Pathophysiology and pharmacotherapy of spasmodic torticollis: a review

Anticholinergic drugs for parkinsonism and other movement disorders

Anticholinergic (AC) drugs, a medication class that acts by blocking nicotinic and muscarinic acetylcholine receptors, were first utilized for therapeutic purposes in the mid-19th century. Initial applications were as symptomatic therapy for Parkinson disease (PD), a practice continuing to the present. Initially, the AC drugs used were naturally-occurring plant compounds. Synthetic AC drugs were developed in the late 1940s and predominated in neurological therapeutics. Until the advent of pharmaceuticals acting upon striatal dopaminergic motor pathways, AC drugs provided the only effective means for lessening tremors and other clinical problems of the PD patient. However, because dopaminergic compounds are so effective at meeting the needs of the typical PD patient, AC medications are far less utilized by clinicians today. In recent years, there has been only a few investigations of AC drugs as neurological treatments. This review will revisit the clinical landscape of AC pharmacology and application for movement disorders along with recent research in search of improving therapeutics with AC drugs.

Treatment of cervical dystonia with Botox (onabotulinumtoxinA): Development, insights, and impact

Cervical dystonia (CD), the most common focal dystonia encountered in neurologic practice, is a chronic disorder in which the muscles of the neck involuntarily contract and cause abnormal postures and movements of the head, neck, and shoulders. Treatment of CD prior to botulinum toxin was unsatisfactory, as existing therapies often did not improve symptoms. The use of botulinum toxin for CD grew out of its success in treating blepharospasm, another type of focal dystonia. On the basis of results from a double-blind, placebo-controlled trial, onabotulinumtoxinA was approved in 2000 in the US for the treatment of CD in adults in order to alleviate abnormal head position and neck pain. A subsequent large observational trial further demonstrated the effectiveness of onabotulinumtoxinA for CD, showing improvements in various rating scales, physician-reported measures, and profound positive effects on patient quality of life, including in amelioration of pain and improvements in work productivity. In addition, onabotulinumtoxinA treatment also reduced the complications of CD, as patients no longer develop contractures (permanent muscle and tendon shortening from prolonged untreated dystonia), which markedly limited the range of neck motion. The onset of onabotulinumtoxinA treatment also accompanied advances in understanding the functional anatomy of neck muscles, basal ganglia physiology, and video and other recording technology. Following the success of onabotulinumtoxinA in the treatment of CD, its use has been expanded into numerous other therapeutic indications, and these advances stimulated educational and training programs by various neurologic and other medical societies.

Application of botulinum toxin in pregnancy and its impact on female reproductive health

Introduction: Botulinum toxin (BoNT) is a protein secreted by the anaerobic Gram-negative bacterium Clostridium botulinum. Among the seven known subtypes, type A is the most commonly used in women to treat diseases. It primarily blocks presynaptic release of acetylcholine at the neuromuscular junction, resulting in temporary muscle paralysis; thus, it is suitable for treating dystonia and other systemic diseases. BoNT is used widely for treating diseases that persist throughout, and may worsen during, pregnancy, such as cervical dystonia and achalasia. Thus, it is important to investigate whether BoNT injection during pregnancy causes side effects in pregnant women, fetuses, or newborns.Areas covered: This review highlights the efficiency and safety of BoNT injection in pregnancy. and assessed current literature with respect to the use of BoNT for disease treatment during pregnancy.Expert opinion: BoNT injection does not increase the risk of complications in pregnant women and fetuses. However, the use of BoNT to treat disease during pregnancy requires fully informed consent from patients. In addition, further research is needed to determine how to reduce the side effects of BoNT injection during pregnancy (e.g., by improving drug composition, or adjusting the amount of BoNT or the injection interval).

Comparison of 2 Operative Methods for Treating Laterocollis and Torticollis Subtypes of Spasmodic Torticollis: Follow-Up of 121 Cases

OBJECTIVE

The aim of this study was to compare the effects and complications of microvascular decompression (MVD) and neurectomy of spinal accessory nerve in the treatment of laterocollis and torticollis subtypes spasmodic torticollis (ST).

METHODS

Clinical data were retrospectively collected from 121 patients with laterocollis and torticollis subtypes of ST from January 1, 2012 to January 1, 2016. Among all the patients, 80 were treated by MVD and 41 were treated by neurectomy of spinal accessory nerve. The effect of the surgery was evaluated by the reduction in the Toronto Western spasmodic torticollis rating scale total scores before and after the operation. The mean duration of the postoperative follow-up period was 18.7 months (range, 12-27 months).

RESULTS

At the final follow-up, the Toronto Western spasmodic torticollis rating scale total score in the MVD group and in the neurectomy group was lowered by 50.43% ± 20.3% and 30.23% ± 19.4%, respectively, compared with the preoperative status (P < 0.05). In the MVD group, 25 (31.25%) patients achieved excellent relief, 44 (55%) patients improved moderate spasm, and 11 (13.75%) showed no relief. In the neurectomy group, 6 (14.63%) patients improved with excellent outcome, 7 (17.07%) had moderate relief, and 28 (68.29%) had no relief. There was no mortality or severe complication postoperatively, with the exception of hoarseness, shoulder numbness, and weakness.

CONCLUSIONS

MVD for ST of laterocollis and torticollis subtypes can provide satisfactory and lasting improvements without nerve impairment. MVD is to be preferred to neurectomy of accessory nerve in treating ST of laterocollis and torticollis subtypes.

Lack of influence of EMG biofeedback in relaxation training for spasmodic torticollis

Reports in the American and Japanese literature have suggested that electromyographic (EMG) biofeedback is effective in the treatment of spasmodic torticollis but no conclusive evidence has been reported from controlled studies. A controlled study was therefore undertaken in 11 subjects with spasmodic torticollis. Five patients were randomly allocated to a course of television- monitored relaxation while the remaining six were treated with television- monitored relaxation plus EMG biofeedback. The effects of intervention were assessed by questionnaires, clinical assessment and measurement of integrated EMG activity in both sternomastoid muscles during a five-minute observation period under controlled conditions. The subjects' range of voluntary neck movements and their capacity to suppress their involuntary movements were measured using a computer-assisted movement detection system (Coda 3, Charnwood Dynamics) and standardized videotape recordings, the latter being assessed by two experienced clinicians who did not know the sequence of the recordings. Subjective improvements in symptoms were reported in both groups of subjects, who appeared to gain from the opportunity to discuss harrowing aspects of their experience. However, these subjective results were not associated with any significant changes in the objective measures used and thus provided no support for the use of EMG biofeedback in torticollis.

Microvascular decompression surgery is effective for the laterocollis subtype of spasmodic torticollis: a long-term follow-up result

BACKGROUND

Spasmodic torticollis (ST) is characterized by sustained, involuntary, and painful spasms of specific muscle (s), which results into abnormal posture of the neck and head. Although various treatments for ST have been introduced, none of them shows absolute effectiveness. Earlier research from our department showed that microvascular decompression (MVD) surgery is effective in the short-term for ST patients with confirmed accessory nerve compression. However, the long-term outcome of MVD remains unknown.

METHOD

Twelve ST patients with confirmed accessory nerve compression received MVD surgery of their accessory nerves. We utilized the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) to evaluate the long-term outcome (5.4 ± 0.87 years).

RESULTS

The MVD lowered total TWSTRS scores by 42.8 % in all ST patients. This result, however, only counted for moderate relief. Interestingly, we observed that the laterocollis (LC) subtypes of ST (n = 3) obtained a higher TWSTRS score improvement (86.9 ± 6.2 %), compared to that of the non-LC (28.1 ± 12 %) (P =0.0001). Additionally, the disability (92.7 ± 2 %) subscale score in the LC subtypes had the most prominent improvement compared to the pain (88.1 ± 5.1 %) and severity (81.3 ± 10.5 %).

CONCLUSIONS

In the cases of confirmed accessory nerve compression, the MVD could be considered as a treatment alternative for ST, especially for the LC subtypes.

Long-term efficacy of botulinum toxin A in treatment of various movement disorders over a 10-year period

Although botulinum toxin A (BTX) has been licensed in Canada for treatment of various movement disorders since 1990, few clinical studies regarding its long-term efficacy and side effects have been reported. We conducted a retrospective analysis of 235 patients who received BTX from our movement disorders clinic over a 10-year period (January 1990 to December 1999). A total of 2,616 treatment cycles (multiple injections) were administered to 235 patients with cervical dystonia (CD), hemifacial spasm (HS), blepharospasm (BP), and other movement disorders. Substantial benefit at 5 years was seen in most patients (90% in BP, 88% in HS, 63% in CD, 100% in jaw closing and lower limb dystonia, and 56% in writer's cramp). Benefit was maintained for up to 10 years in CD, HS, and BP data, with a 75.8% benefit reported. Twenty-eight percent of patients discontinued treatment during the follow-up period due to a variety of reasons. Of these, 9.1% of patients developed primary resistance, and 7.5% of patients secondary resistance. Adverse effects, mostly minor, developed in 27% of patients at any one time, occurring over 4.5% of treatment cycles. These were most frequently reported in blepharospasm (22 of 36 patients in 40 cycles), followed by hemifacial spasm (21 of 70 patients in 46 cycles), and cervical dystonia (17 of 106 in 28 cycles). Only 1.3% of patients discontinued therapy due intolerable adverse effects. The results show that BTX is a safe and effective treatment of various types of movement disorders, and most side effects are well tolerated. Discontinuation for any reason was also low after 5 years. Efficacy was maintained after long periods of treatment with high degree of patient satisfaction.

Hypnosis and spasmodic torticollis--report of four cases: a brief communication

Dystonia and particularly spasmodic torticollis are neuromuscular disorders that are extremely resistant to most therapies (physical, medical, or surgical). Torticollis is a unilateral spasm of the neck muscles, particularly of the sternocleidomastoid, that produces violent, tonic turning of the head to one side. The etiology remains uncertain, although the role of psychogenic factors has been emphasized. This article reviews the literature and reports four cases of spasmodic torticollis treated successfully with hypnosis. In all four cases, psychogenic causes were involved. Postural hypnosis (i.e., hypnosis in the standing position) was employed to counteract and minimize muscle spasms due to postural reflexes. A hypnobehavioral approach was adopted along with hypnotic strategies that included hierarchical desensitization, sensory-imaging conditioning, ego-boosting suggestions, and hypnosis-facilitated differential muscle retraining. In two cases, a combined hypnosis and electromyographic-biofeedback approach was used to equilibrate and retrain affected neck muscles. Although the hypnotherapeutic process took several months to induce and stabilize significant changes, outcome results were good to excellent in all cases, with marked reduction of the torticollis and the hypertrophy of the neck muscles as well as a reduced interference of symptoms in daily living.

Botulinum toxin as a therapeutic agent

Botulinum toxin is a presynaptic neuromuscular blocking agent that, when injected intramuscularly in minute quantities, can produce selective muscle weakness. This property is employed therapeutically to provide symptomatic relief in conditions related to excessive muscle activities in strabismus, blepharospasm, hemifacial spasm, cervical dystonia, spasmodic dysphonia (adductor type), and jaw closing dystonia. It is investigational for a long list of medical conditions. It is a marketed drug in a number of countries in the world, but its use has only been approved by different regulatory agencies for use in a limited number of conditions. The long-term effects, appropriate dose for children, and in pregnancy, and maximum dose without causing toxicity remain unclear.

Cervical dystonia due to spinal cord ependymoma: involvement of cervical cord segments in the pathogenesis of dystonia

We report a patient with a progressive motor disorder dominated by pyramidal signs in all four extremities and cervical dystonia in the form of torticollis, who had imaging features of cervical cord tumor on magnetic resonance imaging (MRI) scanning. Ependymoma was the final diagnosis by histology. Cervical dystonia presenting as a manifestation of an identified focal central nervous system (CNS) lesion is infrequent. We believe our patient to be the first adult example of cervical cord tumor giving rise to cervical dystonia. Adding this entity to the list of differential diagnosis of torticollis is considered, and its mechanisms are discussed.

Microvascular decompression for spasmodic torticollis

Twenty patients with spasmodic torticollis (ST) were treated by microvascular decompression (MVD) of the spinal accessory nerves, the upper cervical nerve roots and the brainstem. Thirteen were female and seven male. Median age was 47 years (range 39 to 70 years). Median duration of symptoms was 5 years (range 4 months to 17 years). Ten had right horizontal; nine, left horizontal; and one, retrocollis ST. Twenty-two operations were performed on twenty patients, suboccipital craniectomy and C1 laminectomy in 18 and retromastoid craniectomy in 4 operations. The most common compressing blood vessels were the vertebral artery and/or the posterior inferior cerebellar artery. No nerve section was performed. Three patients died of unrelated conditions, 3, 5 1/2, and 6 years postoperatively, respectively. Minimum follow-up period in the rest of the cases is 5 years (range 5 to 10 years). Thirteen (65%) were cured, four (20%) improved with minimal spasm, one (5%) improved with moderate spasm, and two (10%) improved minimally or unchanged. In most cases the cure or improvement was noticed gradually over 6 months to two years following the operation. There was no operative mortality. Postoperative morbidities included transient cerebrospinal fluid leakage through the surgical incision in one case and an apparent multiple small vessel stroke involving periventricular white matter in one reoperation case with full recovery. MVD for ST is a nondestructive benign procedure with high probability of cure or significant improvement.

Idiopathic spasmodic torticollis: a survey of the clinical syndromes and patients' experiences

We evaluated the medical and psychosocial experiences of 59 patients with idiopathic spasmodic torticollis (ST) by means of a structured questionnaire. The results generally corresponded with those of other studies in the literature. Diagnosis is delayed in many patients, and ST negatively influences the patients' social lives. Because drug treatment and physiotherapy are only of sufficient value in a minority, most patients seek benefit from numerous other therapies, none of which has been shown to improve ST.

CT-scanning and magnetic resonance imaging in idiopathic spasmodic torticollis

Twenty-five consecutive patients with idiopathic spasmodic torticollis (IST) were investigated with computerized tomography (CT) or magnetic resonance imaging (MRI) of the brain. In only six patients (24%) did CT or MRI reveal brain pathology (focal cortical atrophy and lacunary infarcts). No consistent pathological pattern was detected. Consequently, CT and MRI of the brain provides little diagnostic information in this disorder.

Spasmodic torticollis--review of 220 patients

220 patients with isolated and idiopathic spasmodic torticollis were followed and treated over a 14 year period. Each patient was given a short questionnaire leading to the present retrospective data analysis. In most areas, including female preponderance and frequency of postural tremor, the findings confirmed previous studies and highlighted particular points: importance of psychopathological antecedents and association with stressful life-events. The discussion deals with some of the conflicting debates surrounding this unusual disorder. What is the role of psychopathological factors? What is the therapeutic prognosis? The best therapeutic results were obtained by combining anticholinergic drugs, local injections and rehabilitation.

Red cell choline in spasmodic torticollis and in a monozygotic twin pair with Tourette's syndrome

1. Alterations in cholinergic function may play a role in the pathophysiology of idiopathic spasmodic torticollis (ST) and Gilles de la Tourette's syndrome (GTS). We measured red blood cell (RBC) choline in (i) ST (n = 24) and paired controls matched for age and gender (ii) a 20-year old pair of monozygotic twins with GTS, one of whom was moderately affected (CV) and the other virtually recovered (DV) (iii) both parents of the GTS twins, using gas chromatography-mass spectrometry. 2. RBC choline decreased with age in control men (r = -0.76; p less than 0.01) but not in control women. 3. RBC choline (nmol/ml) was higher in control men (18.3 +/- 4.8, X +/- SD) vs control women (13.1 +/- 4.3) (p = 0.025). 4. There was no significant difference in RBC choline (nmol/ml) between ST patients (16.6 +/- 5.0) and controls (15.5 +/- 5.2). 5. The RBC choline values (nmol/ml) in the twins and parents were: 56.6 (CV), 58.3 (DV), 89.8 (father), 38.3 (mother) and in the controls (age 20-24) (n = 5) 18.2 +/- 3.6. 6. These data suggest (i) RBC choline is affected by age and gender (ii) RBC choline is unchanged in ST (iii) the regulation of RBC choline is under genetic control (iv) elevated RBC choline is not a state marker for GTS.

Haloperidol and cognitive shifting

In this study haloperidol appeared to affect the performance on a selected category of cognitive tasks considered to represent shifting aptitude. A pretest--post-test design was used with two groups of subjects: 17 patients suffering from idiopathic spasmodic torticollis, and 17 controls who were matched for age and intelligence. The results are discussed in relation to previous findings on haloperidol and cognition, shifting disorder in Parkinson's disease and changes in behavioural organization found in animals with an experimentally induced dopaminergic hypoactivity.

Improvement in spasmodic torticollis following treatment and withdrawal from high dose lorazepam--clinical observations

1. Six consecutive patients with idiopathic spasmodic torticollis (ST) in whom initial amelioration with lorazepam was lost, improved following withdrawal from high doses of lorazepam (3 entered remission or virtual remission; 3 showed marked to moderate improvement). None of 12 control patients improved. 2. The possibility that benzodiazepine-receptor mechanisms play a role in the pathophysiology of ST is proposed to explain these findings.

Torticollis and blepharospasm in systemic lupus erythematosus

A case of torticollis and blepharospasm as the major manifestation of neurological involvement in systemic lupus erythematosis (SLE) is presented. A 56-year-old woman presented with blepharospasm in February 1985 and with torticollis in April 1985. She was diagnosed as having SLE in 1966, on the basis of positive LE cells, when she presented with fever and joint pains. There was no evidence that she had ever been on major tranquilizers. An attempt has been made to correlate the level of antibody titres and exacerbation of these movements with response to steroids. The possibility of an association between blepharospasm, torticollis, and autoimmune disorders has recently been considered.

Personality in torticollis: a controlled study

The Eysenck Personality Questionnaire, the trait scales of the Leyton Obsessional Inventory, the Spielberger State Trait Anxiety Inventory, and a questionnaire assessing marital status and harmony were completed by 100 torticollis patients and a control group of 49 cervical spondylosis sufferers. Information regarding employment status, and events preceding onset of their complaint was also obtained. The two groups did not differ in terms of any of the personality dimensions evaluated, or in their self-reports of events prior to onset of their illness. The groups differed significantly with regards to marital status (a higher proportion of the torticollis patients were single) but not marital harmony. A significantly higher proportion of the torticollis patients were in the permanently sick category of employment status. Findings of previous studies evaluating personality in torticollis and in sufferers of other disabling physical conditions are considered, and the results are discussed in terms of the effects of disabling chronic physical disorders.

Local treatment of spasmodic torticollis with botulinum toxin

Fifty-six patients with spasmodic torticollis were treated with local injections of botulinum toxin. The drop out rate was 21%. The remaining 44 patients were followed for a period of 3 to 21 months. Thirty-two patients (76%) had pain relief out of 42 presenting with pain; 37 (66%) improved in the amount of sustained movements of torticollis. The efficacy was reproducible after repeated injections.

Spasmodic torticollis: the problem of pathophysiology and assessment

In 17 patients with idiopathic spasmodic torticollis (ST) quantitative indices for both signs (extent and direction of the head deflexions) and complaints (of deflexion, shaking and pain) were collected. In the literature deflexion in the horizontal plane is most frequently considered, but analysis of the data shows that deflexion in the coronal and sagittal planes is also important. Furthermore, it is found that especially the deflexions in the coronal and sagittal plane covariate with the patients' complaints, but not with horizontal deflexion. On the basis of these and related data, it is suggested that we are dealing with at least two subtypes of ST. Finally, the patient's neuroticism and depression scale values are within the normal range and do not show significant correlations with ST duration. The present study provides no evidence that ST is a psychogenic disorder. ST should be regarded as a central nervous system disorder of unknown aetiology.

Double-blind study of botulinum toxin in spasmodic torticollis

In a double-blind trial in 21 patients with spasmodic torticollis botulinum-A toxin produced both subjective and objective improvement, including significant pain relief in 14 of the 16 patients presenting with pain. Side-effects were more frequently reported during placebo administration and no significant systemic adverse reactions were noted.

Electrophoresis and immunoblot of cerebrospinal fluid proteins in spasmodic torticollis

Protein patterns of cerebrospinal fluid (CSF) from patients with spasmodic torticollis (ST) were investigated to determine whether abnormalities previously reported could be detected and further identified. CSF was collected from 12 patients with ST and 6 normal controls. The CSF proteins were analyzed using sodium dodecyl sulfate (SDS) polyacrylamide gel electrophoresis and silver staining. In 11 of the 12 patients with ST, a CSF protein pattern was observed which differed from that in the controls. The identity of the abnormal proteins was ascertained by blotting and immunostaining with specific antisera to IgG and ceruloplasmin (Cp). CSF from 2 of 12 patients had distinct bands staining for IgG and 7 had abnormal immunostaining for Cp.

A pilot study on the use of botulinum toxin in spasmodic torticollis

Dystonic torticollis has been treated with local injections of botulinum toxin in a single blind study of 12 patients. A significant decrease of abnormal movements was recorded, and pain improved. Further studies are desirable to define the optimum dosage and site for injections, and the long term effects of repeated injections.

Spasmodic torticollis: treatment with Tizanidine

A randomized double-blind cross-over study was performed to compare the efficacy of Tizanidine to that of placebo in the treatment of spasmodic torticollis. No evidence was found that Tizanidine was effective in 10 patients with spasmodic torticollis who received Tizanidine during 6 weeks, up to a dose of 12 mg a day.

Spasmodic torticollis and other idiopathic torsion dystonias. Medical management

The pathophysiologic mechanisms of spasmodic torticollis and other idiopathic torsion dystonias remain unknown. Thus, a variety of drugs have been used alone or in combination on an empirical basis to treat these disorders, but to date none have efficacy that is proven and consistent. The drugs in use include anti-cholinergics, benzodiazepines, dopaminergics , and neuroleptics. The variable responses that have been observed are due in part to the heterogeneous nature of these disorders. Trial of several agents or combinations of agents may be necessary before symptoms are satisfactorily controlled. Only when a patient's symptoms are refractory to all medical treatment should he or she be considered a candidate for neurosurgical procedures.

Evaluation of head motility and posture in cats with horizontal torticollis

Unilateral electrolytic lesions and injections of 6-hydroxydopamine (6-OHDA) and 5,7-dihydroxytryptamine (5,7-DHT) were made in structures and pathways linked to the striatopallidal system of cats. The effects of such lesions on horizontal head symmetry and head motility were measured in restrained cats by electrogoniometry. Analysis of electrogoniometric recordings provided (i) an index of head symmetry, (ii) net time-course patterns of head turning in degrees per minute, and (iii) time-course patterns of head motility, measured in number of head movements per minute. All lesions except the electrolytic lesion of the superior colliculus induced an enduring horizontal head asymmetry. Electrolytic, 5,7-DHT, and 6-OHDA lesions made in the medial forebrain bundle induced a nearly total head asymmetry (95 to 98%). Cats in which an electrolytic lesion was made in the substantia nigra reticulata (SNR) also displayed an important head asymmetry (80%). For all lesions except the SNR lesions the direction of the induced head asymmetry was ipsilateral. In 6-OHDA-lesion cats a marked and consistent decrease head motility was also observed. The combined evaluation of head posture and head movements indicated that according to the lesion, head symmetry and head motility are disturbed in different manners. The results further emphasized the complementary contribution of the caudate and SNR in regulation of head symmetry and indicated the advantages of the electrogoniometric method for selectively measuring head posture and movements.

Effect of L-tryptophan on spasmodic torticollis

The effect of L-tryptophan, a precursor of serotonin, and placebo were studied in eight patients with spasmodic torticollis. L-Tryptophan (5 g po as a single dose) which increased free plasma tryptophan 20-53 fold improved only one out of six patients. Two out of three patients, including the subject who improved following an oral load of tryptophan, improved with L-tryptophan combined with nicotinamide, a tryptophan pyrrolase inhibitor, when administered for 1-3 weeks. However, the magnitude of clinical improvement was not impressive. Our findings suggest that impairment of serotonergic function is not a general finding in spasmodic torticollis though it may play a minor role in the manifestation of this movement disorder in some patients. The present study emphasizes therapeutic response, namely, the intrinsic variability of the disorder, the response to placebo in some subjects and the limitations of methods for measuring change.