Brain involvement in spasmodic torticollis

To test or not? The value of diagnostic tests in cervical dystonia

It has long been suspected that idiopathic cervical dystonia is result of a dysfunction of the brain, but the cause of the disease has been elusive. The purpose of this study was to determine the diagnostical value of different radiological and laboratory tests in cases of cervical dystonia. Cerebral computer tomography and/or cerebral magnetic imaging were carried out in all of the 149 patients who were included in this study. A total of 25 scans revealed some minor findings that did not alter patients' management. Of the 128 cervical plain x-ray examinations, 63.1% showed degenerative changes. Cerebrospinal fluid (CSF) was examined in 125 patients, and was normal in 103. Some degree of pathology was found in the remaining 22 CSF samples. All patients under the age of 50 years were tested for serum ceruloplasmin and no decreased level was found. Seven patients had elevated ANA titre; four of them also developed Botulinum toxin antibodies. We can conclude that the detection rate of pathologic findings in patients with idiopathic cervical dystonia is similar to what we can expect in the general population, provided the neurological findings are normal apart from the involuntary movements. In the adult form of typical cervical dystonia we do not recommend any standard laboratory or imaging tests if the neurological examination is normal aside from the abnormal head movements.

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.

[Spasmodic torticollis and frontal meningioma]

A 57 year-old man developed a spasmodic torticollis with involuntary deviation of the head to the right-side. He had a left paramedian frontal meningioma. The association of spasmodic torticollis and other movement disorders has been reported with contralateral lesions in the basal ganglia. Its occurrence in association to a frontal lesion appears to be much less frequent suggesting a possible disorder of frontostriatal connections.

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.

A study of multimodality evoked responses in idiopathic spasmodic torticollis

A wide variety of anatomical sites have been implicated in the pathogenesis of torticollis, based primarily on animal studies. These include lesions in the mesencephalic tegmentum, third ventricle, diencephalon, pre-tectal area, prestitial nucleus of the mid-brain, cervical cord, atlanto-axial junction and motor cortex, amongst others. This study describes the use of multimodality evoked potentials including visual, auditory, bilateral median and peroneal somatosensory evoked responses, undertaken in patients with idiopathic spasmodic torticollis. An attempt was made to non-invasively identify any physiological disruption along these major pathways which could help locate a causative lesion. Normal evoked responses were obtained both ipsilateral and contralateral to the affected side in all patients. It is concluded that the lesion in idiopathic spasmodic torticollis does not discernibly involve the visual, auditory or motor somatosensory pathways.