Specific movement and disability improvements in Burke-Fahn-Marsden Dystonia Rating Scale derived from pallidotomy in refractory patients to medical treatment

BACKGROUND

Dystonia is a movement disorder associated with significant disability and is usually refractory to medical treatment. Pallidotomy may decrease dystonic movements. The aim of this study was to quantify movement and disability improvements through Burke-Fahn-Marsden Dystonia Rating Scale (BFMDRS).

METHODS

We carried out a longitudinal clinical study in patients with refractory primary and secondary dystonia, who underwent radiofrequency (RF) unilateral and bilateral lesions on the postero-ventro-lateral globus pallidus internus (GPi), evaluating the outcomes through BFMDRS and variables as age, time of evolution, etiology, body distribution, planned target coordinates, and lesion size, during a mean follow-up time of 35.67 months.

RESULTS

Nine RF pallidotomies were performed on 6 patients, 7 right-sided and 2 left-sided; three patients were treated unilaterally for one occasion, while the others underwent 2 surgeries, including one staged bilateral procedure. Mean BFMDRS scores for movement were 38.5 preoperative and 25.5 postoperative, and for disability were 20.4 preoperative and 17.3 postoperative. We noticed improvement in movement (32.54%, p = 0.001) and disability (17.23%, p = 0.002). There was one right GPi and internal capsule (IC) infarction with contralateral hemiparesis as sequelae.

CONCLUSIONS

RF pallidotomy is an effective and accessible procedure to reduce BFMDRS scores in refractory dystonia if patients are correctly selected by severity, evolution, and disability as determining factors.

Treatment of focal hand dystonia: current status

BACKGROUND

Focal hand dystonia (FHD) is usually adult-onset focal dystonia that can be associated with marked occupational and functional disability leading to reduced quality of life.

METHODS

Relevant studies on treatment options for FHD, their limitations, and current recommendations were reviewed using the PubMed search until March 31, 2021. Besides, the reference lists of the retrieved publications were manually searched to explore other relevant studies.

RESULTS

and conclusion Currently, botulinum toxin has the best evidence for treatment of FHD, and 20-90% of patients experience symptomatic improvement. However, its benefit is often limited by the reduction of muscle tonus acting on the muscle spindle. Different surgical modalities that have been used to treat focal hand dystonia include lesional surgery, deep brain stimulation, and magnetic resonance-guided focused ultrasound thalamotomy. Recent studies exploring the role of behavioral techniques, sensorimotor training, and neuromodulation for the treatment of focal hand dystonia have reported good outcomes, but larger studies are required before implementing these interventions in practice.

Unilateral pallidotomy in the treatment of cervical dystonia: a retrospective observational study

OBJECTIVE

The objective of this study was to assess the efficacy of unilateral pallidotomy in patients with asymmetrical cervical dystonia.

METHODS

This study retrospectively included 25 consecutive patients with asymmetrical cervical dystonia refractory to botulinum toxin injections, who underwent unilateral pallidotomy between January 2015 and April 2017. Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) scores were evaluated preoperatively and 1 week, 3 months, and 6 months postoperatively. The clinical responses were defined as good responders, exhibiting > 50% improvement in the TWSTRS score at 6 months postsurgery, or poor responders, exhibiting < 50% improvement in TWSTRS scores at 6 months postsurgery.

RESULTS

Twelve and 9 patients showed right- and left-side rotation, respectively; 1 and 3 patients had right- and left-side laterocollis, respectively. The mean age of onset and duration of the disease were 40.2 ± 13.9 and 8.9 ± 10.9 years, respectively. Mean TWSTRS scores were 38.4 ± 12.6 (p < 0.001), 17.3 ± 12.4 (p < 0.001), 19.5 ± 13.4 (p < 0.001), and 20.0 ± 14.7 (p < 0.001), preoperatively and 1 week, 3 months, and 6 months postoperatively, respectively. Fourteen patients (56%) demonstrated > 50% improvement in their TWSTRS total score (mean improvement of TWSTRS total score = 70.5%) 6 months postsurgically. Furthermore, preoperative TWSTRS severity score was a prognostic factor (odds ratio 1.37, 95% confidence interval 1.06-1.78, p = 0.003).

CONCLUSIONS

These results suggest that unilateral pallidotomy is an acceptable treatment option for asymmetrical cervical dystonia. Further investigations with a larger number of cases and longer follow-up period are required to confirm these data.

Staged bilateral pallidotomy for dystonic camptocormia: case report

Camptocormia is a rare, involuntary movement disorder, presenting as truncal flexion while standing or walking, and is mainly observed as a feature of Parkinson's disease (PD) and primary dystonia. Deep brain stimulation (DBS) of the globus pallidus internus is effective for refractory camptocormia observed with PD or dystonia. However, the effectiveness of pallidotomy for camptocormia has not been investigated. The authors report the case of a 38-year-old man with anterior truncal bending that developed when he was 36 years old. Prior to the onset of the symptom, he had been taking antipsychotic drugs for schizophrenia. There were no features of PD; the symptom severely interfered with his walking and daily life. He was given anticholinergics, clonazepam, and botulinum toxin injections, which did not result in much success. Because of the patient's unwillingness to undergo implantation of a hardware device, he underwent staged bilateral pallidotomy with complete resolution for a diagnosis of tardive dystonic camptocormia. The Burke-Fahn-Marsden dystonia rating scale subscore for the trunk before and after bilateral pallidotomy was 3 and 0, respectively. No perioperative adverse events were observed. Effects have persisted for 18 months. Bilateral pallidotomy can be a treatment option for medically refractory dystonic camptocormia without the need for device implantation.

[Unilateral posteroventral pallidotomy in the treatment of drug-induced dyskinesia in Parkinson's disease]

OBJECTIVE

to determine the efficacy of unilateral posteroventral pallidotomy (PVP) in the treatment of drug-induced dyskinesia (DID) in Parkinson's disease (PD).

MATERIAL AND METHODS

We analyzed surgical treatment of 14 patients with PD complicated by DID who underwent unilateral PVP at the Research Center of Neurology in the period between 2012 and 2015. The clinical type of DID was mainly represented by peak-dose choreoathetoid dyskinesia, more pronounced in the distal limbs, and predominantly unilateral. The severity of drug-induced dyskinesia was assessed on the UPDRS scale (part IV-A) before surgery and at 1 week and 6 months after surgery.

RESULTS

One week after pallidotomy, all of the 14 patients had a regression of contralateral dyskinesia by 68.3±9.7%; 50% of patients had a regression of ipsilateral dyskinesias by 43%, on average. In 50% of cases, the dose of levodopa was reduced by 15%, on average. On examination at 6 months after surgery, regression of contralateral dyskinesia was 55.7±8.8%, and the severity of ipsilateral DID returned to the preoperative level. The use of pallidotomy significantly improved the indicators of daily activity and quality of life of patients. There were no significant postoperative complications. Three patients had mild speech disorders in the form of dysarthria, which regressed 2-3 weeks after surgery.