Spasmodic torticollis: a combined clinical study

Can symptoms or signs of cervical dystonia occur without abnormal movements of the head or neck?

INTRODUCTION

Cervical dystonia is defined by excessive contraction of muscles that produce abnormal postures and movements of the head, neck, and sometimes the shoulders. Many affected individuals also have pain, local muscle hypertrophy, and/or abnormally increased EMG activity. However, abnormal movements are considered the defining feature.

CASES

Three cases are described suggesting that some features of cervical dystonia may occur without abnormal movements. In these cases, the only clinical features are pain, local muscle hypertrophy, or abnormal EMG activity. These features may occur years before abnormal movements emerge, or they may occur coincidentally with dystonia affecting regions other than the neck. In some cases, some features associated with cervical dystonia may occur without any obvious abnormal movements.

CONCLUSIONS

Some symptoms of cervical dystonia may occur without abnormal movements of the head or neck. The purpose of this report is not to question current diagnostic criteria for cervical dystonia, but to call attention to a phenomenon that deserves further attention. Such cases may be considered to have a pro-dromal form of cervical dystonia or a formes fruste of cervical dystonia. Whatever diagnostic label is applied, the phenomenon is important to recognize, because symptoms may be readily alleviated with botulinum toxin.

Psychological Traits and Behavioural Influences in Patients with Dystonia-An Observational Cohort Study in a Romanian Neurology Department

(1) Background: Emerging evidence indicates that non-motor symptoms significantly influence the quality of life in dystonic patients. Therefore, it is essential to evaluate their psychological characteristics and personality traits. (2) Methods: Subjects with idiopathic dystonia and a matched control group were enrolled in this prospective observational cohort study. Inclusion criteria for patient group included idiopathic dystonia diagnosis, evolution exceeding 1 year, and signed informed consent. Inclusion criteria for the control group included lack of neurological comorbidities and signed informed consent. All subjects completed the DECAS Personality Inventory along with an additional form of demographic factors. Data (including descriptive statistics and univariate and multivariate analysis) were analyzed with SPSS. (3) Results: In total, 95 participants were included, of which 57 were in the patient group. Females prevailed (80%), and the mean age was 54.64 ± 12.8 years. The most frequent clinical features of dystonia were focal distribution (71.9%) and progressive disease course (94.73%). The patients underwent regular treatment with botulinum toxin (85.95%). In addition, patients with dystonia obtained significantly higher openness scores than controls, even after adjusting for possible confounders (p = 0.006). Personality traits were also different between the two groups, with patients more often being fantasists (p = 0.007), experimenters (p = 0.022), sophists (p = 0.040), seldom acceptors (p = 0.022), and pragmatics (p = 0.022) than control subjects. (4) Conclusion: Dystonic patients tend to have different personality profiles compared to control subjects, which should be taken into consideration by the treating neurologist.

Remission in dystonia - Systematic review of the literature and meta-analysis

In isolated, sporadic dystonia, it has been occasionally reported that some patients might undergo symptom remission. However, the exact clinical characteristics of patients with remission remain understudied. Given the important prognostic and pathophysiological implications of dystonic remission, we here provide a systematic review of the literature and a meta-analysis to assess demographic and clinical features associated with this phenomenon. We also provide a list of operational criteria to better define dystonic remission. Using PubMed and Embase, we conducted a systematic literature search in March 2018. 626 records were screened, 31 studies comprising data of 2551 cases with reports predominantly from patients with cervical dystonia (n = 1319) or blepharospasm/Meige syndrome (n = 704) were included in qualitative analysis. Five studies reporting remission in cervical dystonia were eligible for meta-analysis. Complete remission was reported in 11.8% and partial remission for 4.4% of cases. Remission rates were higher in cervical dystonia than in blepharospasm/Meige (e.g. complete remission 15.4% vs. 5.8% respectively). Remission occurred on average 4.5 years after onset of dystonic symptoms. However, the majority of patients (63.8%) relapsed. Meta-analysis for cervical dystonia showed that patients with remission were significantly younger at symptom onset than patients without remission (mean difference -7.13 years [95% CI: 10.58, -3.68], p < 0.0001). Based on our findings, we propose that the degree, the conditions associated with the onset, and the duration of remission are key factors to be considered in a unifying definition of dystonic remission.

Head Tremor in Cervical Dystonia

Objective:

To compare the clinical characteristics, natural history, and therapeutic outcome of patients with cervical dystonia (CD) with head tremor (HT+) and without head tremor (HT-).

Methods:

We prospectively evaluated 114 consecutive patients of CD over a 9-month period with a detailed questionnaire. Chi-square and t-tests were employed for statistical analysis.

Results:

Seventy-eight (68.4%) patients had head tremor and 27 of them (34.6%) had tremor as one of the first symptoms. Age at onset of symptoms were similar in HT+ and HT- groups; however there was a higher prevalence in women in the former group (66.7% vs. 41.7%; p=0.01). HT+ patients had more frequent positive family history of essential-like hand/head tremor (21.8% vs. 5.5%; p<0.05), associated neck pain (92.3% vs. 77.8%; p<0.05), and essential-like hand tremor (40% vs. 8.3%; p<0.001). They also appeared to have more frequent history of preceding head/neck trauma (14.1% vs. 8.3%), frequent head rotation (88.5% vs. 69.4%) and antecollis (12.8% vs. 5.5%) but less often head tilt (37.2% vs. 47.2%) and gestes antagonistes (60.2% vs. 75%) than the HT- patients; however these differences were not statistically significant. The frequency of prior psychiatric illnesses, the incidence of dystonias in other parts of the body, frequency of retrocollis and shoulder elevation, and spontaneous remission were similar in the two groups.

Conclusions:

Head tremor is common in CD and is more commonly associated with hand tremor and family history of tremor or other movement disorders. This supports a possible genetic association between CD and essential tremor (ET). Linkage studies are required to evaluate the genetic association between CD and ET.

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.

The entity of young onset primary cervical dystonia

Primary cervical dystonia is typically an adult onset condition with symptom onset usually in the fifth and sixth decade. Young onset (<28 years) is uncommon. We report 76 patients with cervical dystonia as a presenting or predominant feature, with disease onset before the age of 28. Male to female ratio was 1.24:1 and the mean onset age was 21 (3-28) years. A family history of tremor and/or dystonia was noted in 26.3%. Depression and anxiety attacks were present in 23.7%. Prior injury or surgery involving the neck was noted in 17.1%. 23 (30.3%) experienced spontaneous partial or complete remissions within the first 5 years of onset, but all relapsed. Cervical dystonia was predominantly rotational torticollis. 30% developed extra-nuchal dystonia and tremor affecting contiguous parts but in only one there was spread to affect the legs. All 15 patients tested for the DYT1 gene were negative. 74% responded favorably to botulinum toxin injections, whereas none of the 13 patients treated with L-Dopa preparations had a beneficial response. The distinctive features of this entity are discussed.

High psychiatric comorbidity in spasmodic torticollis: a controlled study

Disturbed body image and negative self-referent cognitions caused by the postural disfigurement of the head are regarded as the main reason for elevated depression scores in spasmodic torticollis (ST), but this factor was never controlled for. We therefore compared 48 patients with ST and 48 patients with alopecia areata (AA) who were matched for age, sex, and body image dissatisfaction. Psychiatric diagnoses were based on a structured psychiatric interview (SCID-I). Results of patients with ST and AA were compared with a matched sample of the representative German population. Odds ratios to develop psychiatric comorbidity for patients with ST compared with patients with AA were significantly increased throughout nearly all assessed DSM-IV categories. Logistic regression analysis showed that (1) depressive coping and (2) belonging to the group of patients with ST correlated with a significantly higher rate of current psychiatric diagnosis. We conclude that high psychiatric comorbidity in ST is unlikely to be a mere consequence of chronic disease and disfigurement.

Social phobia in spasmodic torticollis

OBJECTIVES

To study the prevalence of psychiatric comorbidity assessed by the use of a structured clinical interview in a large, representative sample of patients with spasmodic torticollis (ST) and to test the hypothesis that social phobia would be highly prevalent.

METHODS

In a consecutive cohort of 116 patients with ST treated with botulinum toxin overall psychiatric comorbidity was studied prospectively with the structured clinical interview (SCID) for DSM-IV axis I disorders. Physical disability and psychosocial variables were also assessed with standardised self rating questionnaires.

RESULTS

41.3% of the subjects met DSM-IV clinical criteria A-G for current social phobia as the primary psychiatric diagnosis. This figure rose to 56% including secondary and tertiary psychiatric diagnosis. There was no correlation between severity of disease (Tsui score, severity of pain, body image dissatisfaction score) and psychiatric comorbidity. The only significant predictor of psychiatric comorbidity was depressive coping behaviour (logistic regression analysis, p < 0.01; OR=10.8). Compared with a representative sample of the general adult population, in the patients with ST the prevalence of clinically relevant social phobia is 10-fold, of mood disorders 2.4-fold, and of lifetime psychiatric comorbidity 2.6-fold increased.

CONCLUSIONS

A particularly high prevalence of social phobia was found in the cohort of patients with ST. The finding of a high prevalence of social phobia and depressive coping behaviour as the main predictor of psychiatric comorbidity may make a subgroup of patients with ST particularly amenable to specific psychotherapeutic interventions.

Post-traumatic cervical dystonia: a distinct entity?

BACKGROUND/OBJECTIVE

The incidence of head/neck trauma preceding cervical dystonia (CD) has been reported to be 5-21%. There are few reports comparing the clinical characteristics of patients with and without a history of injury. Our aim was to compare the clinical characteristics of idiopathic CD (CD-I) to those with onset precipitated by trauma (CD-T).

METHODS

We evaluated 114 consecutive patients with CD over a 9-month period. All patients were interviewed using a detailed questionnaire and had a neurological examination. Their clinical charts were also reviewed.

RESULTS

Fourteen patients (12%) had mild head/neck injury within a year preceding the onset of CD. Between the two groups (CD-I and CD-T), the gender distribution (F:M of 3:2), family history of movement disorders (32% vs. 29%), the prevalence of gestes antagonistes (65% vs. 64%), and response to botulinum toxin were similar. There were non-specific trends, including an earlier age of onset (mean ages 43.3 vs. 37.6), higher prevalence of neck pain (86% vs. 100%), head tremor (67% vs. 79%), and dystonia in other body parts (23% vs. 36%) in CD-T.

CONCLUSIONS

CD-I and CD-T are clinically similar. Trauma may be a triggering factor in CD but this was only supported by non-significant trends in its earlier age of onset.

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.

Treatment of spasmodic torticollis with intradural selective rhizotomies

To determine the effects of ventral cervical and selective spinal accessory nerve rhizotomy on spasmodic torticollis, 58 patients who had undergone surgery between 1979 and 1987 were reviewed retrospectively. At the time of surgery, each nerve rootlet was electrically stimulated to determine its effect on the nuchal musculature prior to sectioning. Forty-nine patients (85%) had a marked improvement in their condition, with 33 (57%) attaining an excellent result and 16 (28%) noting significant improvement. Patients complained of abnormal head posture, nuchal muscle spasms, and pain prior to surgery. Muscle spasms were completely relieved in 42 patients (72%) and markedly reduced in 10 (17%). Of the 47 patients with preoperative pain, 30 (64%) were free of their pain and eight (17%) noted that the pain was reduced in intensity and frequency. Thirty-four patients (59%) reported that their resting head posture was restored to a neutral position. The likelihood that a patient's head posture returned to normal was inversely proportional to the preoperative duration of the spasmodic torticollis. Twenty-six patients (45%) suffered mild transient difficulty with swallowing solid foods in the immediate postoperative period. In most cases these minor difficulties abated in the months following surgery.

Clinical and polymyographic investigation of spasmodic torticollis

Polymyographic recordings were used to identify the most dystonic muscles suitable for local injection with botulinum toxin in 100 patients with spasmodic torticollis (TS). Rotating TS (72% of the patients) was due to dystonic activity of the splenius muscle ipsilateral to and/or the sternocleidomastoid muscle contralateral to the side of chin deviation. One-third of these patients had also dystonic activation of the contralateral splenius muscle and, rarely, the contralateral trapezius muscle. Ten patients had laterocollis due to dystonic activation of all recorded muscles on one side of the neck. Nine patients had retrocollis due to activity of both splenius muscles and rarely additional activity in both trapezius muscles. The type of dystonic muscle activity was found to be tonic, phasic or tremulous. Besides the evaluation of spontaneous dystonic EMG activity further examination during the "geste antagoniste" or the muscle activity during rotating head movements can provide additional information. It is concluded that polymyography may provide a rationale for identifying the dystonic muscles underlying the different forms of TS. It may prove to be helpful for the successful therapy with botulinum toxin and may be useful in differentiating tremulous torticollis from other types of head tremor.

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.

[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.

Idiopathic cervical dystonia: clinical characteristics

We reviewed detailed clinical features of 266 patients with idiopathic cervical dystonia, commonly called spasmodic torticollis. Mean age at onset (41 years), female-to-male ratio (1.9:1), clustering of onset between ages 30 and 59 (70%), familial history of dystonia (12%), and remissions (9.8%) were similar to those found in previous studies. In contrast to the single prior large clinical study of this disorder, no predominance of right-handers or significant thyroid disease was found. Pain, which occurred in 75% of patients and contributed to disability score (p less than 0.01), distinguishes this syndrome from all other focal dystonias. Pain was also strongly associated with constant (vs. intermittent) head turning, severity of head turning, and presence of spasm. Eighty-three percent of patients had deviation of the head of greater than 75% of the time when sitting with the head unsupported (constant head deviation at rest). Of the 97% who had head turning, 81% also had head tilting in various combinations. The 23% with hand tremor had an older age at onset (mean, 46 vs. 41 years; p less than 0.05). An earlier age at onset (p less than 0.05) was seen in patients with a family history of dystonia (mean, 36 years), with trauma shortly preceding symptoms (mean, 36 years), with a change in the direction of head turning (mean, 30 years), and with remissions (mean, 33 years). Jerky movements or forced transient spasms of the head occurred in 62% of the patients, and these patients would be the ones for whom the designation "spasmodic torticollis" could logically apply.(ABSTRACT TRUNCATED AT 250 WORDS)

Vestibular hyperreactivity in patients with idiopathic spasmodic torticollis

Ocular motor tests performed on 14 patients with idiopathic spasmodic torticollis were normal. The vestibulo-ocular reflex tested in eight patients showed a significant high level in seven. It is suggested that this phenomenon is secondary rather than the cause of spasmodic torticollis.

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.

Treatment of movement disorders with trihexyphenidyl

The clinical efficacy of the trihexyphenidyl was investigated in 100 patients with movement disorders. The study group consisted of 54 women and 46 men. Their ages ranged from 18 to 70 years, and their duration of illness varied from a few months to 36 years. Each patient had a videotape of the movements and a neurological examination, before administration of the drug, at the time of maximum or effective dosage, and one week after withdrawal from trihexyphenidyl. The drug was administered at an initial total daily dose of 2 mg and gradually increased to a total daily dose of 60 mg over a period of 4-6 weeks. Improvements were rated both clinically and from the videotapes. Three groups of movement disorders demonstrated a significant response to trihexyphenidyl: (1) dystonia 37%; tonic torticollis demonstrated a significantly better response than the clonic variant (80% vs. 22%). (2) rhythmic-oscillatory movements of brainstem-cerebellar origin (palatal myoclonus, pendular nystagmus, facial myokymia) 90%; (3) cerebellar tremor 75%. Among 32 responders, 17 (56%) continued taking trihexyphenidyl beyond 24 months. Side effects consisted of dryness of the mouth, jitteriness, stomatitis, blurred vision, and forgetfulness.

Depression in torticollis: a controlled study

Eighty-five patients with idiopathic, persistent spasmodic torticollis were compared to a control group of 49 patients with cervical spondylosis to assess (1) the prevalence of psychiatric disorder prior to and following the onset of their physical complaint, and (2) to establish the effect of torticollis on self-reports of depression on the Beck Depression Inventory, and self-rated hopelessness on the Hopelessness Scale. The prevalence of psychiatric disorder in the two groups did not differ. The torticollis patients had significantly higher mean scores on the Beck Depression Inventory, but did not differ from the control group in terms of hopelessness. Self-referent negative cognitions such as self-blame, self-accusation, self-punitive thoughts, and negative body-image emerged as the prominent component of depression in torticollis, which has implications for the management of depression in torticollis.

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.

Epidemiology of focal and generalized dystonia in Rochester, Minnesota

The epidemiology of generalized and focal dystonias was investigated in the Rochester, Minnesota, population over the period 1950-1982. The crude incidence of generalized dystonia was 2 per million persons per year, and for all focal dystonias combined, 24 per million per year. The crude prevalence rate was 34 per million persons for generalized dystonia and 295 per million persons for all focal dystonias. Torticollis was the most common focal dystonia; essential blepharospasm, oromandibular dystonia, spasmodic dysphonia, and writer's cramp were less common and had roughly equal incidence and prevalence rates.

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.

The Foerster-Dandy operation for the treatment of spasmodic torticollis

The short-term results of the Foerster-Dandy operation in 9 patients with spasmodic torticollis had been studied retrospectively. A good result was obtained for dyskinetic movement, but less for head tilt. Neck pains improved in 4 patients, but developed in 2 other patients postoperatively. Limitation of neck motility and abduction of the arms was seen in all patients. One patient died following a cerebral sinus thrombosis. Other surgical procedures are discussed and the results of studies of anterior rhizotomy are compared. The Foerster-Dandy procedure is indicated for severe disability or pain of more than 2 years duration not responding to other treatments.

EMG investigations in patients with torticollis

EMGs have been performed on patients suffering from organic torticollis, hysterical torticollis and on normal control subjects. The EMG activity of the sternomastoid muscles during head rotation in control subjects and those with hysterical torticollis showed similar characteristics and neither group showed a response to body tilt. Subjects suffering from organic torticollis, however, did show a response to tilt. The results suggest that the response to backward tilt might aid in distinguishing the organic and hysterical forms of torticollis.

Spasmodic torticollis relieved by removal of a cervical foreign body

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Vestibular involvement in spasmodic torticollis

Vestibular findings in a group of 35 patients with spasmodic torticollis without other otological or neurological symptoms were reviewed. The most consistent abnormality, present in more than 70% of cases, was a directional preponderance of vestibular nystagmus in the dark in a direction opposite to the head (chin) deviation. Rigidly clamping the head to a rotating chair did not abolish the directional preponderance. In the presence of optic fixation the directional preponderance was less frequent and its severity tended to diminish as a function of the duration of the disease. Smooth pursuit and optokinetic nystagmus were only occasionally affected. The results are indicative of primary involvement of the vestibular system in spasmodic torticollis and are discussed in terms of a break-down of the central mechanisms conveying sensory information responsible for head and eye orientation.

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.

Remission in spasmodic torticollis

In 26 patients with spasmodic torticollis followed up for a median period of 12 years, the frequency of sustained remission was 23%, the median duration of remission was 8 years and duration of torticollis before remission 3 years. These results are more favourable than stated in the literature and should be taken into consideration before recommending surgical treatment.

Brainstem conduction abnormalities in spasmodic dysphonia

Twelve spasmodic dysphonia patients were evaluated by three different auditory brainstem response parameters; 75% were abnormal. Three of the 12 had prolonged wave I-V interpeak latency. Seven had pathologic wave V latency shifts at a high stimulus rate. Amplitude ratios were normal for all subjects. The authors hypothesize that spasmodic dysphonia is a disorder of variable cranial nerve symptom presentations, and offer several possible models to account for its sporadic representation in the nervous system.

Spasmodic torticollis: a behavioral perspective

The literature on spasmodic torticollis is critically reviewed. The currently most popular etiological hypothesis characterizes torticollis as an extrapyramidal disorder, the symptoms of which are aggravated by stress, but there is no unequivocal evidence available to support this view. Psychological mechanisms have been suggested but not elaborated or tested in any detail. A wide range of treatments has been advocated but controlled studies have not been reported, and the problems of assessing outcome have never been tackled adequately. Behavioral treatments have been evaluated more rigorously than other approaches (particularly EMG feedback training), and the literature suggests that they benefit some patients. It is argued that psychologists have the potential for making a very significant contribution to the understanding and management of torticollis. In discussing outcome measures, the more promising techniques that have been used are summarized and a list is presented of the factors which must be considered when assessing torticollis symptoms. Directions for future research are outlined and priorities suggested.

Effect of L-glutamine and isoniazid on torticollis and segmental dystonia

Fourteen patients with spasmodic torticollis and other segmental dystonic syndromes, who were refractory to previous forms of therapy, were selected for treatment with drugs intended to elevate brain gamma-aminobutyric acid (GABA) levels. These patients were simultaneously given diazepam, isoniazid, pyridoxine, and large doses of L-glutamine. Involuntary spasmodic activity improved to varying degrees in 7 patients; in 2 the dyskinesia became worse. Transient alteration of renal or hepatic function occurred in 6 patients and mild euphoria unrelated to neurological improvement in 8. Two patients are still being treated. Deficiency of GABA may be a factor in some patients with these disorders.

Treatment of neurogenic torticollis by microvascular lysis of the accessory nerve roots - indication, technique, and first results

For treatment of spasmodic torticollis (s.T.) microsurgical decompression of the intraspinal-intracranial portion of the accessory nerve (a.N.) has been performed in 11 patients with proved neurogenic lesions of the accessory nerve-dependent muscles. Neurogenic lesions were discovered by meticulous electromyographic (EMG) examination in 26 out of 32 patients with s.T. Based on the EMG findings and a.N. roots were exposed, mostly bilaterally. During operation we found in each case tight adhesions to adjacent structures, in particular the vertebral artery (v.A.), the posterior inferior cerebellar artery (PICA), and spinal arteries. Moreover, various nerve anastomoses were found between the upper dorsal cervical roots and the spinal a.N. roots. After neurovascular lysis and dissection of anastomoses, to C 1 in particular, the a.N. was protected with teflon-foam (Prosthex). Immediately after surgery torticollis had improved in all but one case. Further improvement was achieved by exercises. These first favourable results, and the fact that nerve decompression is less destructive that other surgical procedures in treatment of s.T., make us feel justified in recommending this procedure further to patients suffering from s.T. with proved neurogenic lesions.

Unexplained chest pain in patients with normal coronary arteriograms: a follow-up study of functional status

Approximately 10 per cent of patients referred for coronary arteriography because of chest pain have angiographically normal coronary arteries and no other heart disease. We examined the functional status of 57 patients who had undergone catheterization (23 men and 34 women), all of whom were told that their hearts were normal, that their pain was noncardiac, and that no limitation on activity was necessary. At a mean follow-up time of 16 +/- 7.7 months, 27 of the 57 patients (47 per cent) still described their activity as limited by chest pain (before catheterization, 42 of 57 or 74 per cent); 29 of 57 (51 per cent) were unable to work (before catheterization, 36 of 57 or 63 per cent); and 25 of 57 (44 per cent) still believed that they had heart disease (before catheterization, 45 of 57 or 79 per cent). Use of medical facilities was significantly reduced after catheterization (P < 0.001). At follow-up the physician was more likely than the patient to believe that the symptoms had improved. We conclude that many of these patients remain limited in activity and may benefit from further efforts at comunication and rehabilitation.

The surgical treatment of spasmodic torticollis

The results of upper cervical anterior rhizotomy and accessory nerve section in the treatment of twenty patients with spasmodic torticollis are reviewed. The majority of these patients presented with pain in addition to postural deformity. There was no evidence in any of them to suggest that the condition was psychogenic. Good results can be expected, particularly in those patients without evidence of cervical spondylosis. We suggest that in symptomatic torticollis surgery is more effective than medical, psychiatric, or other described forms of treatment. Electromyography may be helpful to delineate the affected musculature and to assess postoperative improvement. The operating microscope is a valuable adjunct to surgery to preserve radicular vessels and ensure total division of the relevant motor roots.

Pathophysiology and pharmacotherapy of spasmodic torticollis: a review

The few existing neuropathological, neurochemical, and neuropharmacological studies have shed little light on the pathophysiology of spasmodic torticollis (ST). The relevance of experimental ST in animals and drug-induced ST in man to idiopathic ST is unclear. Most pharmacotherapeutic endeavors have focused on drugs affecting basal ganglia function. Unfortunately, problems of sample size, clinical heterogeneity of patient population, research design, objective evaluation of response, documentation of key data, and adequacy of duration of follow-up make interpretation of published results difficult. Because of the heterogeneity of ST, investigations aimed at establishing a neurotransmitter profile for each patient by observing the acute response to a test dose of drugs affecting cholinergic, dopaminergic, serotonergic, and gamma-aminobutyric acid systems may provide a more rational basis to the selection of treatment.