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Xu B, Ma W, Li H, Li S. Improvements in Nerve Dissection Surgery Methodology for Spasmodic Torticollis Treatment. World Neurosurg 2021; 156:33-42. [PMID: 34464776 DOI: 10.1016/j.wneu.2021.08.094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Revised: 08/19/2021] [Accepted: 08/20/2021] [Indexed: 11/15/2022]
Abstract
Spasmodic torticollis is the most common focal dystonia and is characterized by aberrant involuntary contraction of muscles of the neck and shoulders, which greatly affects patients' quality of life. Consequently, patients with this condition often desire treatment to alleviate their symptoms. The common clinical treatments for spasmodic torticollis include interventions such as drug therapy, botulinum toxin injections, and surgery. Surgical treatment is feasible for patients who do not respond well to other treatments or who are resistant to drugs. The gradual improvement of surgeons' understanding of anatomy and the ongoing developments in surgical techniques since their advent in the 1640s have resulted in many innovative surgical approaches that have led to improvements in the treatment of spasmodic torticollis. Previously used surgical treatments that result in uncertain outcomes, various postoperative complications, and serious damage to motor functions of the head and neck have gradually been discontinued. Nerve dissection surgery is the most common surgical treatment for spasmodic torticollis. This article reviews existing research on nerve dissection surgery for the treatment of spasmodic torticollis and the history of its development, along with the advantages and disadvantages of various surgical improvements. This article aims to provide clinicians with practical advice.
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Affiliation(s)
- Baoxin Xu
- Department of Neurosurgery, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
| | - Weining Ma
- Department of Neurosurgery, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
| | - Han Li
- Department of Neurosurgery, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
| | - Shaoyi Li
- Department of Neurosurgery, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China.
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Hirsig A, Barbey C, Schüpbach MW, Bargiotas P. Oculomotor functions in focal dystonias: A systematic review. Acta Neurol Scand 2020; 141:359-367. [PMID: 31990980 DOI: 10.1111/ane.13224] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 01/09/2020] [Accepted: 01/20/2020] [Indexed: 12/20/2022]
Abstract
Focal Dystonia (FD) is a chronic neurological disorder, which causes twisting and repetitive movements and abnormal postures induced by involuntary sustained contractions of agonist and antagonist muscles. Based on the hypothesis that several dystonia-related brain regions, including cerebellum, are implicated in oculomotor disturbances (OCD), a number of studies investigated oculomotor function in patients with dystonia. However, conceptual clarity with respect to the used assessment tools and interpretation of the findings is lacking in the literature. This is the first article to systematically review studies that assessed oculomotor function in patients with FD. In total, 329 publications, published until September 1, 2019, were identified through MEDLINE search. Twenty out of 329 studies, involving 232 subjects in total, met the inclusion criteria. Most of the studies reported oculomotor disturbances in patients with FD. Abnormalities included asymmetry in vestibulo-ocular reflex (VOR), disturbances in saccadic functions, and prolonged latencies of eye motion. Discrepancies in the results could be explained, at least partially, by the long period of time over which the reviewed studies were published, the different methods used for testing the eye movements, and the limited number of patients assessed since the majority of data derived from case reports or small-scale studies. Further prospective studies with larger subject numbers are needed, using advanced tools for the assessment of oculomotor function in focal dystonia.
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Affiliation(s)
- Anna Hirsig
- Department of Neurology University Hospital (Inselspital) and University of Bern Bern Switzerland
| | - Carolin Barbey
- Department of Neurology University Hospital (Inselspital) and University of Bern Bern Switzerland
| | - Michael W.M. Schüpbach
- Department of Neurology University Hospital (Inselspital) and University of Bern Bern Switzerland
| | - Panagiotis Bargiotas
- Department of Neurology University Hospital (Inselspital) and University of Bern Bern Switzerland
- Department of Neurology Medical School University of Cyprus Nicosia Cyprus
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Assessment of hand functions in patients with idiopathic cervical dystonia. Hum Mov Sci 2020; 70:102581. [PMID: 31950896 DOI: 10.1016/j.humov.2020.102581] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Revised: 11/23/2019] [Accepted: 01/08/2020] [Indexed: 12/18/2022]
Abstract
Cervical dystonia (CD) is the most common form of focal dystonia characterized by involuntary contractions of the neck muscles, causing abnormal rotation of the head into specific directions. Studies report that idiopathic dystonia is a developmental disorder of the sensorimotor circuits, involving both the cortico-striatal and thalamo-cortical pathways. It is also suggested that enhanced cortical plasticity extends beyond the clinically affected region and may also be detected in the unaffected upper limbs of the patient with CD. In the present study, we aimed at exploring if patients with CD had hand motor dysfunctions. Forty patients with idiopathic CD and 40 healthy controls were included in this study. Dystonic symptoms were assessed by means of The Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS). Stanford Health Assessment Questionnaire (HAQ) was used to assess functional status. Quality of life (QoL) was assessed by using the Medical Outcomes Study Short Form 36-Item Health Survey (SF 36). Grip strength was assessed by using hand dynamometers. Tip pinch, lateral pinch and chuck pinch of the hand were assessed by using a pinchmeter. Fingertip dexterity and hand coordination was assessed using Purdue Pegboard. Duruoz Hand Index (DHI) was used for the assessment of hand functions. There were no significant differences between the groups in grip and pinch strengths of hands and fingers. As to the fingertip dexterity, patients with CD had a mean Pin 1 and Pin 2 test score of 10.6 ± 2.8 and 10.8 ± 3.2 respectively and a mean assembling test score of 5.2 ± 2.0. These results were significantly worse than those of the healthy controls. As to the SF 36 sub-scores, there were significant differences between the groups in all SF 36 sub-scores (p < .001). This study indicates that patients with CD suffer a deteriorated fine motor coordination of hands without dystonic involvement of upper extremities. Furthermore, lower SF 36 scores in patients with CD suggest poorer health-related quality of life.
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Mascia MM, Carmagnini D, Defazio G. Cannabinoids and dystonia: an issue yet to be defined. Neurol Sci 2019; 41:783-787. [PMID: 31848779 DOI: 10.1007/s10072-019-04196-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Accepted: 12/11/2019] [Indexed: 01/28/2023]
Abstract
Dystonia is a movement disorder characterized by sustained or intermittent muscle contractions causing abnormal movements and postures. Besides motor manifestations, patients with dystonia also display non-motor signs and symptoms including psychiatric and sensory disturbances. Symptomatic treatment of motor signs in dystonia largely relies on intramuscular botulinum toxin injections and, in selected cases, on deep brain stimulation. Oral medications and physical therapy offer a few benefits only in a minority of patients. Cannabinoids have been shown to be a complementary treatment in several neurological disorders but their usefulness in dystonia have not been systematically assessed. Given recent policy changes in favor of cannabis use in clinical practice and the request for alternative treatments, it is important to understand how cannabinoids may impact people with dystonia. Reviewing the evidence so far available and our own experience, cannabinoids seem to be effective in single cases but further studies are required to improve our understanding on their role as complementary treatment in dystonia.
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Affiliation(s)
- Marcello Mario Mascia
- Department of Medical Sciences and Public Health, Neurology Unit, University of Cagliari and AOU Cagliari, Monserrato, Cagliari, Italy.
| | - Daniele Carmagnini
- Department of Medical Sciences and Public Health, Neurology Unit, University of Cagliari and AOU Cagliari, Monserrato, Cagliari, Italy
| | - Giovanni Defazio
- Department of Medical Sciences and Public Health, Neurology Unit, University of Cagliari and AOU Cagliari, Monserrato, Cagliari, Italy
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Nevrlý M, Hluštík P, Hok P, Otruba P, Tüdös Z, Kaňovský P. Changes in sensorimotor network activation after botulinum toxin type A injections in patients with cervical dystonia: a functional MRI study. Exp Brain Res 2018; 236:2627-2637. [PMID: 29971454 PMCID: PMC6153868 DOI: 10.1007/s00221-018-5322-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Accepted: 06/28/2018] [Indexed: 11/26/2022]
Abstract
Botulinum toxin type A (BoNT) is considered an effective therapeutic option in cervical dystonia (CD). The pathophysiology of CD and other focal dystonias has not yet been fully explained. Results from neurophysiological and imaging studies suggest a significant involvement of the basal ganglia and thalamus, and functional abnormalities in premotor and primary sensorimotor cortical areas are considered a crucial factor in the development of focal dystonias. Twelve BoNT-naïve patients with CD were examined with functional MRI during a skilled hand motor task; the examination was repeated 4 weeks after the first BoNT injection to the dystonic neck muscles. Twelve age- and gender-matched healthy controls were examined using the same functional MRI paradigm without BoNT injection. In BoNT-naïve patients with CD, BoNT treatment was associated with a significant increase of activation in finger movement-induced fMRI activation of several brain areas, especially in the bilateral primary and secondary somatosensory cortex, bilateral superior and inferior parietal lobule, bilateral SMA and premotor cortex, predominantly contralateral primary motor cortex, bilateral anterior cingulate cortex, ipsilateral thalamus, insula, putamen, and in the central part of cerebellum, close to the vermis. The results of the study support observations that the BoNT effect may have a correlate in the central nervous system level, and this effect may not be limited to cortical and subcortical representations of the treated muscles. The results show that abnormalities in sensorimotor activation extend beyond circuits controlling the affected body parts in CD even the first BoNT injection is associated with changes in sensorimotor activation. The differences in activation between patients with CD after treatment and healthy controls at baseline were no longer present.
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Affiliation(s)
- Martin Nevrlý
- Department of Neurology, University Hospital and Faculty of Medicine and Dentistry of Palacký University, I. P. Pavlova 6, 775 20, Olomouc, Czech Republic.
| | - Petr Hluštík
- Department of Neurology, University Hospital and Faculty of Medicine and Dentistry of Palacký University, I. P. Pavlova 6, 775 20, Olomouc, Czech Republic
- Department of Radiology, University Hospital and Faculty of Medicine and Dentistry of Palacký University, Olomouc, Czech Republic
| | - Pavel Hok
- Department of Neurology, University Hospital and Faculty of Medicine and Dentistry of Palacký University, I. P. Pavlova 6, 775 20, Olomouc, Czech Republic
| | - Pavel Otruba
- Department of Neurology, University Hospital and Faculty of Medicine and Dentistry of Palacký University, I. P. Pavlova 6, 775 20, Olomouc, Czech Republic
| | - Zbyněk Tüdös
- Department of Radiology, University Hospital and Faculty of Medicine and Dentistry of Palacký University, Olomouc, Czech Republic
| | - Petr Kaňovský
- Department of Neurology, University Hospital and Faculty of Medicine and Dentistry of Palacký University, I. P. Pavlova 6, 775 20, Olomouc, Czech Republic
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Bologna M, Paparella G, Fabbrini A, Leodori G, Rocchi L, Hallett M, Berardelli A. Effects of cerebellar theta-burst stimulation on arm and neck movement kinematics in patients with focal dystonia. Clin Neurophysiol 2016; 127:3472-3479. [PMID: 27721106 DOI: 10.1016/j.clinph.2016.09.008] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 07/11/2016] [Accepted: 09/04/2016] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To investigate the cerebellar inhibitory influence on the primary motor cortex in patients with focal dystonia using a cerebellar continuous theta-burst stimulation protocol (cTBS) and to evaluate any relationship with movement abnormalities. METHODS Thirteen patients with focal hand dystonia, 13 patients with cervical dystonia and 13 healthy subjects underwent two sessions: (i) cTBS over the cerebellar hemisphere (real cTBS) and (ii) cTBS over the neck muscles (sham cTBS). The effects of cerebellar cTBS were quantified as excitability changes in the contralateral primary motor cortex, as well as possible changes in arm and neck movements in patients. RESULTS Real cerebellar cTBS reduced the excitability in the contralateral primary motor cortex in healthy subjects and in patients with cervical dystonia, though not in patients with focal hand dystonia. There was no correlation between changes in primary motor cortex excitability and arm and neck movement kinematics in patients. There were no changes in clinical scores or in kinematic measures, after either real or sham cerebellar cTBS in patients. CONCLUSIONS The reduced cerebellar inhibitory modulation of primary motor cortex excitability in focal dystonia may be related to the body areas affected by dystonia as opposed to being a widespread pathophysiological abnormality. SIGNIFICANCE The present study yields information on the differential role played by the cerebellum in the pathophysiology of different focal dystonias.
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Affiliation(s)
- Matteo Bologna
- Department of Neurology and Psychiatry, Sapienza University of Rome, Rome, Italy; Neuromed Institute IRCCS, Pozzilli (IS), Italy
| | - Giulia Paparella
- Department of Neurology and Psychiatry, Sapienza University of Rome, Rome, Italy
| | - Andrea Fabbrini
- Department of Neurology and Psychiatry, Sapienza University of Rome, Rome, Italy
| | - Giorgio Leodori
- Department of Neurology and Psychiatry, Sapienza University of Rome, Rome, Italy
| | - Lorenzo Rocchi
- Department of Neurology and Psychiatry, Sapienza University of Rome, Rome, Italy
| | - Mark Hallett
- Human Motor Control Section, National Institute of Neurological Disorders and Stroke - NINDS, Bethesda, MD, USA
| | - Alfredo Berardelli
- Department of Neurology and Psychiatry, Sapienza University of Rome, Rome, Italy; Neuromed Institute IRCCS, Pozzilli (IS), Italy.
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Arezzo JC, Seto S, Schaumburg HH. Sensory-motor assessment in clinical research trials. HANDBOOK OF CLINICAL NEUROLOGY 2014; 115:265-78. [PMID: 23931786 DOI: 10.1016/b978-0-444-52902-2.00016-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/10/2023]
Abstract
The assessment of changes in sensory-motor function in clinical research presents a unique set of difficulties. Clinimetrics is the science of measurement as related to the identification of a clinical disorder, the tracing of the progression of the condition under study, and calculation of its impact. The selection of appropriate measures for clinical studies of sensory-motor function must consider validity, sensitivity, specificity, responsiveness, reliability, and feasibility. Reasonable measures of motor function in clinical research include manual examination of muscle strength, electrophysiology, functional scales, patient-reported outcomes (e.g., quality of life), and for severe conditions such as ALS, survival. The assessment of sensory function includes targeted electrophysiology and QOL, as well as more focused measures such as quantitative sensory testing and the scoring of positive symptoms. Each individual measure and each combination of endpoints has its strengths and limitations.
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Affiliation(s)
- Joseph C Arezzo
- Department of Neuroscience, Albert Einstein College of Medicine, New York, USA; Department of Neurology, Albert Einstein College of Medicine, New York, USA.
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Melgari J, Zappasodi F, Porcaro C, Tomasevic L, Cassetta E, Rossini P, Tecchio F. Movement-induced uncoupling of primary sensory and motor areas in focal task-specific hand dystonia. Neuroscience 2013; 250:434-45. [DOI: 10.1016/j.neuroscience.2013.07.027] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2013] [Revised: 06/10/2013] [Accepted: 07/03/2013] [Indexed: 11/28/2022]
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Elble RJ. Defining dystonic tremor. Curr Neuropharmacol 2013; 11:48-52. [PMID: 23814537 PMCID: PMC3580791 DOI: 10.2174/157015913804999478] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2012] [Revised: 06/08/2012] [Accepted: 07/03/2012] [Indexed: 11/22/2022] Open
Abstract
A strong association between dystonia and tremor has been known for more than a century. Two forms of tremor in dystonia are currently recognized: 1) dystonic tremor, which is tremor produced by dystonic muscle contraction and 2) tremor associated with dystonia, which is tremor in a body part that is not dystonic, but there is dystonia elsewhere. Both forms of tremor in dystonia frequently resemble essential tremor or another pure tremor syndrome (e.g., isolated head and voice tremors and task-specific writing tremor), and relationships among these tremor disorders have long been debated. Misdiagnosis is common because mild dystonia is frequently overlooked in patients with tremor. It is now clear that essential tremor is a syndrome, not a specific disease, and the use of essential tremor as a specific clinical diagnosis is arguably an impediment to elucidating this and other pure tremor syndromes and their relationship to dystonia. A new classification, primary tremor, is proposed and would be used for any disorder in which tremor is the sole or principal abnormality with no identifiable etiology other than possible genetic inheritance. This classification scheme would facilitate tremor research by moving the focus from the narrow question "Is it essential tremor?" to a broader consideration of what genetic and environmental factors cause primary tremor disorders, and how do they relate to dystonia and other neurological disorders.
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Affiliation(s)
- Rodger J Elble
- Department of Neurology, Southern Illinois University School of Medicine, 751 North Rutledge, PO Box 19643, Springfield, IL 62794-9643, USA
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Abstract
STUDY DESIGN Resident's case problem. BACKGROUND A 56-year-old man was referred to physical therapy for analysis of unusual gait, first noticed 3 years previously when running. Prior to this evaluation, the patient had seen multiple orthopaedic, sports medicine, and neurological specialists while undergoing repeated and extensive testing. Ten months of testing and treatment, including conservative and surgical management, did not provide an explanation for the gait abnormality or result in improvement of the patient's condition. DIAGNOSIS The patient's physical examination was relatively unremarkable, considering the severity of the gait abnormality. Distinct abnormalities were apparent with computerized gait analysis and dynamic electromyography, and, when combined with the physical examination findings, led to a suspicion of the task-specific disorder of runner's dystonia. The patient was referred to a neurologist specializing in movement-related disorders, with a final confirmed diagnosis of primary task-specific dystonia with first onset during running (ie, runner's dystonia). DISCUSSION Idiopathic, task-specific dystonia of the lower extremity is documented as a very rare occurrence, yet increasing trends in running participation may result in a higher incidence of this condition. Improved awareness of runner's dystonia in the present case might have enhanced the clinical decision-making process and resulted in more timely and effective treatment solutions. Clinical examination findings, including computerized gait analysis and electromyography, in conjunction with imaging, blood, and genetic testing, can aid in the diagnosis of runner's dystonia. LEVEL OF EVIDENCE Differential diagnosis, level 4.
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Trompetto C, Avanzino L, Marinelli L, Mori L, Pelosin E, Roccatagliata L, Abbruzzese G. Corticospinal excitability in patients with secondary dystonia due to focal lesions of the basal ganglia and thalamus. Clin Neurophysiol 2012; 123:808-14. [DOI: 10.1016/j.clinph.2011.06.033] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2010] [Revised: 05/20/2011] [Accepted: 06/26/2011] [Indexed: 11/16/2022]
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Filipović SR. Functional anatomy of dystonia – Getting the higher definition picture. Clin Neurophysiol 2012; 123:638-9. [DOI: 10.1016/j.clinph.2011.08.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2011] [Accepted: 08/20/2011] [Indexed: 11/27/2022]
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Bertram KL, Williams DR. Diagnosis of dystonic syndromes—a new eight-question approach. Nat Rev Neurol 2012; 8:275-83. [DOI: 10.1038/nrneurol.2012.39] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Valls-Sole J. Assessment of excitability in brainstem circuits mediating the blink reflex and the startle reaction. Clin Neurophysiol 2011; 123:13-20. [PMID: 22030138 DOI: 10.1016/j.clinph.2011.04.029] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2011] [Revised: 04/13/2011] [Accepted: 04/15/2011] [Indexed: 11/18/2022]
Abstract
Excitability is probably the concept that fits better with the definition of the role of neurophysiology in the study of brainstem functions and circuits. Neurophysiological techniques are likely the best suited of all paraclinical tests for documenting the eventual excitability changes that may occur in certain physiological states and in many neurological disorders. The best known test of brainstem excitability is the blink reflex. While a single stimulus can already indicate the readiness of the interneuronal path and the facial motoneurons to fire, pairs of stimuli (conditioning and test) are suited to analyze the degree of excitability recovery after a single discharge. Another brainstem reflex circuit, which excitability testing can be of interest for physiological and clinical exams is the one involved in the startle reaction. The size of the responses and their habituation are the typical measures of excitability of the startle reflex circuit. Prepulse inhibition is a method to modulate both, the blink reflex and the startle reaction. It is defined as the inhibitory effect caused by a stimulus of an intensity low enough not to induce a response by itself on the response elicited by a subsequent stimulus. The circuits of the blink reflex, startle reaction and prepulse inhibition share some commonalities but they are different enough for the three techniques to provide unique, clinically relevant, information in certain conditions. The role of neurophysiology is not limited to testing those functions. It is important also for the assessment of many other circuits, such as those implicated in eye movements, vestibular reflexes, arousal, sleep, breathing, or autonomic reactions, which are not considered in this review.
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Affiliation(s)
- Josep Valls-Sole
- EMG Unit, Neurology Department, Hospital Clinic, University of Barcelona, Spain.
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Ruge D, Cif L, Limousin P, Gonzalez V, Vasques X, Hariz MI, Coubes P, Rothwell JC. Shaping reversibility? Long-term deep brain stimulation in dystonia: the relationship between effects on electrophysiology and clinical symptoms. Brain 2011; 134:2106-15. [PMID: 21705425 DOI: 10.1093/brain/awr122] [Citation(s) in RCA: 101] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Long-term results show that benefits from chronic deep brain stimulation in dystonia are maintained for many years. Despite this, the neurophysiological long-term consequences of treatment and their relationship to clinical effects are not well understood. Previous studies have shown that transcranial magnetic stimulation measures of abnormal long-term potentiation-like plasticity (paired associative stimulation) and GABAa-ergic inhibition (short-interval intracortical inhibition), which are seen in dystonia, normalize after several months of deep brain stimulation. In the present study, we examine the same measures in a homogenous group of 10 DYT1 gene-positive patients after long-term deep brain stimulation treatment for at least 4.5 years. Recordings were made 'on' deep brain stimulation and after stopping deep brain stimulation for 2 days. The results show that: (i) on average, prior to discontinuing deep brain stimulation, the paired associative stimulation response was almost absent and short-interval intracortical inhibition was reduced compared with normal. This pattern differs from that in both healthy volunteers and from the typical pattern of enhanced plasticity and reduced inhibition seen in deep brain stimulation-naïve dystonia. It is similar to that seen in untreated Parkinson's disease and may relate to thus far unexplained clinical phenomena like parkinsonian symptoms that have sometimes been observed in patients treated with deep brain stimulation. (ii) Overall, there was no change in average physiological or clinical status when deep brain stimulation was turned off for 2 days, suggesting that deep brain stimulation had produced long-term neural reorganization in the motor system. (iii) However, there was considerable variation between patients. Those who had higher levels of plasticity when deep brain stimulation was 'on', had the best retention of clinical benefit when deep brain stimulation was stopped and vice versa. This may indicate that better plasticity is required for longer term retention of normal movement when deep brain stimulation is off. (iv) Patients with the highest plasticity 'on' deep brain stimulation were those who had been receiving stimulation with the least current drain. This suggests that it might be possible to 'shape' deep brain stimulation of an individual patient to maximize beneficial neurophysiological patterns that have an impact on clinical status. The results are relevant for understanding long-term consequences and management of deep brain stimulation in dystonia.
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Affiliation(s)
- Diane Ruge
- Sobell Department of Motor Neuroscience and Movement Disorders, UCL Institute of Neurology, University College London, 33 Queen Square, London WC1N3BG, UK.
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Albanese A, Asmus F, Bhatia KP, Elia AE, Elibol B, Filippini G, Gasser T, Krauss JK, Nardocci N, Newton A, Valls-Solé J. EFNS guidelines on diagnosis and treatment of primary dystonias. Eur J Neurol 2011; 18:5-18. [PMID: 20482602 DOI: 10.1111/j.1468-1331.2010.03042.x] [Citation(s) in RCA: 261] [Impact Index Per Article: 20.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES to provide a revised version of earlier guidelines published in 2006. BACKGROUND primary dystonias are chronic and often disabling conditions with a widespread spectrum mainly in young people. DIAGNOSIS primary dystonias are classified as pure dystonia, dystonia plus or paroxysmal dystonia syndromes. Assessment should be performed using a validated rating scale for dystonia. Genetic testing may be performed after establishing the clinical diagnosis. DYT1 testing is recommended for patients with primary dystonia with limb onset before age 30, and in those with an affected relative with early-onset dystonia. DYT6 testing is recommended in early-onset or familial cases with cranio-cervical dystonia or after exclusion of DYT1. Individuals with early-onset myoclonus should be tested for mutations in the DYT11 gene. If direct sequencing of the DYT11 gene is negative, additional gene dosage is required to improve the proportion of mutations detected. A levodopa trial is warranted in every patient with early-onset primary dystonia without an alternative diagnosis. In patients with idiopathic dystonia, neurophysiological tests can help with describing the pathophysiological mechanisms underlying the disorder. TREATMENT botulinum toxin (BoNT) type A is the first-line treatment for primary cranial (excluding oromandibular) or cervical dystonia; it is also effective on writing dystonia. BoNT/B is not inferior to BoNT/A in cervical dystonia. Pallidal deep brain stimulation (DBS) is considered a good option, particularly for primary generalized or cervical dystonia, after medication or BoNT have failed. DBS is less effective in secondary dystonia. This treatment requires a specialized expertise and a multidisciplinary team.
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Affiliation(s)
- A Albanese
- Istituto Neurologico Carlo Besta, Milan, Italy Università Cattolica del Sacro Cuore, Milan, Italy.
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Opavský R, Hluštík P, Otruba P, Kaňovský P. Sensorimotor network in cervical dystonia and the effect of botulinum toxin treatment: a functional MRI study. J Neurol Sci 2011; 306:71-5. [PMID: 21492880 DOI: 10.1016/j.jns.2011.03.040] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2011] [Revised: 03/18/2011] [Accepted: 03/24/2011] [Indexed: 11/25/2022]
Abstract
BACKGROUND The evidence suggests that the origin of primary dystonia is at least partly associated with widespread dysfunction of the basal ganglia and cortico-striato-thalamo-cortical circuits. The aim of the study was to assess the sensorimotor activation pattern outside the circuits controlling the affected body part in cervical dystonia, as well as to determine task-related activation changes induced by botulinum toxin type A (BoNT-A) treatment. METHODS Seven patients suffering from cervical dystonia and nine healthy controls were examined with functional MRI during skilled hand motor task; the examination was repeated 4 weeks after BoNT-A application to dystonic neck muscles. RESULTS Functional MRI data demonstrated overall reduced extent of hand movement-related cortical activation but greater magnitude of blood oxygenation level dependent signal change in the contralateral secondary somatosensory cortex in patients compared to controls. Effective BoNT-A treatment led to reduced activation of the ipsilateral supplementary motor area and dorsal premotor cortex in patients. The patients' post-treatment sensorimotor maps showed significantly smaller basal ganglia activation compared to controls. CONCLUSIONS These results provide imaging evidence that abnormalities in sensorimotor activation extend beyond circuits controlling the affected body parts in cervical dystonia. The study also supports observations that BoNT-A effect has a correlate at central nervous system level, and such effect may not be limited to cortical and subcortical representations of the treated muscles.
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Affiliation(s)
- Robert Opavský
- Department of Neurology, Faculty of Medicine and Dentistry, Palacký University and University Hospital, Olomouc, Czech Republic.
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Abstract
Dystonia is defined as a motor syndrome characterized by sustained muscle contractions, usually producing twisting and repetitive movements or abnormal postures. Dystonia can be present at rest or worsened by action. Dystonia is commonly classified according to age at onset (childhood, adolescent type, and adult type), etiology (idiopathic, and symptomatic), and distribution (focal dystonia, segmental dystonia, generalized dystonia, multifocal dystonia and hemidystonia). The different subtypes of focal and segmental dystonias may have different clinical features. Neuropsychiatric disorders may be present in dystonia.
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Affiliation(s)
- Carlo Colosimo
- Department of Neurology and Psychiatry and Neuromed Institute (IRCSS), Sapienza University of Rome, Italy
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Lungu C, Tarulli AW, Tarsy D, Mongiovi P, Vanderhorst VG, Rutkove SB. Quantifying muscle asymmetries in cervical dystonia with electrical impedance: a preliminary assessment. Clin Neurophysiol 2010; 122:1027-31. [PMID: 20943436 DOI: 10.1016/j.clinph.2010.09.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2010] [Revised: 08/10/2010] [Accepted: 09/16/2010] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Cervical dystonia (CD) lacks an objective quantitative measure. Electrical impedance myography (EIM) is a non-invasive assessment method sensitive to changes in muscle structure and physiology. We evaluate the potential role of EIM in quantifying CD, hypothesizing that patients would demonstrate differences in the symmetry of muscle electrical resistance compared to controls, and that this asymmetry would decrease after botulinum neurotoxin (BoNT) treatment. METHODS EIM was performed on the sternocleidomastoid (SCM) and cervical paraspinal (PS) muscles of CD patients and age-matched controls. 50 kHz resistance was analyzed, comparing side-to-side asymmetry in patients and controls, and, in patients, before and after BoNT treatment. RESULTS Sixteen patients and 10 controls were included. Resistance asymmetry was on average 3-5 times higher in patients than controls. Receiver operating characteristic analysis demonstrated 91% accuracy of discriminating CD from normal. From pre-treatment to maximum BoNT effect, asymmetry decreased from 20.8(13.9-26.1)% to 6.2(3.1-9.9)% (SCM), and from 16.0(14.3-16.0)% to 8.4(7.0-9.2)% (PS), p<0.05 (median, interquartile range). CONCLUSIONS EIM effectively differentiates normal subjects from CD patients by revealing asymmetries in resistance values and detects improvement in muscle symmetry after treatment. SIGNIFICANCE These results suggest that EIM, a painless, non-invasive measure, can provide a useful quantitative metric in CD evaluation and deserves further study.
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Affiliation(s)
- Codrin Lungu
- Medical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD 20892, United States.
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