Perioperative use of botulinum toxin for movement disorder-induced cervical spine disease

Deep Brain Stimulation Before Anterior Cervical Discectomy and Fusion for a Patient With Cervical Dystonia and Cervical Myelopathy: A Case Report

Cervical dystonia with concurrent cervical myelopathy is a challenging pathology that requires thoughtful management. A 46-year-old female was referred to our center with this presentation. We elected to perform bilateral globus pallidus internus deep brain stimulation (DBS-GPi) prior to C5 to C7 anterior cervical discectomy and fusion (ACDF) to avoid the potential for dystonic movements to negatively impact cervical fusion. The patient was followed up at three months post C5 to C7 ACDF and nine months post DBS-GPi with complete control of tremor and no radiographic evidence of hardware loosening or malalignment. Though this strategy was successful in treating both our patient's cervical myelopathy and cervical dystonia, larger studies need to be conducted to optimize the treatment of patients presenting with these concurrent pathologies.

Botulinum Neurotoxin Injections in Children with Self-Injurious Behaviors

Self-injurious behaviors are repetitive, persistent actions directed toward one's body that threaten or cause physical harm. These behaviors are seen within a broad spectrum of neurodevelopmental and neuropsychiatric conditions, often associated with intellectual disability. Injuries can be severe and distressing to patients and caregivers. Furthermore, injuries can be life-threatening. Often, these behaviors are challenging to treat and require a tiered, multimodal approach which may include mechanical/physical restraints, behavioral therapy, pharmacotherapy, or in some cases, surgical management, such as tooth extraction or deep brain stimulation. Here, we describe a series of 17 children who presented to our institution with self-injurious behaviors in whom botulinum neurotoxin injections were found helpful in preventing or lessening self-injury.

Canadian Physicians' Use of Perioperative Botulinum Toxin Injections to Spastic Limbs: A Cross-sectional National Survey

Objective

To investigate the practice patterns of Canadian physicians who use perioperative botulinum toxin (BoNT) injections to improve surgical outcomes on spastic limbs.

Design

A cross-sectional national survey composed of an invitation email and an 18-item questionnaire was disseminated by a national physical medicine and rehabilitation (PMR) society to 138 physician members involved in spasticity management.

Setting

Not applicable.

Participants

Twenty-five percent of the participants (N=34) fully completed the survey.

Interventions

Not applicable.

Main Outcome Measures

Participants completed an online questionnaire that examined the practice patterns and surgical outcomes associated with perioperative BoNT injections.

Results

The majority (n=21; 84%) of Canadian physicians who inject BoNT perioperatively to improve outcomes of surgeries performed on spastic limbs are specialists in PMR practicing in academic settings. Most respondents (74%) used BoNT injections for perioperative treatment for patients with limb spasticity undergoing surgery. Of those surveyed, 65% of physicians used BoNT preoperatively, 21% used BoNT intraoperatively, and 24% used BoNT postoperatively.Of the physicians who performed BoNT injections preoperatively, 6% performed BoNT injections 7 to 12 weeks preoperatively, 32% performed BoNT injections 4 to 6 weeks preoperatively, 47% performed BoNT injections 2 to 3 weeks preoperatively, and 15% performed BoNT injections 0 to 1 week preoperatively. The majority of physicians (85%) responded that injecting BoNT perioperatively may improve a patient's surgical outcome and all of the participants (100%) stated that BoNT did not contribute to any perioperative complications or adverse effects. Qualitative responses emphasized that successful outcomes from the perioperative BoNT were linked to enhanced collaboration with surgeons and that more research is needed to determine the optimal timing of perioperative BoNT.

Conclusion

Canadian physicians, mostly PMR specialists, administer perioperative BoNT to improve outcomes of surgeries performed on spastic limbs. The optimal timing for perioperative BoNT was suggested to be 2 to 3 weeks before the surgery by 47% of survey respondents. All participating physicians responded that perioperative BoNT did not contribute to any known perioperative complications or adverse events. This study highlights the importance of conducting more robust research to better understand optimal timing for perioperative BoNT injection, enhancing collaboration between physicians and surgeons, and increasing awareness of perioperative BoNT when planning for surgeries on spastic limbs.

Perioperative Botulinum Toxin Injections to Enhance Surgical Outcomes in Patients With Spasticity: Preoperative, Intraoperative, and Postoperative Case Reports

Spasticity causes an array of disabilities, which in turn may lead to the need for surgical intervention. Spasticity itself may also negatively affect surgical outcomes. This report reviews the potential benefit of perioperative (before, during, or after surgery) botulinum toxin (BoNT) injections for 3 patients with spasticity due to spinal cord injury, stroke, or multiple sclerosis. We discuss perioperative BoNT in 3 time periods: preoperatively, intraoperatively, and postoperatively. The cases demonstrate the use of perioperative BoNT in decreasing pain, improving wound healing, and improving surgical outcomes. We conclude by discussing the potential use of perioperative BoNT for surgical interventions in patients with spasticity and the need for further high-quality research in this field.

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.

Peri-operative Botulinum Neurotoxin injection to improve outcomes of surgeries on spastic limbs: A systematic review

Our objective was to systematically review literature regarding the rationale and current evidence for peri-operative Botulinum Neurotoxin (BoNT) injection to improve outcomes of surgeries on spastic limbs. We conducted a systematic search of databases MEDLINE, EMBASE, and Cochrane Central Register of Controlled until March 2020, using the PRISMA guidelines. After assessing all titles and abstracts against inclusion criteria, full texts were reviewed for studies of potential interest. The inclusion criteria were studies on humans with any study design, published in all languages. Participants had to have underlying limb spasticity and be scheduled to undergo surgery on one or more spastic limb(s). BoNT had to be administered peri-operatively to improve surgical outcomes and not solely for the purpose of alleviating spasticity. The risk of bias was evaluated using the Physiotherapy Evidence Database (PEDro) scoring system for randomized controlled trials (RCTs) and the Downs and Black tool for RCTs and non-randomized trials. Further, the level of evidence was evaluated using a five-level scale (simplified form of Sackett). Five studies met our inclusion criteria comprising a total of 90 participants, of both pediatric and adult age groups, with underlying limb spasticity, who received BoNT perioperatively to improve outcomes of the surgeries performed on spastic limbs. Interventions were intramuscular BoNT injection prior to, at the time of, or after surgery on a spastic limb for the purpose of improving surgical outcomes, and not solely for alleviating muscle spasticity. Outcome measures were surgical success/failure, post-operative pain and analgesic use, sleep quality, adverse events, spasticity control e.g. Modified Ashworth Scale. Our literature search yielded 5 articles that met the inclusion criteria. Current evidence supports peri-operative injection of BoNT to improve outcomes of surgeries performed on spastic limbs. There is level 1 evidence that BoNT administered pre-operatively is effective for reducing pain, spasticity, and analgesic use in pediatric patients with cerebral palsy (CP). This is supported by level 4 evidence from a retrospective case series. Level 5 evidence from case reports highlights the potential for the use of BONT in the peri-operative period. There is level 1 evidence that BoNT administered intra-operatively is not effective for reducing pain and analgesic use in pediatric patients with CP. This lack of benefit may reflect sub-optimal timing of injections, different methods of injection, different timing of the primary outcome measure, and/or differences in adjunctive therapies, but further research is required.

Acute Spinal Cord Contusion in a Patient with Multiple Upper Cervical Fractures, Parkinson's Disease, and Torticollis: Surgical Management

Case Report. Spine surgery in patients with Parkinson's disease (PD) involves increased risk. We describe a case of cervical myelopathy in a patient with PD, multiple fractures involving the atlas and axis vertebrae, and spasmodic torticollis. The patient was successfully treated with an upper cervical decompression and occipital-cervical (OC) fusion surgery. Strategies for torticollis reduction and successful surgical outcome are discussed. Risks and benefits must be carefully weighed when considering occipital cervical fusion in PD patients. Conclusion. Intraoperative manual reduction of laterocollis is possible after general endotracheal anesthesia, and continuous neuromonitoring is established. Use of optimizing strategies such as perioperative botulinum injections and intraoperative O-arm navigation should be considered.

Botulinum Toxin Injections as a Treatment of Postoperative Chronic Neck Pain Secondary to Cervical Spine Surgery

Postoperative neck pain is a relatively common consequence of cervical spine surgeries such as anterior cervical discectomy with fusion and laminoplasty. Botulinum toxin injections are a relatively new treatment option to target muscle spasms, a possible cause of postoperative neck pain. This systematic review aims to evaluate the current literature highlighting the utilization of botulinum toxin for treating postoperative neck pain. The literature search resulted in one preliminary case–control trial, one case series and one case report. The use of Botox in these studies had promising benefits on postoperative neck pain, by reducing visual analog scores and improving objective measures of muscle tone such as cervical lordosis angle. While not seen in these studies, the use of botulinum toxin injections into the muscles of the region of the head, neck, and shoulder is not without risks such as focal muscle loss, joint instability, and respiratory and swallowing difficulty. With this in mind, while botulinum toxin may be a promising treatment for these patients, further well-designed studies are needed to further assess the treatments efficacy and safety in this patient population.

[Cervical myelopathy in the hyperkinetic form of cerebral palsy: combination of botulinum therapy with surgical treatment]

The article describes the case of cervical myelopathy with tetraparesis and sphincter disorders, as a complication of cervical dystonia in a patient with hyperkinetic form of cerebral palsy. Left-side laterocollis in combination with the same side laterocaput was noted. Myelopathy symptoms progressed gradually over one year. The main clinical problems were: the inability to conduct a qualitative MRI study due to hyperkinesis, which required anesthesia, and the high risk of perioperative complications and relapses of cervical myelopathy. Before the surgery, botulinum therapy of cervical dystonia with abobotulotoxin in the total dose 1000ED was administered that led to regression of hyperkinesis. Microsurgical decompression of the spinal canal with the installation of fixation system at the level of C7-Th1 vertebrae was performed. After surgery, the neck was fixed with a Philadelphia collar. There were no complications after surgery or displacement of the stabilizing structure. This case report indicates the possibility of development of cervical myelopathy in cervical dystonia and demonstrates the need of pre - and post-operative botulinum therapy of cervical dystonia to prevent possible complications and relapses in the postoperative period.

Progressive Cervical Spondylotic Myelopathy Caused by Tic Disorders in a Young Adult with Tourette Syndrome

Involuntary movement of the cervical spine can cause damage to the cervical spinal cord. Cervical myelopathy may occur at an early age in involuntary movement disorders, such as tics. We report the case of a 21-year-old man with Tourette syndrome, who developed progressive quadriparesis, which was more severe in the upper extremities. The patient had abnormal motor tics with hyperflexion and hyperextension of the cervical spine for more than 10 years. High-signal intensity intramedullary lesions were observed at C3-4-5-6 level on T2 weighted magnetic resonance imaging. Examinations were performed for high-signal intensity intramedullary lesions that may occur at a young age, but no other diseases were detected. Botulinum toxin injection to the neck musculature and medication for tic disorders were administered. However, the myelopathy was further aggravated, as the involuntary cervical movement still remained. Therefore, laminoplasty was performed at C3-4-5-6, with posterior fixation at C2-3-4-5-6-7 to alleviate the symptoms. The neurological signs and symptoms improved dramatically. The management of tic disorders should be the first priority during treatment. However, surgical treatment may be necessary, if symptoms worsen after appropriate treatment.

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.

Cervical myelopathy in patients with athetoid cerebral palsy

STUDY DESIGN

Retrospective clinical study.

OBJECTIVE

To report the surgical outcomes of patients with cervical myelopathy associated with athetoid cerebral palsy and to assess whether a halo vest is necessary for postoperative external immobilization.

SUMMARY OF BACKGROUND DATA

Although a halo vest has remained the first choice for postoperative external immobilization of patients with cervical myelopathy associated with cerebral palsy, simplification of this method has been attempted in recent years. Studies focusing on postoperative external immobilization are rare.

METHODS

Since 2001, 20 patients underwent surgery with posterior instrumented fusion or posterior fixation and anterior decompression with fusion with a year or longer follow-up. Before 2004, all patients were given a halo vest for postoperative external immobilization. After 2004, halo vests were not used, and when abnormal involuntary neck movements were severe, an intramuscular injection of botulinum toxin was administered before and after surgery. Surgical outcomes, surgical methods and complications were compared between the group that used a halo vest and the group that did not use a halo vest.

RESULTS

In the halo vest group, the average Japanese Orthopedic Association score was 6.9 points before surgery and 9.3 points at 1-year follow-up. The average recovery rate was 25.0%. In the group without halo vest use, the average Japanese Orthopedic Association score was 5.8 points before surgery and 9.9 points at 1-year follow-up. The average recovery rate was 35.7%. The group without halo vest use achieved outcomes equal to those achieved in the group with halo vest use. The frequency of complications was less without halo vest use than with halo vest use.

CONCLUSION

No inferiority in clinical outcomes was seen if postoperative halo vest use was omitted. Progress in surgical instrumentation and injection of botulinum toxin may explain this result.

Cervical spondylotic myelopathy caused by violent motor tics in a child with Tourette syndrome

INTRODUCTION

We report a case of a 9-year-old boy with Tourette syndrome (TS) who developed progressive quadriparesis that was more severe in the upper extremities.

CASE REPORT

He had experienced frequent and violent motor tics consisting of hyperflexion and hyperextension for years. Magnetic resonance imaging (MRI) revealed a focal high-signal intensity cord lesion and adjacent cervical spondylotic changes. Initially, the patient was observed for several months because of diagnostic uncertainty; his neurological status had improved and later worsened again. Anterior cervical discectomy of C3-4 and fusion immediately followed by posterior fixation were performed. After surgery, the neck collar was applied for 6 months. His neurological signs and symptoms improved dramatically. TS with violent neck motion may cause cervical spondylotic myelopathy at an early age.

CONCLUSIONS

The optimal management is still unclear and attempts to control tics should be paramount. Circumferential fusion with neck bracing represents a viable treatment option.

Multiple neck operations in a patient with severe motor tics because of Tourette's syndrome: a case report

INTRODUCTION

In patients with Tourette's syndrome who have severe motor tics, involuntary neck movements can enhance degenerative changes in the cervical spine, occasionally causing myelopathy. There have been a limited number of reports on surgical treatment for cervical myelopathy caused by Tourette's syndrome, and a consensus for surgical treatment has not been fully established. To the best of our knowledge, this is the first report that describes a case of cervical myelopathy in a patient with Tourette's syndrome with severe motor tics who has undergone multiple surgeries of the cervical spine.

CASE PRESENTATION

A 44-year-old Asian man with severe motor tics due to Tourette's syndrome presented with cervical myelopathy. Previously, he had undergone an anterior discectomy and spinal fusion with ceramics at the C3-C4 and C5-C6 levels, but required further surgery because of displacement of the ceramics. After the second operation, he developed compression myelopathy at the sandwiched (C4-C5) disc level, and had to undergo a C4-C5 anterior discectomy and spinal fusion, which was unsuccessful.As a salvage operation, we performed a C3-C7 decompression and spinal fusion from both the anterior and posterior approaches. By thorough postoperative external immobilization of his neck, our patient's spinal fusion was successful and his neurological improvements were maintained for more than 10 years.

CONCLUSIONS

Patients with Tourette's syndrome with cervical myelopathy are at risk of having multiple neck operations to correct their symptoms. Postoperative immobilization and the correct selection of surgical procedure are quite important for successful spinal fusion and for avoiding complications at adjacent levels in these patients.

Current and future medical treatment in primary dystonia

Dystonia is a hyperkinetic movement disorder, characterized by involuntary and sustained contractions of opposing muscles causing twisting movements and abnormal postures. It is often a disabling disorder that has a significant impact on physical and psychosocial wellbeing. The medical therapeutic armamentarium used in practice is quite extensive, but for many of these interventions formal proof of efficacy is lacking. Exceptions are the use of botulinum toxin in patients with cervical dystonia, some forms of cranial dystonia (in particular, blepharospasm) and writer's cramp; deep brain stimulation of the pallidum in generalized and segmental dystonia; and high-dose trihexyphenidyl in young patients with segmental and generalized dystonia. In order to move this field forward, we not only need better trials that examine the effect of current treatment interventions, but also a further understanding of the pathophysiology of dystonia as a first step to design and test new therapies that are targeted at the underlying biologic and neurophysiologic mechanisms.

European clinical guidelines for Tourette syndrome and other tic disorders. Part II: pharmacological treatment

To develop a European guideline on pharmacologic treatment of Tourette syndrome (TS) the available literature was thoroughly screened and extensively discussed by a working group of the European Society for the Study of Tourette syndrome (ESSTS). Although there are many more studies on pharmacotherapy of TS than on behavioral treatment options, only a limited number of studies meets rigorous quality criteria. Therefore, we have devised a two-stage approach. First, we present the highest level of evidence by reporting the findings of existing Cochrane reviews in this field. Subsequently, we provide the first comprehensive overview of all reports on pharmacological treatment options for TS through a MEDLINE, PubMed, and EMBASE search for all studies that document the effect of pharmacological treatment of TS and other tic disorders between 1970 and November 2010. We present a summary of the current consensus on pharmacological treatment options for TS in Europe to guide the clinician in daily practice. This summary is, however, rather a status quo of a clinically helpful but merely low evidence guideline, mainly driven by expert experience and opinion, since rigorous experimental studies are scarce.

Botulinum toxin assessment, intervention and aftercare for paediatric and adult niche indications including pain: international consensus statement

Evidence is emerging for the use of botulinum neurotoxin type-A (BoNT-A) for niche indications including pain independent of spasticity. Pain indications such as chronic nociceptive back pain, piriformis syndrome, chronic myofascial pain, pelvic pain, complex regional pain syndrome, facial pain and neuropathic pain are outlined in this paper. Of these, class I evidence is available for the treatment of chronic nociceptive low back pain, piriformis syndrome, myofascial pain, facial pain, neuropathic pain and plantar fasciitis. Peri-operative use of BoNT-A is emerging, with indications including planning for surgery and facilitating surgery, as well as healing and improving analgesia post-operatively. Evidence is limited, although there are some reports that clinicians are successfully using BoNT-A peri-operatively. There is class I evidence showing pre-operative use of BoNT-A has a beneficial effect on outcomes following adductor-release surgery. The use of BoNT for treatment of tremor, other than neck tremor in the setting of cervical dystonia, including evidence for upper limb tremor, cranial tremor and non-dystonic neck tremor is reviewed. The evidence is variable at this stage, and further study is required to develop definitive recommendations for the clinical utility of BoNT-A for these indications.

Botulinum toxin to control an incapacitating tic in a child with a clavicular fracture

We present the case of an 11-year-old boy who suffered from an undefined tic disorder and incidentally sustained a traumatic fracture of the clavicle. The fracture healing course was complicated by the tic activity, and the frequency and intensity of the tics were worsened by the presence of clavicular pain. He underwent surgery and his management required the collaboration of orthopaedic surgeons, the Acute Pain Service, neurologists for tic management and rehabilitation physicians who performed the intramuscular injections of botulinum toxin. We recommend a multidisciplinary and multimodal approach to managing patients suffering from tic disorders and highlight the consideration of intramuscular injections of botulinum toxin, which were successful for this patient.

Adult-onset dystonia

Dystonia is defined as involuntary sustained muscle contractions producing twisting or squeezing movements and abnormal postures. The movements can be stereotyped and repetitive and they may vary in speed from rapid to slow; sustained contractions can result in fixed postures. Dystonic disorders are classified into primary and secondary forms. Several types of adult-onset primary dystonia have been identified but all share the characteristic that dystonia (including tremor) is the sole neurologic feature. The forms most commonly seen in neurological practice include cranial dystonia (blepharospasm, oromandibular and lingual dystonia and spasmodic dysphonia), cervical dystonia (also known as spasmodic torticollis) and writer's cramp. These are the disorders that benefit most from botulinum toxin injections. A general characteristic of dystonia is that the movements or postures may occur in relation to specific voluntary actions by the involved muscle groups (such as in writer's cramp). Dystonic contractions may occur in one body segment with movement of another (overflow dystonia). With progression, dystonia often becomes present at rest. Dystonic movements typically worsen with anxiety, heightened emotions, and fatigue, decrease with relaxation, and disappear during sleep. There may be diurnal fluctuations in the dystonia, which manifest as little or no involuntary movement in the morning followed by severe disabling dystonia in the afternoon and evening. Morning improvement (or honeymoon) is seen with several types of dystonia. Patients often discover maneuvers that reduce the dystonia and which involve sensory stimuli such as touching the chin lightly in cervical dystonia. These maneuvers are known as sensory tricks, or gestes antagonistes. This chapter focuses on adult-onset focal dystonias including cranial dystonia, cervical dystonia, and writer's cramp. The chapter begins with a review of the epidemiology of focal dystonias, followed by discussions of each major type of focal dystonia, covering clinical phenomenology, differential genetics, and diagnosis. The chapter concludes with discussions of the pathophysiology, the few pathological cases published of adult-onset focal dystonia and management options, and a a brief look at the future.

What mediates the relationship between family meals and adolescent health issues

OBJECTIVE

To determine whether the frequency of family meals in childhood is associated with positive health outcomes in adolescence through the mediating links of increased family cohesion and positive coping skills.

DESIGN

Data were obtained from the National Heart, Lung, and Blood Institute Growth and Health Study (NGHS), a 10-year longitudinal study of 2,379 black and white girls assessed annually from ages 9-19. The mediational analysis framework of H. C. Kraemer and colleagues (2001) was used to test the hypothesis that the frequency of family meals in childhood (Study Years 1 and 3) would be related to health outcomes (Study Year 10) through the mediating links of family cohesion and coping skills (Study Years 7/8), after adjusting for baseline (Year 1) demographics as well as previous levels of the outcome variables (Years 5/6).

MAIN OUTCOME MEASURES

Several measures of adolescent health variables were included as outcome measures. These included the Perceived Stress Scale, three Eating Disorders Inventory subscales (drive for thinness, body dissatisfaction, and bulimia), number of days of alcohol and tobacco consumption, and engaging in extreme weight control behaviors (e.g., self-induced vomiting).

RESULTS

More frequent family meals in the first 3 study years predicted greater family cohesion and problem- and emotion-focused coping in Years 7 and 8. Family cohesion mediated family meals and risk of smoking in Year 10. Problem-focused coping mediated family meals and both stress and disordered eating-related attitudes and behaviors in Year 10.

CONCLUSION

Eating together as a family during childhood may have multiple benefits in later years.

Malignant Tourette syndrome

The aim of this work was to draw attention to potentially life-threatening symptoms associated with Tourette syndrome (TS) and to explore their relationship to TS comorbidities. Medical records of all patients with TS evaluated at our Movement Disorders Clinic between July 2003 and July 2006 were reviewed. Data on patients with malignant TS, defined as >or=2 emergency room (ER) visits or >or=1 hospitalizations for TS symptoms or its associated behavioral comorbidities, were entered into a dataset and analyzed. Five illustrative cases are described. Of 333 TS patients evaluated during the 3-year period, 17 (5.1%) met the criteria for malignant TS. Hospital admission or ER visits were for tic-related injuries, self-injurious behavior (SIB), uncontrollable violence and temper, and suicidal ideation/attempts. Compared with patients with nonmalignant TS, those with malignant TS were significantly more likely to have a personal history of obsessive compulsive behavior/disorder (OCB/OCD), complex phonic tics, coprolalia, copropraxia, SIB, mood disorder, suicidal ideation, and poor response to medications. Although TS is rarely a disabling disorder, about 5% of patients referred to a specialty clinic have life-threatening symptoms. Malignant TS is associated with greater severity of motor symptoms and the presence of >or=2 behavioral comorbidities. OCD/OCB in particular may play a central role in malignant TS; obsessive compulsive qualities were associated with life-threatening tics, SIB, and suicidal ideation. Malignant TS is more refractory to medical treatment than nonmalignant TS.

Tourette's syndrome with cervical disc herniation

Tourette's syndrome is manifested in a broad spectrum of motor, vocal, and behavioral disturbances. Movement disorders, such as tics, may contribute to the development of cervical myelopathy owing to the effects of involuntary movements on the neck. However, the association of cervical myelopathy with motor tics of the head and neck is rare. We report here a case of a violent, repetitive neck extension due to Tourette's syndrome that developed cervical myelopathy caused by cervical disc herniation.

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.

Delineation of the motor disorder of Lesch-Nyhan disease

Lesch-Nyhan disease (LND) is caused by deficiency of the purine salvage enzyme hypoxanthine-guanine phosphoribosyltransferase (HPRT). Affected individuals exhibit over-production of uric acid, along with a characteristic neurobehavioural syndrome that includes mental retardation, recurrent self-injurious behaviour and motor disability. Prior studies involving relatively small numbers of patients have provided different conclusions on the nature of the motor disorder. The current study includes the results of a multi-centre international prospective study of the motor disorder in the largest cohort of patients studied to date. A total of 44 patients ranging from 2 to 38 years presented a characteristic motor syndrome that involved severe action dystonia superimposed on baseline hypotonia. Although some patients also displayed other extrapyramidal or pyramidal signs, these were always less prominent than dystonia. These results are compared with a comprehensive review of 122 prior reports that included a total of 254 patients. Explanations for the differing observations available in the literature are provided, along with a summary of how the motor disorder of LND relates to current understanding of its pathophysiology involving the basal ganglia.

Cervical spondylotic myelopathy in athetoid cerebral palsy patients: about five cases

We herein report five cases of cerebral palsy athetosic patients with spondyloid cervical myelopathy. Four of them underwent decompressive surgery. The level of cervicarthrosis differs from a control population with a more frequent osteoarthritis on the lower cervical spine. The diagnosis of spondylotic cervical myelopathy is frequently overlooked because of the insidious progression of neurologic disorders and of the pre-existent neurological handicap. Depressive syndrome is often evoked in such a situation, and thus responsible for a delay of diagnosis. The presence of an hypersignal in T2 MRI sequences is still controversial. For some authors it is an indication for surgery, which is the treatment with the best functional results.

CONCLUSION

Cervical spondylotic myelopathy must be evoked in patients with athetoid cerebral palsy who complain about a decrease of their functional ability.

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.

Botulinum toxin in clinical practice

Botulinum toxin, the most potent biological toxin, has become a powerful therapeutic tool for a growing number of clinical applications. This review draws attention to new findings about the mechanism of action of botulinum toxin and briefly reviews some of its most frequent uses, focusing on evidence based data. Double blind, placebo controlled studies, as well as open label clinical trials, provide evidence that, when appropriate targets and doses are selected, botulinum toxin temporarily ameliorates disorders associated with excessive muscle contraction or autonomic dysfunction. When injected not more often than every three months, the risk of blocking antibodies is slight. Long term experience with this agent suggests that it is an effective and safe treatment not only for approved indications but also for an increasing number of off-label indications.

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.

Role for botulinum toxin in back pain treatment in adults with cerebral palsy: report of a case

OBJECTIVE

To report a case illustrating the usefulness of botulinum toxin A in the treatment of spinal dystonia responsible for low back pain and postural disorders.

METHODS

Critical appraisal of a case report.

CASE REPORT

A young woman with cerebral palsy had lumbar paraspinal muscle dystonia responsible for pain and hyperlordosis unresponsive to oral medications for muscle spasm. Botulinum toxin A (Botox(R), 200 U) was injected into the paraspinal muscles at six sites, to good effect.

DISCUSSION

The few reported cases consistently show a favorable effect of local botulinum toxin A injections in patients with painful paraspinal muscle dystonia related to neurological disease or chronic low back pain.

CONCLUSION

Botulinum toxin A may be a useful treatment for incapacitating painful dystonia of the paraspinal muscles. This treatment improves posture in the sitting position and facilitates the fitting of orthotic devices. Furthermore, botulinum toxin A treatment may help to determine whether an intrathecal baclofen test is in order.

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.

Pharmacological management of tics in patients with TS

This article reviews the evidence published in the English language literature concerning the pharmacological treatment of tics in patients with Tourette Syndrome. The focus is on the efficacy and safety of the current treatments. A clinical approach to pharmacological management of Tourette Syndrome patients is outlined.

Lesch-Nyhan disease and the basal ganglia

The purpose of this review is to summarize emerging evidence that the neurobehavioral features of Lesch-Nyhan disease (LND), a developmental disorder caused by congenital deficiency of the purine salvage enzyme hypoxanthine-guanine phosphoribosyltransferase (HPRT), may be attributable to dysfunction of the basal ganglia. Affected individuals have severe motor disability described by prominent extrapyramidal features that are characteristic of dysfunction of the motor circuits of the basal ganglia. They also display disturbances of ocular motility, cognition, and behavioral control that may reflect disruption of other circuits of the basal ganglia. Though neuropathologic studies of autopsy specimens have revealed no obvious neuroanatomical abnormalities in LND, neurochemical studies have demonstrated 60-90% reductions in the dopamine content of the basal ganglia. In addition, recent PET studies have documented significant reductions in dopamine transporters and [18F]fluorodopa uptake in the basal ganglia. These findings support the proposal that many of the neurobehavioral features of LND might be related to dysfunction of the basal ganglia.

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

OBJECTIVES

To characterise the pattern of and risk factors for degenerative changes of the cervical spine in patients with spasmodic torticollis and to assess whether these changes affect outcome after selective peripheral denervation.

METHODS

Preoperative CT of the upper cervical spine of 34 patients with spasmodic torticollis referred for surgery were reviewed by two radiologists blinded to the clinical findings. Degenerative changes were assessed for each joint separately and rated as absent, minimal, moderate, or severe. Patients were clinically assessed before surgery and 3 months postoperatively by an independent examiner using standardised clinical rating scales. For comparison of means a t test was carried out. To determine whether an association exists between the side of degenerative changes and type of spasmodic torticollis a chi(2) test was used. Changes in severity, disability, and pain before and after surgery were calculated using a Wilcoxon matched pairs signed ranks test.

RESULTS

Fourteen out of 34 patients had moderate or severe degenerative changes. They were predominantly found at the C2/C3 and C3/C4 level and were significantly more likely to occur on the side of the main direction of the spasmodic torticollis (p = 0.015). There was no significant difference in age, sex, duration of torticollis, overall severity, degree of disability, or pain between the group with either no or minimal changes and the group with moderate or severe changes. However, in the second group the duration of inadequate treatment was longer (10.1 v 4.8 years; p=0.009), head mobility was more restricted (p = 0.015), and head tremor was more severe (p = 0.01). At 3 months postoperatively, patients with n or minimal degenerative changes showed a significant improvement in pain and severity whereas no difference was found in those with moderate or severe changes.

CONCLUSIONS

Patients with spasmodic torticollis have an increased risk of developing premature degenerative changes of the upper cervical spine that tend to be on the side towards which the head is turned or tilted and compromise outcome after surgery. Effective early treatment of spasmodic torticollis with botulinum toxin seems to have a protective effect. Patients with spasmodic torticollis and restricted head mobility who do not adequately respond to treatment should undergo imaging of the upper cervical spine. Patients with imaging evidence of moderate or severe degenerative changes seem to respond poorly to selective peripheral denervation.

The effect of muscle-tone-reducing procedures in athetotic head movements: partial nerve block by lidocaine and surgical release of the neck muscles

OBJECTIVE

To investigate the effect of muscle-tone-reducing procedures (MTRPs), i.e. partial nerve block by lidocaine (PNB) and surgical release of muscle attachment to bone (SRMAB), on incessant involuntary head movements in athetotic patients.

METHODS

Pre/post-MTRP changes in neck-muscle activities, glabella movement and maximum isometric forces of the head were measured in six athetotic patients with severe spondylotic myelopathy resulting from incessant involuntary head movements.

RESULTS

Pre/post-MTRP changes in neck-muscle activities resembled those after gamma-block. In four patients, PNB reduced the maximum isometric force by no more than 40% of pre-PNB force, while decreasing the amount of involuntary head movements to 37-65% of the pre-PNB value in the frontal plane. MRSAB reduced the force by less than 40% of pre-SRMAB force in 4 MRSAB tested patients, while decreasing the amount of involuntary head movements to 12-45% of the pre-SRMAB value in all 6 patients.

CONCLUSION

MTRPs reduced involuntary head movements significantly while preserving voluntary muscle forces relatively well. PNB and SRMAB procedures have in common the effect of reducing gain in the myotatic reflex pathway by decreasing the excitatory inflows to alpha-motoneurons via muscle spindle Ia-afferents, which resulted from blocking mainly gamma-efferent conduction by PNB, and reducing background tension in muscle spindles by SRMAB.

Developmental changes of cortical and cerebellar motor control: a clinical positron emission tomography study with children and adults

Functional neuroimaging data regarding the development of motor organization in normal children and adolescents are virtually unavailable because of ethical concerns. As an alternative approach, we studied child and adult lesion patients, focusing on movement of the hand ipsilateral to the lesion and on brain activations in the contralesional hemisphere. [15O]-water positron emission tomography was performed during rest and sequential finger-thumb tapping in 10 children (aged 6 to 14 years) and 15 adults (aged 18 to 74 years) with unilateral lesion. We expected more distinct activation/deactivation patterns during movement in adults than in children. While there were no group differences in activation of primary and secondary motor cortices, deactivations in nonmotor cortex were significantly more pronounced in adults than in children. This indirectly supports our hypothesis of developmental focalization of cerebral motor control. Activations in the cerebellum and vermis were significantly stronger in the adults than in the children, possibly reflecting normal developmental patterns.

Preoperative treatment with botulinum toxin to facilitate cervical fusion in dystonic cerebral palsy. Report of two cases

The authors report the use of high-dose botulinum toxin A for muscle relaxation prior to surgery for cervical spine fixation in two patients with dystonic cerebral palsy that included severe cervical dystonia. Both patients had recently developed progressive cervical myelopathy and surgery was planned to halt the insidious progressive weakness. However, marked dystonic posturing of the neck would have compromised their tolerance of halo fixation and subsequently impeded postoperative fusion. Preoperative chemodenervation of selected cervical muscles with injections of high-dose botulinum toxin A eliminated all involuntary neck movements, permitting the patients to tolerate halo fixation and facilitating postoperative spinal fusion. It is concluded that botulinum toxin A can be used safely and effectively in the preoperative management of patients with cervical dystonia and cervical spondylitic myelopathy.

Future therapies of Tourette syndrome

Currently available pharmacologic therapies for Tourette syndrome often are characterized by limited effectiveness and unacceptable side effect profiles. In recent years, however, a series of new approaches have emerged which may lead to novel, more effective, and better tolerated treatments of tics and associated behavioral problems. Especially promising is the wide range of new atypical antipsychotic medications with unique and diverse receptor affinity profiles that are entering clinical practice. Over the next few years, intensive research efforts will be required to characterize the effect of the new atypical antipsychotics in patients with Tourette syndrome and related disorders, and to determine which sets of symptoms and which subgroups of patients best respond to particular agents. In the near future, corticotropin-releasing factor antagonists and agents which act on excitatory amino acid neurotransmitter systems also will become available and may provide treatment interventions, which theoretically could alter the long term course and outcome of Tourette syndrome. In addition, nonpharmacologic interventions, such as immunologic and behavior therapies, are receiving increasing attention and may provide an alternative or supplement to medication for selected subgroups of Tourette syndrome patients.

Severe motor tics causing cervical myelopathy in Tourette's syndrome

We describe two patients with Tourette's syndrome in whom severe motor tics involving the neck were complicated by cervical myelopathy. The first patient, a 21-year-old man, had complex tics consisting of violent twisting and extending movements of the neck preceded by an irresistible urge to produce the abnormal postures. Two years after onset of these tics, paraesthesias, sensory deficits up to the level of C4, and a gait disturbance developed. Neuroimaging studies confirmed compressive myelopathy, and the symptoms gradually improved with botulinum toxin injections in the posterior cervical muscles. The second patient, a 42-year-old man, had violent clonic tics consisting of thrusting head jerks. The repetitive flexion-extension neck movements had been present since the age 10 years. At age 23, he developed progressive weakness of all four extremities and bladder and sexual dysfunction. Myelography demonstrated cervical spinal canal stenosis with retrospondylosis from C3 through C5 and a Klippel-Feil malformation. After cervical decompression by C3-C5 laminectomies, his spinal cord symptoms improved temporarily. The tics, however, continued, and the neurologic deficits of cervical myelopathy progressed again after age 34. He did not benefit from a second operation. This report draws attention to the possibility that some tics can produce disabling compressive myelopathy. Early diagnosis and treatment of the movement disorder is essential in such cases.