Pattern of premature degenerative changes of the cervical spine in patients with spasmodic torticollis and the impact on the outcome of selective peripheral denervation

Postoperative hematoma in cervical spondylosis patient complicated with Huntington's disease: Case report and literature review

Hematoma is a life-threatening complication of anterior surgery in cervical spondylosis patients. Herein, we report a cervical spondylosis patient complicated with Huntington's disease, who developed unexpected neck hematoma after anterior cervical discectomy and fusion (ACDF) surgical treatment. During the debridement, we found no noticeable vessel lesions and concluded that the occurrence of postoperative hematoma might be due to the drainage displacement caused by excessive uncontrolled movements of the neck after the operation. The patient recovered well, and further literature review suggests that chorea secondary to Huntington's disease likely increases mechanical stress on the cervical spine, indicating an internal relationship between degenerative cervical spondylosis and Huntington's disease. Cervical spondylotic patients complicated with Huntington's disease can be treated with surgical intervention but need to be immobilized and under close observation.

Cervical Myeloradiculopathy and Atlantoaxial Instability in Cervical Dystonia

OBJECTIVE

Atlantoaxial instability, although rarely reported in the literature, can be associated with cervical dystonia (CD) and may lead to compression of the cord at the craniovertebral junction. We present a case series of 4 patients of longstanding CD with neurologic complications. Treatment strategies and challenges are discussed.

METHODS

Retrospective analysis of 4 cases of longstanding CD with complications of myelopathy or radiculopathy.

RESULTS

The average age at onset of complications was 28 years (range, 17-37). The average duration of CD was 23.75 years. Narrowing of the craniovertebral junction was seen in 3 patients, of which 2 had os odontoideum, and 1 had rotational malalignment at the atlantoaxial joint. One patient had disc desiccation with bulge and intramedullary signal changes in the cord at C3-4 level. Medical treatment was not satisfactory, but botulinum toxin was partly useful in all. One patient had sequelae of myelopathy and did recover partially after deep brain stimulation. Of the 2 patients who underwent surgical fixation with a fusion of the spine, one improved, and the other had no improvement due to irreversible cord damage. The overall outcome was satisfactory only in 2 patients.

CONCLUSIONS

Early-onset CD can lead to cord complications at a young age and at higher levels of the cervical spine and at the cervicovertebral junction. Comprehensive management by a multidisciplinary team is crucial to prevent complications early.

Minor Structural Differences in the Cervical Spine Between Patients With Cervical Dystonia and Age-Matched Healthy Controls

Background: Cervical dystonia is the most common form of focal dystonia. The frequency and pattern of degenerative changes of the cervical spine in patients with cervical dystonia and their relation to clinical symptoms remain unclear as no direct comparison to healthy controls has been performed yet. Here, we used magnetic resonance imaging (MRI) to investigate (1) whether structural abnormalities of the cervical spine are more common in patients with cervical dystonia compared to age-matched healthy controls, (2) if there are clinical predictors for abnormalities on MRI, and (3) to calculate the inter-rater reliability of the respective radiological scales.

Methods: Twenty-five consecutive patients with cervical dystonia and 20 age-matched healthy controls were included in the study. MRI scans of the cervical spine were analyzed separately by three experienced raters blinded to clinical information, applying different MRI rating scales. Structural abnormalities were compared between groups for upper, middle, and lower cervical spine segments. The associations between scores differentiating both groups and clinical parameters were assessed in dystonia patients. Additionally, inter-rater reliability of the MRI scales was calculated.

Results: Comparing structural abnormalities, we found minor differences in the middle cervical spine, indicated by a higher MRI total score in patients but no significant correlation between clinical parameters and MRI changes. Inter-rater reliability was satisfying for most of the MRI rating scales.

Conclusion: Our results do not provide evidence for a role of MRI of the cervical spine in the routine work-up of patients with cervical dystonia in the absence of specific clinical signs or symptoms.

Comorbidity and retirement in cervical dystonia

BACKGROUND

Cervical dystonia (CD) is the most common form of dystonia. The onset of CD is usually before 60 years of age and it may cause severe functional and psychosocial impairment in everyday life. Recently non-motor symptoms have been reported to occur in CD substantially affecting the quality of life.

METHODS/PATIENTS

We studied comorbidities of patients with primary focal CD in Finland based on ICD-10 codes obtained from the care registry and patient records of 937 confirmed adult isolated focal CD patients between the years 2007-2016. The retirement months and diagnosis of retirement were calculated from pension registry information. The results were compared with 3746 age and gender-matched controls.

RESULTS

Most prominent comorbidities with primary focal CD were depression (14%), anxiety (7%), and back pain (11%). The retirement age was significantly younger in CD patients compared to control group controls (59.0 years, 95% CI 58.5-59.5 vs. 61.7 years, 95% CI 61.6-61.9) years, p < 0.001). For dystonia patients the most common diagnoses for retirement due to sickness were dystonia (51%), depression (14%), and anxiety (8%). Patients with anxiety and depression retired earlier than other dystonia patients.

DISCUSSION

Cervical dystonia considerably reduces working ability and leads to earlier retirement. Anxiety and depression are most notable comorbidities and their co-occurrence further reduces working ability. Our results suggest that more health care resources should be administered in treatment of CD to longer maintain working ability of CD patients. Further, psychiatric comorbidities should be taken into consideration in CD treatment.

Compensatory head posture and neck problems: is there an association? A cohort study of nystagmus patients

PURPOSE

The aims of this study were twofold: to investigate if a compensatory head posture due to nystagmus causes long-term neck problems or adversely effects quality of life and to survey ophthalmologists on their opinions and management of these patients.

METHODS

A case-controlled study was carried out to assess the range of neck movements in patients with compensatory head posture due to congenital nystagmus. Exclusion criteria included known neck problems, vertebrobasilar insufficiency, and age less than 16 years. Neck movements were assessed using an inclinometer. Quality of life and disability was assessed using the American Academy of Orthopaedic Surgeons' Cervical Spine Questionnaire. One hundred and fifty consultant ophthalmologists throughout the United Kingdom were surveyed via a postal questionnaire.

RESULTS

The range of motion in these patients (n=20) was limited when compared to matched controls especially for lateral flexion (P=0.001) and extension (P=0.003). However, despite limited movement, patients did not perceive a disability and there was no adverse effect on quality of life. In all 55% of ophthalmologists believed compensatory head posture due to nystagmus leads to long-term neck problems. About 46% had personal experience of patients with long-term neck problems due to nystagmus. Eighty-four per cent were influenced in their decision to operate by the presence of a head posture.

CONCLUSIONS

Significant restriction in neck movements exists in nystagmus patients with compensatory head posture, although this does not appear to adversely affect quality of life.

Atlantoaxial rotatory subluxation associated with cervical dystonia

STUDY DESIGN

Case report.

OBJECTIVE

To document an interesting case of cervical dystonia associated with atlantoaxial rotatory subluxation and compressive myelopathy.

SUMMARY OF BACKGROUND DATA

Dystonia is an involuntary disorder characterized by twisting, pulling, and sustained contractions, which may be extremely powerful and painful. Cervical dystonia can contribute to the development of cervical spondylosis. However, cervical dystonia with atlantoaxial rotatory subluxation is very rare. Only 2 cases of primary dystonia with atlantoaxial subluxation have been reported previously.

METHODS

We present the case of a 53-year-old man who had dystonic movements involving the neck. The head tilted to the left and rotated to the right. The subluxation was reduced by a sensory trick. Involuntary movements of the neck worsened. After 2 years, neck pain and difficulty in walking developed.

RESULT

Cervical MRI showed atlantoaxial subluxation with compression of the spinal cord at C1-C2. Computed axial tomography of the cervical spine demonstrated rotatory subluxation of the atlas on the axis. Surgical intervention combined with globus pallidus internus-deep-brain stimulation and atlantoaxial fixation successfully controlled the cervical dystonia and atlantoaxial rotatory subluxation.

CONCLUSION

Although this case is extremely rare, clinicians should be keep in mind that cervical dystonia may carry a risk of atlantoaxial subluxation, potentially progressing to myelopathy. Neurosurgery combined with globus pallidus internus-deep-brain stimulation and atlantoaxial fixation is one treatment option for cervical dystonia with atlantoaxial rotatory subluxation.

Dystonic Movement Disorders and Spinal Degenerative Disease

The occurrence of degenerative spinal disease subsequent to dystonic movement disorders has been neglected and has received more attention only recently. Spinal surgery is challenging with regard to continuous mechanical stress when treatment of the underlying movement disorder is insufficient. To characterize better the particular features of degenerative spinal disease in patients with dystonia and to analyze operative strategies, we reviewed the available published data. Epidemiologic studies reveal that degenerative spinal disorders in patients with dystonia and choreoathetosis occur much earlier than in the physiological aging process. Dystonic movement disorders more often affect the spine at higher cervical levels (C(2-5)), in contrast to spinal degeneration with age which manifests more frequently at the middle and lower cervical spine (C(5-7)). Degenerative changes of the cervical spine are more likely to occur on the side where the chin is rotated or tilted to. Various operative approaches for treatment of spinal pathologies have been advocated in patients with dystonic movement disorders. The available data do not allow making firm statements regarding the superiority of one approach over the other. Posterior approaches were first used for decompression, but additional anterior fusion became necessary in many instances. Anterior approaches with or without instrumented fusion yielded more favorable results, but drawbacks are pseudarthrosis and adjacent-level disease. Parallel to the development of posterior fusion techniques, circumferential surgery was suggested to provide a maximum degree of cord decompression and a higher fusion rate. Perioperative local injections of botulinum toxin were used initially to enhance patient comfort with halo immobilization, but they are also applied in patients without external fixation nowadays. Treatment algorithms directed at the underlying movement disorder itself, taking advantage of new techniques of functional neurosurgery, combined with spinal surgery have recently been introduced and show promising results.

Surgical Treatment of Cervical Myeloradiculopathy Associated with Movement Disorders

OBJECTIVE

Movement disorders may be associated with advanced cervical myeloradiculopathy, which represents a major management challenge. We report on eight patients with movement disorders causing progressive cervical myeloradiculopathy who were treated successfully by cervical decompression and reconstruction.

RESULTS

The mean age of our patients was 44 years with a male/female ratio of 3:1. The average duration of symptoms prior to presentation was 10 months. The most common levels decompressed and reconstructed were C3-C4 and C4-C5. Six cases showed improvement, and two cases showed stabilization of neurologic status at a mean follow-up of 21 months. Our management strategy and results are interpreted in the context of a systematic review of the literature in which 78 cases are reported.

CONCLUSIONS

Movement disorders cause premature cervical spondylosis most commonly involving the C3-C4 and C4-C5 levels. Ventral pathology with kyphotic angulation requires corpectomy or discectomy with or without posterior decompression and reconstruction. Decompression should always be combined with segmental internal fixation. Perioperative use of botulinum toxin and halo vest immobilization can increase the rate of clinical success but requires vigilance to minimize complications. Laminectomy with lateral mass fixation may be used successfully in the absence of kyphotic deformity.

Decreased neck muscle strength is highly associated with pain in cervical dystonia patients treated with botulinum toxin injections

OBJECTIVES

To compare the isometric neck muscle strength of cervical dystonia patients treated with botulinum toxin injections with that of healthy control subjects and to evaluate the association between neck strength, neck pain, and disability in these patients.

DESIGN

Clinical cross-sectional study.

SETTING

Outpatient rehabilitation and neurology clinics in a Finnish hospital.

PARTICIPANTS

Twenty-three patients with cervical dystonia with botulinum toxin-treated neck muscles and 23 healthy control subjects.

INTERVENTIONS

Not applicable. Main outcome measures Isometric neck strength was measured by a special neck strength measurement system. Disability was measured by the Neck Disability Index, and pain and symptoms of cervical dystonia by a visual analog scale.

RESULTS

Isometric neck strength in all directions measured was significantly lower (25%-44%) in the cervical dystonia patients than in the healthy controls. Neck pain levels reported during the strength tests (r range, -.36 to -.70) and neck pain experienced during the preceding week (r range, -.52 to -.63) were inversely associated with isometric strength results. The difference between sides in rotation strength was 35% in the patient group (P<.001), whereas no significant difference between sides was found in the healthy controls. Fifty-one percent of the patients reported moderate or severe disability. Pain, stiffness, and incorrect position of the head were the most prominent symptoms.

CONCLUSIONS

Cervical dystonia patients with botulinum toxin-treated neck muscles showed significantly lower maximal neck strength than healthy controls. The patients also had a statistically significant difference between sides in neck rotation strength. Thus, strength measures may be useful to detect disturbance in the function of the neck muscles.

Orthopedic and neurological complications of cervical dystonia--review of the literature

Cervical dystonia is the most frequent form of focal dystonia. Further, cervical dystonia can occur as a feature of segmental or generalized dystonias and cerebral palsy. Treatment with botulinum toxin to relieve pain and improve functional and psychological outcome is effective, but expensive. However, pharmacoeconomic studies evaluating treatment and disease costs have not taken into consideration the long-term complications of cervical dystonia. Here we present a review of the medical literature on orthopedic and neurological complications arising from cervical dystonia, including cervical spine degeneration, spondylosis, disk herniation, vertebral subluxations and fractures, radiculopathies and myelopathies. In summary, complications are more often reported in generalized dystonia and cerebral palsy than in focal dystonia. The prevalence is not well established, published estimations go from 18 to 41% in selected populations. Awareness of the frequent occurrence of complications and screening for symptoms of radiculomyelopathy in patients with dystonia is essential to avoid irreversible spinal cord damage. Complications of cervical dystonia need to be taken into consideration when weighting risks and calculating costs of the disease and its treatment.

Fracture of the odontoid process complicating tardive dystonia

We report on a 57-year-old woman with frequent and powerful retrocollis. The involuntary movements combined with rheumatoid arthritis and osteoporosis led to a fracture of the axial odontoid process. Neurologists with a focus on movement disorders should screen for diseases putting the patient at risk for spinal lesions and consider early treatment.

New perspectives on dystonia

Dystonia is a syndrome of sustained muscular contractions with numerous underlying etiologies. This review examines the varied phenomenology of dystonias, its evolving classification including recent genetic data as well as its clinical investigation and treatment. Although age of onset, anatomical distribution and family history are key elements of the investigation of dystonia, classification increasingly relies on etiologic and genetic criteria. Physiological abnormalities in striato-cortical circuits are common in dystonia but the pathophysiology is still unclear. In recent years, a great deal has been learned on the more common primary dystonias such as primary torsion dystonia and on dystonia-plus syndromes such as dopamine responsive dystonia. Treatment of dystonia has also evolved and there are now a number of therapeutic agents with clear beneficial effects including anticholinergics, benzodiazepines, and botulinum toxin and there is growing interest in neurofunctional surgery including deep brain stimulation.

Other noncosmetic uses of BOTOX

Botulinum toxin A has a wide variety of clinical applications, which are related by blockade of acetylcholine and often are related to abnormal muscle contractures. These applications include ocular disorders, disorders of the upper aerodigestive tract, dystonia and hemifacial spasm, cosmetic, gastrointestinal disorders, genitourinary disorders, management of pain, and use in autonomic nervous system disorders. Many of these diseases will be discussed with regard to their treatment with botulinum toxin compared to conventional treatments. Advantages and disadvantages of botulinum toxin use are delineated. General guidelines for adult and pediatric dosing will also be discussed.

Pallidal deep brain stimulation in patients with cervical dystonia and severe cervical dyskinesias with cervical myelopathy

OBJECTIVES

Surgical treatment of complex cervical dystonia and of cervical dyskinesias associated with cervical myelopathy is challenging. In this prospective study, the long term effect of chronic pallidal stimulation in cervical dystonia and on combining the technique with spinal surgery in patients with severe cervical dyskinesias and secondary cervical myelopathy is described.

METHODS

Eight patients with a history of chronic dystonia who did not achieve adequate benefit from medical treatment or botulinum toxin injection participated in the study. Five patients had complex cervical dystonia with tonic postures and phasic movements. Three patients had rapidly progressive cervical myelopathy secondary to severe cervical dyskinesias and dystonia in the context of a generalised movement disorder. Quadripolar electrodes were implanted in the posteroventral lateral globus pallidus internus with stereotactic CT and microelectrode guidance. In the three patients with secondary cervical myelopathy, spinal surgery was performed within a few weeks and included multilevel laminectomies and a four level cervical corporectomy with spinal stabilisation.

RESULTS

Improvement of the movement disorder was noted early after pallidal surgery, but the full benefit could be appreciated only with a delay of several months during chronic stimulation. Three months after surgery, patients with cervical dystonia had improved by 38% in the severity score, by 54% in the disability score, and by 38% in the pain score of a modified version of the Toronto western spasmodic torticollis rating scale. At a mean follow up of 20 months, the severity score had improved by 63%, the disability score by 69%, and the pain score by 50% compared with preoperatively. There was also sustained amelioration of cervical dyskinesias in the three patients who underwent spinal surgery. Lead fractures occurred in two patients. The mean amplitude needed for chronic deep brain stimulation was 3.8 V at a mean pulse width of 210 micros, which is higher than that used for pallidal stimulation in Parkinson's disease.

CONCLUSIONS

Chronic pallidal stimulation is effective for complex cervical dystonia and it is a useful adjunct in patients with cervical dyskinesias and secondary cervical myelopathy who undergo spinal surgery.

Botulinum toxin for the treatment of cervical dystonia

Cervical dystonia (CD) manifests clinically through involuntary spasms of neck muscles, producing abnormal head and neck movements and postures, which is often associated with pain. CD is the most common form of focal dystonia presenting to movement disorders clinics. Chemodenervation with botulinum toxin (BTX) has become the first-line treatment for CD, producing satisfactory relief of symptoms in > 80% of cases. Unresolved issues that may impact on the overall results include the method of selection for injection sites (clinical vs. electromyography), dosing, dilution and the role and relative efficacy of the different BTX serotypes. A guiding therapeutic principle of BTX injections is to achieve optimal results with the lowest possible dosage and frequency of administration. This strategy is critical in order to keep the risk of immunoresistance at a minimum. Development of antibodies that block the effects of BTX, usually associated with frequent injections of high doses, is the main reason for secondary unresponsiveness to this treatment. Although the mechanism of denervation at the neuromuscular junction by BTX is relatively well understood, the role of changes in muscle spindles and myopathic pain mechanisms, as well as secondary changes at the level of the basal ganglia, thalamus and cortex and their role in response to BTX, all need further exploration.

Dystonia: an update on genetics and treatment

Recent years have seen many advances in our understanding of the genetics of the dystonias, with 13 loci identified to date. The DYT1 gene, which causes most cases of childhood-onset generalized primary dystonia, was cloned in 1997, and use of cell models has begun to unravel the role of its protein (torsinA) in both health and disease. Treatment of more severe dystonia has been a difficult area, with only limited success from medical therapies. Recently, there has been increasing interest in the use of globus pallidus deep brain stimulation and a number of reports have shown promising results.

Focal dystonia: the role of botulinum toxin

Botulinum toxin (BTX) has been found to be effective in a wide range of focal dystonias. Debate surrounds the selection of injection sites. In general, localization is satisfactory by clinical examination, but poor response, requiring localization of deep muscles, may necessitate use of electromyography for localization. Delineation of optimal doses of BTX is a work in progress; as studies have tended to show efficacy at lower doses than used in the past, the trend is to use lower doses. This is important, because development of antibodies to BTX, the main reason for secondary resistance to this treatment, is more frequent with larger doses and shorter inter-injection intervals. Although the mechanism of denervation of the neuromuscular injunction by BTX is relatively well understood, secondary changes at the level of the basal ganglia, thalamus, and cortex, and their role in response to BTX, need further exploration.

Other noncosmetic uses of BOTOX

Botulinum toxin A has a wide variety of clinical applications, which are related by blockade of acetylcholine and often are related to abnormal muscle contractures. These applications include ocular disorders, disorders of the upper aerodigestive tract, dystonia and hemifacial spasm, cosmetic, gastrointestinal disorders, genitourinary disorders, management of pain, and use in autonomic nervous system disorders. Many of these diseases will be discussed with regard to their treatment with botulinum toxin compared to conventional treatments. Advantages and disadvantages of botulinum toxin use are delineated. General guidelines for adult and pediatric dosing will also be discussed.