for "mild depression" or "neurasthenia." Tardive dystonia, in general, may respond favorably to pallidal deep brain stimulation (DBS). Nevertheless, it remains unclear thus far whether or not similar beneficial outcome is achieved with pallidal DBS in different subgroups of patients with tardive dystonia. Four women (mean age 59 years at surgery) underwent stereotactic pallidal DBS in the frame of an observational study. Tardive dystonia occurred secondary to medication with fluspirilene and haloperidol, and injection of long-acting depot neuroleptics prescribed for mild depression or "nervousness." Assessment included the Burke-Fahn-Marsden (BFM) scale preoperatively and at 12 months follow-up. Extended follow-up was available at a mean of 27.3 months postoperatively (range 16-36 months). There were no surgically related complications. All 4 patients experienced sustained statistically significant benefit from pallidal DBS. Mean improvement at 12 months was 77% for the BFM motor score (range, 45-91%; P = 0.043), and 84% at the last available follow-up (range, 70-91%; P = 0.03). This was paralleled by improvement of the BFM disability score. Chronic pallidal DBS in patients with tardive dystonia without a history of major psychosis provides sustained improvement which is similar to that in other subgroups of patients with tardive dystonia. This effect is stable on extended follow-up for up to 3 years.
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Kang DW, Kang JH, Lee MS, Chang JW. Posttraumatic Hemidystonia Treated with Unilateral Globus Pallidus Interna Stimulation: Long-Term Follow-up and Radiologic Features. Neuromodulation 2010; 13:261-4. [DOI: 10.1111/j.1525-1403.2010.00306.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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131
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Sakas DE, Stavrinou LC, Boviatsis EJ, Stathis P, Themistocleous M, Gatzonis S. Restoration of erect posture by deep brain stimulation of the globus pallidus in disabling dystonic spinal hyperextension. J Neurosurg 2010; 112:1279-82. [DOI: 10.3171/10.3171/2009.10.jns09588] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Dystonia is a movement disorder notoriously difficult to treat. While primary dystonia is classically considered to respond well to deep brain stimulation (DBS), treatment of secondary dystonia yields variable results. Patient selection should be done on a case-by-case basis. Clearly, there is a need to accumulate additional information with regard to prognostic factors that may aid neurosurgeons in selecting those patients in whom the disorder is most likely to respond favorably to pallidal DBS.
The authors report the case of a 29-year-old man with secondary dystonia due to perinatal hypoxia. The most prominent symptom was what we have termed ectatocormia—that is, severe, fixed truncal hyperextension and retrocollis, exacerbated by phasic, twisting movements of the trunk and head. This made it impossible for the patient to maintain a normal upright posture or to walk. The patient underwent bilateral DBS of the globus pallidus internus (GPi), and the authors observed impressive improvement in motor abilities and function. The patient's body adopted the normal upright posture and he became able to walk again, 4 months after the commencement of GPi stimulation.
This report, along with others, emphasizes that the GPi as an ideal target for alleviating axial tonic symptoms. The presence of normal MR imaging findings, a phenotypical purity of predominantly dystonic symptoms, and a younger age seem to favor a positive outcome.
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Affiliation(s)
- Damianos E. Sakas
- 1Unit of Functional Neurosurgery, Department of Neurosurgery, University of Athens, Evangelismos Hospital; and
- 2P. S. Kokkalis Hellenic Center for Neurosurgical Research, Athens, Greece
| | - Lampis C. Stavrinou
- 1Unit of Functional Neurosurgery, Department of Neurosurgery, University of Athens, Evangelismos Hospital; and
- 2P. S. Kokkalis Hellenic Center for Neurosurgical Research, Athens, Greece
| | - Efstathios J. Boviatsis
- 1Unit of Functional Neurosurgery, Department of Neurosurgery, University of Athens, Evangelismos Hospital; and
- 2P. S. Kokkalis Hellenic Center for Neurosurgical Research, Athens, Greece
| | - Pantelis Stathis
- 1Unit of Functional Neurosurgery, Department of Neurosurgery, University of Athens, Evangelismos Hospital; and
- 2P. S. Kokkalis Hellenic Center for Neurosurgical Research, Athens, Greece
| | - Marios Themistocleous
- 1Unit of Functional Neurosurgery, Department of Neurosurgery, University of Athens, Evangelismos Hospital; and
- 2P. S. Kokkalis Hellenic Center for Neurosurgical Research, Athens, Greece
| | - Stylianos Gatzonis
- 1Unit of Functional Neurosurgery, Department of Neurosurgery, University of Athens, Evangelismos Hospital; and
- 2P. S. Kokkalis Hellenic Center for Neurosurgical Research, Athens, Greece
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Collins KL, Lehmann EM, Patil PG. Deep brain stimulation for movement disorders. Neurobiol Dis 2010; 38:338-45. [DOI: 10.1016/j.nbd.2009.11.019] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2009] [Revised: 11/20/2009] [Accepted: 11/26/2009] [Indexed: 10/20/2022] Open
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Kefalopoulou Z, Paschali A, Markaki E, Ellul J, Chroni E, Vassilakos P, Constantoyannis C. Regional cerebral blood flow changes induced by deep brain stimulation in secondary dystonia. Acta Neurochir (Wien) 2010; 152:1007-14. [PMID: 20182892 DOI: 10.1007/s00701-010-0612-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2009] [Accepted: 02/02/2010] [Indexed: 12/12/2022]
Abstract
PURPOSE The purpose of the present study is to investigate the effect of deep brain stimulation (DBS) on regional cerebral blood flow (rCBF) in cases of secondary dystonia as well as to correlate the rCBF changes with clinical outcomes. METHODS Six patients with medically intractable secondary dystonia who underwent DBS surgery were included in this study. Burke-Fahn-Mardsen Dystonia Rating Scale (BFMDRS) was used for the assessment of dystonia, before and after surgery. Single photon emission computed tomography (SPECT) of the brain was performed postoperatively in the two stimulation states (ON-DBS and OFF-DBS) and the changes of rCBF in the three following brain regions of interest (ROIs): primary motor cortex, premotor and supplementary motor cortex, and prefrontal cortex were evaluated. RESULTS Two patients exhibited excellent response to DBS, two patients got moderate benefit after the procedure, and in two patients, no clinical improvement was achieved. A mean improvement of 49.1% (0-90.7%) in BFMDRS total scores was found postoperatively. Brain SPECT data analysis revealed an overall decrease in rCBF in the investigated ROIs, during the ON-DBS state. Clinical improvement was significantly correlated with the observed decrease in rCBF in the presence of DBS. CONCLUSIONS When conservative treatment fails to relieve severely disabled patients suffering from secondary dystonia, DBS may be a promising therapeutic alternative. Moreover, this study indicates a putative role of brain SPECT imaging as a postoperative indicator of clinical responsiveness to DBS.
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Affiliation(s)
- Zinovia Kefalopoulou
- Functional Neurosurgery Unit, Department of Neurosurgery, Medical School of Patras, Patras, Greece
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Abstract
IMPORTANCE OF THE FIELD Dystonia is a neurological syndrome characterized by involuntary twisting movements and unnatural postures. It has many different manifestations and causes, and many different treatment options are available. These options include physical and occupational therapy, oral medications, intramuscular injection of botulinum toxins, and neurosurgical interventions. AREAS COVERED IN THIS REVIEW In this review, we first summarize the treatment options available, then we provide suggestions from our own experience for how these can be applied in different types of dystonia. In preparing this review article, an extensive literature search was undertaken using PubMed. Only selected references from 1970 to 2008 are cited. WHAT THE READER WILL GAIN This review is intended to provide the clinician with a practical guide to the treatment of dystonia. TAKE HOME MESSAGE Treatment of dystonia begins with proper diagnosis and classification, followed by an appropriate search for underlying etiology, and an assessment of the functional impairment associated with the dystonia. The therapeutic approach, which is usually limited to symptomatic therapy, must then be tailored to the individual needs of the patient.
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Affiliation(s)
- Leslie J Cloud
- Emory University, Department of Neurology, 1841 Clifton Road NE, Room 329, Atlanta, GA 30029, USA
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135
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Abstract
Surgery for dystonia has a history stretching back for centuries including myotomy and other procedures on the musculoskeletal system. In the last century lesional procedures, mainly involving the pallidum became popular. More recently, with the advent of deep brain stimulation, bilateral medial pallidal stimulation has become commonplace. This review describes the issues with patient selection, technical aspects of implantation and effects as well as complications of the technique. Some of the rarer types of dystonia that have also been treated with DBS are also described.
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Affiliation(s)
- Tipu Z Aziz
- Department of Neurosurgery, The John Radcliffe Hospital, Oxford, UK.
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136
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Hamasaki K, Yamada K, Hamasaki T, Kuratsu JI. GPi-pallidal stimulation to treat generalized dystonia in Cockayne syndrome. Mov Disord 2010; 25:656-8. [DOI: 10.1002/mds.22992] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Petacchi E, Armellin MT, Facchin D, Gubernale M, Moret O, Buffoni M, Salghetti AM, Martinuzzi A. The dystonic child treated with deep brain stimulation: ICF reading of a high-tech approach. Disabil Rehabil 2009; 31 Suppl 1:S159-69. [DOI: 10.3109/09638280903317849] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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139
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Susatia F, Malaty IA, Foote KD, Wu SS, Zeilman PR, Mishra M, Rodriguez RL, ul Haq I, Jacobson CE, Sun A, Okun MS. An evaluation of rating scales utilized for deep brain stimulation for dystonia. J Neurol 2009; 257:44-58. [DOI: 10.1007/s00415-009-5261-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2008] [Revised: 06/22/2009] [Accepted: 07/08/2009] [Indexed: 11/24/2022]
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Abstract
Deep brain stimulation (DBS) has been used to treat various neurological and psychiatric disorders. Over the years, the most suitable surgical candidates and targets for some of these conditions have been characterized and the benefits of DBS well demonstrated in double-blinded randomized trials. This review will discuss some of the areas of current investigation and potential new applications of DBS.
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Affiliation(s)
- Nasir Raza Awan
- Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Canada
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141
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Vidailhet M, Yelnik J, Lagrange C, Fraix V, Grabli D, Thobois S, Burbaud P, Welter ML, Xie-Brustolin J, Braga MCC, Ardouin C, Czernecki V, Klinger H, Chabardes S, Seigneuret E, Mertens P, Cuny E, Navarro S, Cornu P, Benabid AL, Le Bas JF, Dormont D, Hermier M, Dujardin K, Blond S, Krystkowiak P, Destée A, Bardinet E, Agid Y, Krack P, Broussolle E, Pollak P. Bilateral pallidal deep brain stimulation for the treatment of patients with dystonia-choreoathetosis cerebral palsy: a prospective pilot study. Lancet Neurol 2009; 8:709-17. [PMID: 19576854 DOI: 10.1016/s1474-4422(09)70151-6] [Citation(s) in RCA: 247] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Cerebral palsy (CP) with dystonia-choreoathetosis is a common cause of disability in children and in adults, and responds poorly to medical treatment. Bilateral pallidal deep brain stimulation (BP-DBS) of the globus pallidus internus (GPi) is an effective treatment for primary dystonia, but the effect of this reversible surgical procedure on dystonia-choreoathetosis CP, which is a subtype of secondary dystonia, is unknown. Our aim was to test the effectiveness of BP-DBS in adults with dystonia-choreoathetosis CP. METHODS We did a multicentre prospective pilot study of BP-DBS in 13 adults with dystonia-choreoathetosis CP who had no cognitive impairment, little spasticity, and only slight abnormalities of the basal ganglia on MRI. The primary endpoint was change in the severity of dystonia-choreoathetosis after 1 year of neurostimulation, as assessed with the Burke-Fahn-Marsden dystonia rating scale. The accuracy of surgical targeting to the GPi was assessed masked to the results of neurostimulation. Analysis was by intention to treat. FINDINGS The mean Burke-Fahn-Marsden dystonia rating scale movement score improved from 44.2 (SD 21.1) before surgery to 34.7 (21.9) at 1 year post-operatively (p=0.009; mean improvement 24.4 [21.1]%, 95% CI 11.6-37.1). Functional disability, pain, and mental health-related quality of life were significantly improved. There was no worsening of cognition or mood. Adverse events were related to stimulation (arrest of the stimulator in one patient, and an adjustment to the current intensity in four patients). The optimum therapeutic target was the posterolateroventral region of the GPi. Little improvement was seen when the neurostimulation diffused to adjacent structures (mainly to the globus pallidus externus [GPe]). INTERPRETATION Bilateral pallidal neurostimulation could be an effective treatment option for patients with dystonia-choreoathetosis CP. However, given the heterogeneity of motor outcomes and the small sample size, results should be interpreted with caution. The optimum placement of the leads seemed to be a crucial, but not exclusive, factor that could affect a good outcome. FUNDING National PHRC; Cerebral Palsy Foundation: Fondation Motrice/APETREIMC; French INSERM Dystonia National Network; Medtronic.
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Affiliation(s)
- Marie Vidailhet
- AP-HP, Groupe hospitalier Pitié-Salpêtrière, Fédération de Neurologie, Paris, F-75013, France.
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Sensi M, Cavallo MA, Quatrale R, Sarubbo S, Biguzzi S, Lettieri C, Capone JG, Tugnoli V, Tola MR, Eleopra R. Pallidal stimulation for segmental dystonia: Long term follow up of 11 consecutive patients. Mov Disord 2009; 24:1829-35. [DOI: 10.1002/mds.22686] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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Deep brain stimulation for secondary dystonia: results in 8 patients. Acta Neurochir (Wien) 2009; 151:473-8; discussion 478. [PMID: 19322514 DOI: 10.1007/s00701-009-0281-x] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2008] [Accepted: 03/10/2009] [Indexed: 10/21/2022]
Abstract
BACKGROUND Dystonia is a medically intractable condition characterized by involuntary twisting movements and/or abnormal postures. Deep Brain Stimulation (DBS) has been used successfully in various forms of dystonia. In the present study, we report on eight patients with secondary dystonia, treated with DBS in our clinic. METHOD Eight patients (five males, three females) underwent DBS for secondary dystonia. The etiology of dystonia was cerebral palsy (n = 2), drug-induced (n = 1), post encephalitis (n = 2) and postanoxic dystonia (n = 3). The functional capacity was evaluated before and after surgery with the use of Burke-Fahn-Mardsen Dystonia Rating Scale (BFM scale), both movement and disability scale (MS and DS, respectively). The target for DBS was the globus pallidus internus (GPi) in 7 patients and in one patient, with postanoxic damaged pallidum, the ventralis oralis anterior (Voa) nucleus. Brain perfusion scintigraphy using Single Photon Emission Computed Tomography (SPECT) was performed in two separate studies for each patient, one in the "off-DBS" and the other in the "on-DBS" state. FINDINGS Postoperative both MS and DS scores were found to be significantly lower compared to preoperative scores (p = 0.018 and p = 0.039, respectively). Mean improvement rate after DBS was 41.4% (0-94.3) and 29.5% (0-84.2) in MS and DS scores, respectively. The SPECT Scan, during the "on-DBS" state, showed a decrease in regional cerebral blood flow (rCBF), compared to the "off-DBS" state. CONCLUSIONS Our results seem promising in the field of secondary dystonia treatment. More studies with greater number of patients and longer follow-up periods are necessary in order to establish the role of DBS in the management of secondary dystonia. Finally, the significance of brain SPECT imaging in the investigation of dystonia and functional effects of DBS should be further evaluated.
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van Rijn MA, van Hilten JJ, van Dijk JG. Spatiotemporal integration of sensory stimuli in complex regional pain syndrome and dystonia. J Neural Transm (Vienna) 2009; 116:559-65. [DOI: 10.1007/s00702-009-0220-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2009] [Accepted: 03/20/2009] [Indexed: 10/20/2022]
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Sani S, Ostrem JL, Shimamoto S, Levesque N, Starr PA. Single unit "pauser" characteristics of the globus pallidus pars externa distinguish primary dystonia from secondary dystonia and Parkinson's disease. Exp Neurol 2009; 216:295-9. [PMID: 19146856 PMCID: PMC2659350 DOI: 10.1016/j.expneurol.2008.12.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2008] [Revised: 12/01/2008] [Accepted: 12/03/2008] [Indexed: 11/16/2022]
Abstract
The presence of high frequency discharge neurons with long periods of silence or "pauses" in the globus pallidus pars externa (GPe) is a unique identifying feature of this nucleus. Prior studies have demonstrated that pause characteristics reflect synaptic inputs into GPe. We hypothesized that GPe pause characteristics should distinguish movement disorders whose basal ganglia network abnormalities are different. We examined pause characteristics in 224 GPe units in patients with primary generalized dystonia, Parkinson's disease (PD), and secondary dystonia, undergoing single unit microelectrode recording for DBS placement in the awake state. Pauses in neuronal discharge were identified using the Poisson surprise method. Mean pause length in primary dystonia (606.8373.3) was higher than in PD (557.4366.6) (p<0.05). Interpause interval (IPI) was lower in primary dystonia (2331.63874.1) than PD (3646.45894.5) (p<0.01), and mean pause frequency was higher in primary dystonia (0.140.10) than PD (0.070.12) (p<0.01). Comparison of pause characteristics in primary versus secondary generalized dystonia revealed a significantly longer mean pause length in primary (606.8373.3) than in secondary dystonia (495.6236.5) (p<0.01). IPI was shorter in primary (2331.6+/-3874.1) than in secondary dystonia (3484.5+/-3981.6) (p<0.01). The results show that pause characteristics recorded in the awake human GPe distinguish primary dystonia from Parkinson's disease and secondary dystonia. The differences may reflect increased phasic input from striatal D2 receptor positive cells in primary dystonia, and are consistent with a recent model proposing that GPe provides capacity scaling for cortical input.
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Affiliation(s)
- Sepehr Sani
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California 94143, USA
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Shannon K. Painful involuntary neck movements in a 45-year-old woman. Mov Disord 2008. [DOI: 10.3109/9780203008454-78] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Pretto TE, Dalvi A, Kang UJ, Penn RD. A prospective blinded evaluation of deep brain stimulation for the treatment of secondary dystonia and primary torticollis syndromes. J Neurosurg 2008; 109:405-9. [PMID: 18759568 DOI: 10.3171/jns/2008/109/9/0405] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECT The aim of this study was to provide an objective assessment of deep brain stimulation (DBS) for groups of patients with mixed secondary dystonia and primary torticollis syndromes by a blinded evaluation of 13 consecutive patients who underwent ineffective medical treatment and botulinum toxin injections. METHODS Nine patients with secondary dystonia and 4 with cranial dystonia involving prominent spasmodic torticollis were selected for a DBS implant after they underwent unsuccessful medical treatment. Preoperative videos and neurological assessments were obtained and the DBS implant was inserted into the globus pallidus internus. Postoperatively, DBS parameters were adjusted to provide optimal benefit. Postoperative videotapes and quality of life scores were obtained. Blinded randomized evaluation of videotapes was performed by a neurologist specializing in movement disorders. Videos were scored using the Unified Dystonia Rating Scale, Toronto Western Spasmodic Torticollis Rating Scale, Burke-Fahn-Marsden Dystonia Rating Scale, or Abnormal Involuntary Movement Scale. Quality of life scoring was assessed using a standardized 7-point Global Rating Scale. RESULTS All 13 patients completed preoperative videotaping, medical assessment, and surgery. Optimal DBS programming was completed in 6.5 visits over 5.9 months. Seven patients reported marked improvement, 3 reported moderate improvement, 2 reported slight improvement or no change, and 1 was lost to follow-up. Examiner scores on the Global Rating Scale reflected patient self-reported scores. CONCLUSIONS Global subjective gains and notable objective improvement were observed in 11 of 13 patients. Although the benefits were variable and not fully predictable, they were of sufficient magnitude to justify offering the procedure when medications and botulinum toxin injections have failed.
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Affiliation(s)
- Theresa E Pretto
- Department of Neurology, The University of Chicago, Illinois 60637, USA.
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Rezai AR, Machado AG, Deogaonkar M, Azmi H, Kubu C, Boulis NM. Surgery for movement disorders. Neurosurgery 2008; 62 Suppl 2:809-38; discussion 838-9. [PMID: 18596424 DOI: 10.1227/01.neu.0000316285.52865.53] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Movement disorders, such as Parkinson's disease, tremor, and dystonia, are among the most common neurological conditions and affect millions of patients. Although medications are the mainstay of therapy for movement disorders, neurosurgery has played an important role in their management for the past 50 years. Surgery is now a viable and safe option for patients with medically intractable Parkinson's disease, essential tremor, and dystonia. In this article, we provide a review of the history, neurocircuitry, indication, technical aspects, outcomes, complications, and emerging neurosurgical approaches for the treatment of movement disorders.
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Affiliation(s)
- Ali R Rezai
- Center for Neurological Restoration, and Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio 44122, USA.
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Abstract
This article reviews three poorly recognized yet relatively common presentations of hyperactive orofacial movement disorders: oromandibular dystonia, orofacial dyskinesia, and drug-induced extrapyramidal syndrome reactions. Orofacial movement disorders are often misdiagnosed as temporomandibular disorders, hence understanding these conditions is pertinent for the practitioner treating orofacial pain. Aspects of epidemiology, etiology, pathophysiology, clinical presentation, and diagnosis are discussed along with treatment considerations for these orofacial movement disorders.
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Affiliation(s)
- Ramesh Balasubramaniam
- Department of Oral Medicine, University of Pennsylvania, School of Dental Medicine, 240 South 40th Street, Philadelphia, PA 19104, USA.
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