Cervical dystonia: unresolved issues and future challenges

Improvements in Nerve Dissection Surgery Methodology for Spasmodic Torticollis Treatment

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.

Rationale and design of a prospective study: Cervical Dystonia Patient Registry for Observation of OnaBotulinumtoxinA Efficacy (CD PROBE)

Background

A registry of patients with cervical dystonia (Cervical Dystonia Patient Registry for Observation of onaBotulinumtoxinA Efficacy [CD PROBE]) was initiated to capture data regarding physician practices and patient outcomes with onabotulinumtoxinA (BOTOX^®, Allergan, Inc., Irvine, CA, USA). Methods and baseline demographics from an interim analysis are provided.

Methods/Design

This is a prospective, multicenter, clinical registry in the United States enrolling subjects with cervical dystonia (CD) who are toxin naïve and/or new to the physicians' practices, or who had been in a clinical trial but received their last injection ≥ 16 weeks prior to enrollment. Subjects are followed over 3 injection cycles of onabotulinumtoxinA, with assessments at time of injection and 4-6 weeks later. Information on physician's practice, patient demographics, CD disease history, duration of treatment intervals and neurotoxin dose, dilution, use of electromyography, and muscles injected are collected. Outcomes are assessed by physicians and subjects using various questionnaires.

Discussion

This ongoing registry includes 609 subjects with the following baseline data: 75.9% female, 93.6% Caucasian, mean age 57.6 ± 14.3, age at symptom onset 48.3 ± 16.2, and time to diagnosis 5.4 ± 8.6 years, with an additional 1.0 ± 3.5 years before treatment. Of those employed at the time of diagnosis, 36.6% stopped working as a result of CD. CD PROBE, the largest clinical registry of CD treatment, will provide useful data on current treatment practices with onabotulinumtoxinA, potentially leading to refinements for optimization of outcomes.

Trial registration

NCT00836017

Surgery for cervical dystonia: the emergence of denervation and myotomy techniques and the contributions of early surgeons at The Johns Hopkins Hospital

Cervical dystonia is a psychologically and physically disabling disease that has intrigued clinicians since the early history of surgery. Because of its elusive etiology, its operative treatment has had an extended evolutionary voyage. Early surgical approaches involved resection of the sternocleidomastoid muscle. Later recognition of more diffuse involvement of the posterior neck muscles led to the introduction of new techniques with more effective results. A review of available surgical patient records at The Johns Hopkins Hospital from around the turn of the 20th century provided a glimpse of the early history of the operative treatment for torticollis through the work of some of the leaders of surgery, including Halsted, Cushing, and specifically Finney. Here, the authors present a segment of history on the surgical treatment of this disease as it relates to the introduction of myotomy and denervation techniques.