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Miura I, Horisawa S, Kawamata T, Taira T. Myotomy and Selective Peripheral Denervation Based on 18F-FDG PET/CT in Intractable Cervical Dystonia: A Case Report. NMC Case Rep J 2023; 10:99-102. [PMID: 37131496 PMCID: PMC10149141 DOI: 10.2176/jns-nmc.2022-0392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 02/09/2023] [Indexed: 05/04/2023] Open
Abstract
Cervical dystonia, characterized by the involuntary contraction of cervical muscles, is the most common form of adult dystonia. In a patient with intractable cervical dystonia, we carried out a myotomy of the left obliquus capitis inferior and selective peripheral denervation (SPD) of the posterior branches of the C3-C6 spinal nerves based on preoperative 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography/computed tomography (PET/CT). The patient was a 65-year-old, right-handed man with an unremarkable medical history. His head rotated involuntarily to the left. Medication and botulinum toxin injections were ineffective, and surgical treatment was considered. 18F-FDG PET/CT imaging revealed FDG uptake in the left obliquus capitis inferior, right sternocleidomastoideus, and left splenius capitis. Myotomy of the left obliquus capitis inferior and SPD of the posterior branches of the C3-C6 spinal nerves was performed under general anesthesia. During the 6-month follow-up, the patient's Toronto Western Spasmodic Torticollis Rating Scale score improved from 35 to 9. This case shows that preoperative 18F-FDG PET/CT is effective in identifying dystonic muscles and determining the surgical strategy for cervical dystonia.
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Affiliation(s)
- Isamu Miura
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Shiro Horisawa
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Takakazu Kawamata
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Takaomi Taira
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
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Cui Z, Chen T, Wang J, Jiang C, Gao Q, Mao Z, Pan L, Ling Z, Zhang J, Li X. The Long-Term Efficacy, Prognostic Factors, Safety, and Hospitalization Costs Following Denervation and Myotomy of the Affected Muscles and Deep Brain Stimulation in 94 Patients with Spasmodic Torticollis. Brain Sci 2022; 12:brainsci12070881. [PMID: 35884688 PMCID: PMC9313216 DOI: 10.3390/brainsci12070881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 06/26/2022] [Accepted: 06/27/2022] [Indexed: 02/01/2023] Open
Abstract
The surgical methods for treating spasmodic torticollis include the denervation and myotomy (DAM) of the affected muscles and deep brain stimulation (DBS). This study reports on the long-term efficacy, prognostic factors, safety, and hospitalization costs following these two procedures. We collected data from 94 patients with spasmodic torticollis, of whom 41 and 53 were treated with DAM and DBS, respectively, from June 2008 to December 2020 at the Chinese People’s Liberation Army General Hospital. We used the Tsui scale and the global outcome score of the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) to evaluate the preoperative and postoperative clinical conditions in all patients. We also determined the costs of hospitalization, prognostic factors, and serious adverse events following the two surgical procedures. The mean follow-up time was 68.83 months (range = 13–116). Both resection surgery and DBS showed good results in terms of Tsui (Z = −5.103, p = 0.000; Z = −6.210, p = 0.000) and TWSTRS scores (t = 8.762, p = 0.000; Z = −6.308, p = 0.000). Compared with the DAM group, the preoperative (47.71, range 24–67.25) and postoperative (18.57, range 0–53) TWSTRS scores in the DBS group were significantly higher (Z = −3.161, p = 0.002). We found no correlation between prognostic factors and patient age, gender, or disease duration for either surgical procedure. However, prognostic factors were related to the length of the postoperative follow-up period in the DBS surgery group (Z = −2.068, p = 0.039; Z = −3.287, p = 0.001). The mean hospitalization cost in the DBS group was 6.85 times that found in the resection group (Z = −8.284, p = 0.000). The total complication rate was 4.26%. We found both resection surgery and DBS showed good results in the patients with spasmodic torticollis. Compared with DAM, DBS had a greater improvement in TWSTRS score; however, it was more expensive. Prognostic factors were related to the length of the postoperative follow-up period in patients who underwent DBS surgery.
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Affiliation(s)
- Zhiqiang Cui
- Department of Neurosurgery, The First Medical Clinical Center, PLA General Hospital, Beijing 100853, China; (Z.C.); (J.W.); (Z.M.); (L.P.); (Z.L.); (J.Z.)
| | - Tong Chen
- Department of Neurology, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing 100853, China;
| | - Jian Wang
- Department of Neurosurgery, The First Medical Clinical Center, PLA General Hospital, Beijing 100853, China; (Z.C.); (J.W.); (Z.M.); (L.P.); (Z.L.); (J.Z.)
| | - Chao Jiang
- School of Basic Medical Sciences, North China University of Science and Technology, No. 21 Bohai Road, Caofeidian Eco-City, Tangshan 063210, China; (C.J.); (Q.G.)
| | - Qingyao Gao
- School of Basic Medical Sciences, North China University of Science and Technology, No. 21 Bohai Road, Caofeidian Eco-City, Tangshan 063210, China; (C.J.); (Q.G.)
| | - Zhiqi Mao
- Department of Neurosurgery, The First Medical Clinical Center, PLA General Hospital, Beijing 100853, China; (Z.C.); (J.W.); (Z.M.); (L.P.); (Z.L.); (J.Z.)
| | - Longsheng Pan
- Department of Neurosurgery, The First Medical Clinical Center, PLA General Hospital, Beijing 100853, China; (Z.C.); (J.W.); (Z.M.); (L.P.); (Z.L.); (J.Z.)
| | - Zhipei Ling
- Department of Neurosurgery, The First Medical Clinical Center, PLA General Hospital, Beijing 100853, China; (Z.C.); (J.W.); (Z.M.); (L.P.); (Z.L.); (J.Z.)
| | - Jianning Zhang
- Department of Neurosurgery, The First Medical Clinical Center, PLA General Hospital, Beijing 100853, China; (Z.C.); (J.W.); (Z.M.); (L.P.); (Z.L.); (J.Z.)
| | - Xuemei Li
- Cadre Medical Department, The First Medical Clinical Center, PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing 100853, China
- Correspondence: ; Fax: +10-66938442
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Jetjumnong C, Norasetthada T. Modified McKenzie-Dandy operation for a cervical dystonia patient who failed selective peripheral denervation: A case report and literature review. Surg Neurol Int 2022; 13:31. [PMID: 35242397 PMCID: PMC8888194 DOI: 10.25259/sni_844_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Accepted: 01/07/2022] [Indexed: 11/04/2022] Open
Abstract
Background:
Cervical dystonia (CD) is a rare and difficult-to-treat disorder. Various neurosurgical options are available, each with its own set of advantages and disadvantages. We investigated using the modified McKenzie-Dandy operation for a patient with CD who failed selective peripheral denervation (SPD).
Case Description:
A 42-year-old man presented left-sided rotational torticollis for 3 years. He was referred for surgery after treating with a variety of oral medications and repeated botulinum toxin injections that became ineffective. For the first operation, the patient underwent SPD (modified Bertrand’s operation); unfortunately, the postoperative outcome was unsatisfactory, and the operation was considered a failure. After his symptoms did not improve after 6 months, the modified McKenzie-Dandy operation was performed. Immediately following surgery, he experienced satisfactory outcomes. He was able to resume his normal activities and employment after 1 month after recovering from his temporary swallowing difficulties. He only complained of minor neck pain and no recurrence was observed after 3 years follow-up.
Conclusion:
For patients who have failed SPD, a modified McKenzie-Dandy procedure is a feasible and effective option. The procedure is relatively safe when performed properly, and the long-term effects can be maintained.
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Smit M, Albanese A, Benson M, Edwards MJ, Graessner H, Hutchinson M, Jech R, Krauss JK, Morgante F, Pérez Dueñas B, Reilly RB, Tinazzi M, Contarino MF, Tijssen MAJ. Dystonia Management: What to Expect From the Future? The Perspectives of Patients and Clinicians Within DystoniaNet Europe. Front Neurol 2021; 12:646841. [PMID: 34149592 PMCID: PMC8211212 DOI: 10.3389/fneur.2021.646841] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 04/19/2021] [Indexed: 01/02/2023] Open
Abstract
Improved care for people with dystonia presents a number of challenges. Major gaps in knowledge exist with regard to how to optimize the diagnostic process, how to leverage discoveries in pathophysiology into biomarkers, and how to develop an evidence base for current and novel treatments. These challenges are made greater by the realization of the wide spectrum of symptoms and difficulties faced by people with dystonia, which go well-beyond motor symptoms. A network of clinicians, scientists, and patients could provide resources to facilitate information exchange at different levels, share mutual experiences, and support each other's innovative projects. In the past, collaborative initiatives have been launched, including the American Dystonia Coalition, the European Cooperation in Science and Technology (COST-which however only existed for a limited time), and the Dutch DystonieNet project. The European Reference Network on Rare Neurological Diseases includes dystonia among other rare conditions affecting the central nervous system in a dedicated stream. Currently, we aim to broaden the scope of these initiatives to a comprehensive European level by further expanding the DystoniaNet network, in close collaboration with the ERN-RND. In line with the ERN-RND, the mission of DystoniaNet Europe is to improve care and quality of life for people with dystonia by, among other endeavors, facilitating access to specialized care, overcoming the disparity in education of medical professionals, and serving as a solid platform to foster international clinical and research collaborations. In this review, both professionals within the dystonia field and patients and caregivers representing Dystonia Europe highlight important unsolved issues and promising new strategies and the role that a European network can play in activating them.
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Affiliation(s)
- Marenka Smit
- Expertise Centre Movement Disorders Groningen, Department of Neurology, University Medical Centre Groningen, Groningen, Netherlands
| | - Alberto Albanese
- Department of Neurology, Istituto di Ricovero e Cura a Carattere Scientifico Humanitas Research Hospital, Milan, Italy
| | | | - Mark J. Edwards
- Neuroscience Research Centre, Institute of Molecular and Clinical Sciences, St George's University of London, London, United Kingdom
| | - Holm Graessner
- Institute of Medical Genetics and Applied Genomics and Centre for Rare Diseases, University of Tübingen, Tübingen, Germany
| | - Michael Hutchinson
- Department of Neurology, St. Vincent's University Hospital, Dublin, Ireland
| | - Robert Jech
- Department of Neurology and Centre of Clinical Neuroscience, First Faculty of Medicine, Charles University, Prague, Czechia
| | - Joachim K. Krauss
- Department of Neurosurgery, Medizinische Hochschule Hannover, Hanover, Germany
| | - Francesca Morgante
- Neuroscience Research Centre, Institute of Molecular and Clinical Sciences, St George's University of London, London, United Kingdom
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Belen Pérez Dueñas
- Pediatric Neurology Research Group, Hospital Vall d'Hebron–Institut de Recerca (VHIR), Barcelona, Spain
| | - Richard B. Reilly
- School of Medicine, Trinity College, The University of Dublin, Dublin, Ireland
| | - Michele Tinazzi
- Department of Neuroscience, Biomedicine and Movement Science, University of Verona, Verona, Italy
| | - Maria Fiorella Contarino
- Department of Neurology, Leiden University Medical Centre, Leiden, Netherlands
- Department of Neurology, Haga Teaching Hospital, The Hague, Netherlands
| | - Marina A. J. Tijssen
- Expertise Centre Movement Disorders Groningen, Department of Neurology, University Medical Centre Groningen, Groningen, Netherlands
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Abstract
The dystonias are a large and heterogenous group of disorders characterized by excessive muscle contractions leading to abnormal postures and/or repetitive movements. Their clinical manifestations vary widely, and there are many potential causes. Despite the heterogeneity, helpful treatments are available for the vast majority of patients. Symptom-based therapies include oral medications, botulinum toxins, and surgical interventions. For some subtypes of dystonia, specific mechanism-based treatments are available. Advances in understanding the biological basis for many types of dystonia have led to numerous recent clinical trials, so additional treatments are likely to become available in the very near future.
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Abstract
PURPOSE OF REVIEW This article provides a summary of the state of the art in the diagnosis, classification, etiologies, and treatment of dystonia. RECENT FINDINGS Although many different clinical manifestations of dystonia have been recognized for decades, it is only in the past 5 years that a broadly accepted approach has emerged for classifying them into specific subgroups. The new classification system aids clinical recognition and diagnosis by focusing on key clinical features that help distinguish the many subtypes. In the past few years, major advances have been made in the discovery of new genes as well as advances in our understanding of the biological processes involved. These advances have led to major changes in strategies for diagnosis of the inherited dystonias. An emerging trend is to move away from heavy reliance on the phenotype to target diagnostic testing toward a broader approach that involves large gene panels or whole exome sequencing. SUMMARY The dystonias are a large family of phenotypically and etiologically diverse disorders. The diagnosis of these disorders depends on clinical recognition of characteristic clinical features. Symptomatic treatments are useful for all forms of dystonia and include oral medications, botulinum toxins, and surgical procedures. Determination of etiology is becoming increasingly important because the number of disorders is growing and more specific and sometimes disease-modifying therapies now exist.
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Wojtasiewicz T, Butala A, Anderson WS. Dystonia. Stereotact Funct Neurosurg 2020. [DOI: 10.1007/978-3-030-34906-6_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Ravindran K, Ganesh Kumar N, Englot DJ, Wilson TJ, Zuckerman SL. Deep Brain Stimulation Versus Peripheral Denervation for Cervical Dystonia: A Systematic Review and Meta-Analysis. World Neurosurg 2018; 122:e940-e946. [PMID: 30419402 DOI: 10.1016/j.wneu.2018.10.178] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 10/26/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND Cervical dystonia is a disabling medical condition that drastically decreases quality of life. Surgical treatment consists of peripheral nerve denervation procedures with or without myectomies or deep brain stimulation (DBS). The current objective was to compare the efficacy of peripheral denervation versus DBS in improving the severity of cervical dystonia through a systematic review and meta-analysis. METHODS A search of PubMed, MEDLINE, EMBASE, and Web of Science electronic databases was conducted in accordance with PRISMA guidelines. Preoperative and postoperative Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) total scores were used to generate standardized mean differences and 95% confidence intervals (CIs), which were combined in a random-effects model. Both mean percentage and absolute reduction in TWSTRS scores were calculated. Absolute reduction was used for forest plots. RESULTS Eighteen studies met the inclusion criteria, comprising 870 patients with 180 (21%) undergoing DBS and 690 (79%) undergoing peripheral denervation procedures. The mean follow-up time was 31.5 months (range, 12-38 months). In assessing the efficacy of each intervention, forest plots revealed significant absolute reduction in total postoperative TWSTRS scores for both peripheral denervation (standardized mean difference 1.54; 95% CI 1.42-1.66) and DBS (standardized mean difference 2.07; 95% CI 1.43-2.71). On subgroup analysis, DBS therapy was significantly associated with improvement in postoperative TWSTRS severity (standardized mean difference 2.08; 95% CI 1.66-2.50) and disability (standardized mean difference 2.12; 95% CI 1.57-2.68) but not pain (standardized mean difference 1.18; 95% CI 0.80-1.55). CONCLUSIONS Both peripheral denervation and DBS are associated with a significant reduction in absolute TWSTRS total score, with no significant difference in the magnitude of reduction observed between the 2 treatments. Further comparative data are needed to better evaluate the long-term results of both interventions.
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Affiliation(s)
- Krishnan Ravindran
- Department of Neurosurgery, Vanderbilt University Medical Center School, Nashville, Tennessee, USA
| | - Nishant Ganesh Kumar
- Department of Surgery, Section of Plastic Surgery, University of Michigan, Ann Arbor, Michigan
| | - Dario J Englot
- Department of Neurosurgery, Vanderbilt University Medical Center School, Nashville, Tennessee, USA
| | - Thomas J Wilson
- Department of Neurosurgery, Stanford University, Stanford, California, USA
| | - Scott L Zuckerman
- Department of Neurosurgery, Vanderbilt University Medical Center School, Nashville, Tennessee, USA.
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Huh R, Song IU, Chung M. Neuropsychological consequences of pallidal deep brain stimulation altering brain networks. J Clin Neurosci 2018; 54:50-56. [DOI: 10.1016/j.jocn.2018.05.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 02/27/2018] [Accepted: 05/17/2018] [Indexed: 02/07/2023]
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Contarino MF, Van Den Dool J, Balash Y, Bhatia K, Giladi N, Koelman JH, Lokkegaard A, Marti MJ, Postma M, Relja M, Skorvanek M, Speelman JD, Zoons E, Ferreira JJ, Vidailhet M, Albanese A, Tijssen MAJ. Clinical Practice: Evidence-Based Recommendations for the Treatment of Cervical Dystonia with Botulinum Toxin. Front Neurol 2017; 8:35. [PMID: 28286494 PMCID: PMC5323428 DOI: 10.3389/fneur.2017.00035] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Accepted: 01/25/2017] [Indexed: 12/14/2022] Open
Abstract
Cervical dystonia (CD) is the most frequent form of focal dystonia. Symptoms often result in pain and functional disability. Local injections of botulinum neurotoxin are currently the treatment of choice for CD. Although this treatment has proven effective and is widely applied worldwide, many issues still remain open in the clinical practice. We performed a systematic review of the literature on botulinum toxin treatment for CD based on a question-oriented approach, with the aim to provide practical recommendations for the treating clinicians. Key questions from the clinical practice were explored. Results suggest that while the beneficial effect of botulinum toxin treatment on different aspects of CD is well established, robust evidence is still missing concerning some practical aspects, such as dose equivalence between different formulations, optimal treatment intervals, treatment approaches, and the use of supportive techniques including electromyography or ultrasounds. Established strategies to prevent or manage common side effects (including excessive muscle weakness, pain at injection site, dysphagia) and potential contraindications to this treatment (pregnancy and lactation, use of anticoagulants, neurological comorbidities) should also be further explored.
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Affiliation(s)
- Maria Fiorella Contarino
- Department of Neurology, Haga Teaching Hospital, The Hague, Netherlands; Department of Neurology, Leiden University Medical Centre, Leiden, Netherlands
| | - Joost Van Den Dool
- Department of Neurology AB 51, University Medical Centre Groningen, Groningen, Netherlands; ACHIEVE Centre of Expertise, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, Netherlands
| | - Yacov Balash
- Movement Disorders Unit of the Department of Neurology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Kailash Bhatia
- Sobell Department, Institute of Neurology, National Hospital for Neurology, University College London , London , UK
| | - Nir Giladi
- Movement Disorders Unit of the Department of Neurology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Johannes H Koelman
- Department of Neurology/Clinical Neurophysiology, Academic Medical Center , Amsterdam , Netherlands
| | - Annemette Lokkegaard
- Department of Neurology, Copenhagen University Hospital Bispebjerg , Copenhagen , Denmark
| | - Maria J Marti
- Department of Neurology, Hospital Clinic i Universitari, Institut D'Investigacio Biomedica August Pi i Sunyer (IDIBAPS), CIBERNED , Barcelona , Spain
| | - Miranda Postma
- Department of Neurology/Clinical Neurophysiology, Academic Medical Center , Amsterdam , Netherlands
| | - Maja Relja
- Movement Disorders Center, Department of Neurology, Clinical Medical Center School of Medicine, Zagreb University , Zagreb , Croatia
| | - Matej Skorvanek
- Department of Neurology, P. J. Safarik University, Kosice, Slovakia; Department of Neurology, University Hospital of L. Pasteur, Kosice, Slovakia
| | - Johannes D Speelman
- Department of Neurology/Clinical Neurophysiology, Academic Medical Center , Amsterdam , Netherlands
| | - Evelien Zoons
- Department of Neurology/Clinical Neurophysiology, Academic Medical Center , Amsterdam , Netherlands
| | - Joaquim J Ferreira
- Clinical Pharmacology Unit, Faculty of Medicine, Instituto de Medicina Molecular, University of Lisbon , Lisbon , Portugal
| | - Marie Vidailhet
- Sorbonne University, UPMC Paris-6, Paris, France; Brain and Spine Institute - ICM, Centre for Neuroimaging Research - CENIR, UPMC UMR 1127, Paris, France; INSERM U 1127, Paris, France; CNRS UMR 7225, Team Control of Normal and Abnormal Movement, Paris, France; Department of Neurology, Salpêtriere Hospital, AP-HP, Paris, France
| | - Alberto Albanese
- Department of Neurology, Humanitas Research Hospital, Milano, Italy; Department of Neurology, Università Cattolica del Sacro Cuore, Milano, Italy
| | - Marina A J Tijssen
- Department of Neurology AB 51, University Medical Centre Groningen , Groningen , Netherlands
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Marion MH, Humberstone M, Grunewald R, Wimalaratna S. British Neurotoxin Network recommendations for managing cervical dystonia in patients with a poor response to botulinum toxin. Pract Neurol 2016; 16:288-95. [PMID: 26976927 PMCID: PMC4975836 DOI: 10.1136/practneurol-2015-001335] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2016] [Indexed: 11/24/2022]
Abstract
Botulinum toxin (BoNT) injections are an effective treatment for cervical dystonia. Approximately 20% of patients eventually stop BoNT treatment, mostly because of treatment failure. These recommendations review the different therapeutic interventions for optimising the treatment in secondary poor responder patients. Immunoresistance has become less common over the years, but the diagnosis has to be addressed with a frontalis test or an Extensor Digitorum Brevis test. In case of immunoresistance to BoNT-A, we discuss the place the different therapeutic options (BoNT-A holidays, BoNT-B injections, alternative BoNT-A injections, deep brain stimulation). When poor responders are not immunoresistant, they benefit from reviewing (1) injections technique with electromyography or ultrasound guidance, (2) muscles selection and (3) dose of BoNT. In addition, in both scenarios, a holistic approach including drug treatment, retraining and psychological support is valuable in the management of these complex and severe cervical dystonia.
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Affiliation(s)
| | - Miles Humberstone
- Department of Neurology, Nottingham University Hospitals, Nottingham, UK Department of Neurology, United Lincolnshire Hospitals, Lincoln, UK
| | - Richard Grunewald
- Department of Neurology, Sheffield Teaching Hospitals NHS FT, Sheffield, UK
| | - Sunil Wimalaratna
- Department of Neurology, Kettering General Hospital NHS Foundation Trust, Kettering, UK
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Wang J, Li J, Han L, Guo S, Wang L, Xiong Z, Ma J, Liang J, Wang L. Selective peripheral denervation for the treatment of spasmodic torticollis: long-term follow-up results from 648 patients. Acta Neurochir (Wien) 2015; 157:427-33; discussion 433. [PMID: 25616622 DOI: 10.1007/s00701-015-2348-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Accepted: 01/08/2015] [Indexed: 01/13/2023]
Abstract
BACKGROUND Selective peripheral denervation (SPD) is currently the primary surgical treatment for spasmodic torticollis (ST). Our objective here is to report on the outcome of patients treated with this procedure for ST in our department. METHODS Between June 1995 and June 2013, 648 patients underwent SPD for ST. We included 293 women (45.2 %) and 355 men (54.8 %) with a mean age of 41.1 years (range, 8-74 years) at the onset of dystonia. Surgery was performed at a mean of 3.6 years (range, 1-32 years) after onset of symptoms. Data on clinical presentation, radiological studies, operation tragedy, clinical outcomes and complications were analysed retrospectively. For evaluation of clinical outcomes, patients' responses were assessed using the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS). RESULTS Results were obtained from all 648 patients with a follow-up period ranging from 11 months to 154 months (mean, 33.4 months). The mean preoperative TWSTRS score was 54.7 ± 18.3 points (range, 39-67 points), which decreased to 31.1 ± 11.6 points postoperatively (range, 1-67 points); a significant improvement was observed between preoperative and postoperative TWSTRS evaluation; the clinical improvement of TWSTRS was 73.5 ± 11.9 %. In addition, no deaths and serious complications occurred in this cohort of patients. CONCLUSIONS SPD is an effective surgical method for patients with ST. This procedure should be recommended if conservative therapy does not offer satisfactory relief of symptoms.
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Affiliation(s)
- Junwen Wang
- Department of Neurosurgery, Wuhan Central Hospital Affiliated to Tongji Medical College, Wuhan, Hubei, 430014, People's Republic of China
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Chung M, Han I, Chung SS, Jang DK, Huh R. Effectiveness of selective peripheral denervation in combination with pallidal deep brain stimulation for the treatment of cervical dystonia. Acta Neurochir (Wien) 2015; 157:435-42. [PMID: 25471274 DOI: 10.1007/s00701-014-2291-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Accepted: 11/20/2014] [Indexed: 12/17/2022]
Abstract
BACKGROUND Selective peripheral denervation (SPD) and deep brain stimulation of the globus pallidus (GPi-DBS) are available surgical options for patients with medically refractory cervical dystonia (CD). There are few data available concerning whether patients who have unsatisfactory treatment effects after primary surgery benefit from a different type of subsequent surgery. The aim of this study was to assess whether combining these surgical procedures (SPD plus GPi-DBS) was effective in patients with unsatisfactory treatment effects after their initial surgery. METHODS Forty-one patients with medically refractory idiopathic CD underwent SPD and/or GPi-DBS. Patients who were dissatisfied with their primary surgery (SPD or GPi DBS) elected to subsequently undergo a different type of surgery. These patients were assessed with the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS). RESULTS SPD alone and GPi-DBS alone were performed in 16 and 21 patients, respectively. Four patients had unsatisfactory treatment effects after the initial surgery and subsequently underwent another type of surgery. Among them, two patients with persistent dystonia after SPD subsequently underwent GPi-DBS, and two other patients who had insufficient treatment effects following GPi-DBS were subsequently treated with SPD. All of these patients experienced sustained improvement from the combined surgical procedures according to the TWSTRS score during a long-term follow-up of 12-90 months. CONCLUSIONS Patients with unsatisfactory treatment effects after an SPD or GPi-DBS experienced improvement from subsequently undergoing other types of surgery. Therefore, combined surgical procedures are additional surgical options with good outcomes in the treatment of patients with residual symptoms after their initial surgery.
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Pallidal neurostimulation in patients with medication-refractory cervical dystonia: a randomised, sham-controlled trial. Lancet Neurol 2014; 13:875-84. [PMID: 25127231 DOI: 10.1016/s1474-4422(14)70143-7] [Citation(s) in RCA: 226] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Cervical dystonia is managed mainly by repeated botulinum toxin injections. We aimed to establish whether pallidal neurostimulation could improve symptoms in patients not adequately responding to chemodenervation or oral drug treatment. METHODS In this randomised, sham-controlled trial, we recruited patients with cervical dystonia from centres in Germany, Norway, and Austria. Eligible patients (ie, those aged 18-75 years, disease duration ≥3 years, Toronto Western Spasmodic Torticollis Rating Scale [TWSTRS] severity score ≥15 points) were randomly assigned (1:1) to receive active neurostimulation (frequency 180 Hz; pulse width 120 μs; amplitude 0·5 V below adverse event threshold) or sham stimulation (amplitude 0 V) by computer-generated randomisation lists with randomly permuted block lengths stratified by centre. All patients, masked to treatment assignment, were implanted with a deep brain stimulation device and received their assigned treatment for 3 months. Neurostimulation was activated in the sham group at 3 months and outcomes were reassessed in all patients after 6 months of active treatment. Treating physicians were not masked. The primary endpoint was the change in the TWSTRS severity score from baseline to 3 months, assessed by two masked dystonia experts using standardised videos, analysed by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00148889. FINDINGS Between Jan 19, 2006, and May 29, 2008, we recruited 62 patients, of whom 32 were randomly assigned to neurostimulation and 30 to sham stimulation. Outcome data were recorded in 60 (97%) patients at 3 months and 56 (90%) patients at 6 months. At 3 months, the reduction in dystonia severity was significantly greater with neurostimulation (-5·1 points [SD 5·1], 95% CI -7·0 to -3·5) than with sham stimulation (-1·3 [2·4], -2·2 to -0·4, p=0·0024; mean between-group difference 3·8 points, 1·8 to 5·8) in the intention-to-treat population. Over the course of the study, 21 adverse events (five serious) were reported in 11 (34%) of 32 patients in the neurostimulation group compared with 20 (11 serious) in nine (30%) of 30 patients in the sham-stimulation group. Serious adverse events were typically related to the implant procedure or the implanted device, and 11 of 16 resolved without sequelae. Dysarthria (in four patients assigned to neurostimulation vs three patients assigned to sham stimulation), involuntary movements (ie, dyskinesia or worsening of dystonia; five vs one), and depression (one vs two) were the most common non-serious adverse events reported during the course of the study. INTERPRETATION Pallidal neurostimulation for 3 months is more effective than sham stimulation at reducing symptoms of cervical dystonia. Extended follow-up is needed to ascertain the magnitude and stability of chronic neurostimulation effects before this treatment can be recommended as routine for patients who are not responding to conventional medical therapy. FUNDING Medtronic.
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