Is camptocormia a primary muscular disease?

Association of kyphotic posture with loss of independence and mortality in a community-based prospective cohort study: the Locomotive Syndrome and Health Outcomes in Aizu Cohort Study (LOHAS)

OBJECTIVES

This study aimed to investigate the association between kyphotic posture and future loss of independence (LOI) and mortality in community-dwelling older adults.

DESIGN

Prospective cohort study.

SETTING

Two Japanese municipalities.

PARTICIPANTS

We enrolled 2193 independent community-dwelling older adults aged≥65 years at the time of their baseline health check-up in 2008. Kyphotic posture was evaluated using the wall-occiput test (WOT) and classified into three categories: non-kyphotic, mild (>0 and ≤4 cm) and severe (>4 cm).

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was mortality and the secondary outcomes were LOI (new long-term care insurance certification levels 1-5) and a composite of LOI and mortality. A Cox proportional hazards model was used to estimate the adjusted HRs (aHRs).

RESULTS

Of the 2193 subjects enrolled, 1621 were included in the primary analysis. Among these, 272 (17%) and 202 (12%) were diagnosed with mild and severe kyphotic postures, respectively. The median follow-up time was 5.8 years. Compared with the non-kyphotic group, the aHRs for mortality were 1.17 (95% CI 0.70 to 1.96) and 1.99 (95% CI 1.20 to 3.30) in the mild and severe kyphotic posture groups, respectively. In the secondary analysis, a consistent association was observed for LOI (mild: aHR 1.70, 95% CI 1.13 to 2.55; severe: aHR 2.08, 95% CI 1.39 to 3.10) and the LOI-mortality composite (mild: aHR 1.27, 95% CI 0.90 to 1.79; severe: aHR 1.83, 95% CI 1.31 to 2.56).

CONCLUSION

Kyphotic posture was associated with LOI and mortality in community-dwelling older adults. Identifying the population with kyphotic posture using the WOT might help improve community health.

The Effect of Posterior Lumbar Spinal Surgery on Biomechanical Properties of Rat Paraspinal Muscles 13 Weeks After Surgery

STUDY DESIGN

Preclinical study in rodents.

OBJECTIVE

To investigate changes in biomechanical properties of paraspinal muscles following a posterior spinal surgery in an animal model.

SUMMARY OF BACKGROUND DATA

Posterior spine surgery damages paraspinal musculature per histological and imaging studies. The biomechanical effects of these changes are unknown.

METHODS

12 Sprague-Dawley rats were divided equally into sham and surgical injury (SI) groups. For sham, the skin and lumbodorsal fascia were incised at midline. For SI, the paraspinal muscles were detached from the vertebrae, per normal procedure. Thirteen weeks postsurgery, multifidus and longissimus biopsies at L1, L3, and L5 levels were harvested on the right. From each biopsy, three fibers and three to six bundles of fibers (∼10-20 fibers ensheathed in their extracellular matrix) were tested mechanically to measure their passive elastic modulus. The collagen content and fatty infiltration of each biopsy were also examined histologically by immunofluorescence staining. Nonparametric statistical methods were used with a 1.25% level of significance.

RESULTS

A total of 220 fibers and 279 bundles of fibers were tested. The elastic moduli of the multifidus and longissimus fibers and longissimus fiber bundles were not significantly different between the SI and sham groups. However, the elastic modulus of multifidus fiber bundles was significantly greater in the SI group compared to sham (SI median 82 kPa, range 23-284; sham median 38 kPa, range 23-50, P = 0.0004). The elastic modulus of multifidus fiber bundles in the SI group was not statistically different between spinal levels (P = 0.023). For histology, only collagen I deposition in multifidus was significantly greater in the SI group (median 20.8% vs. 5.8% for sham, P < 0.0001).

CONCLUSION

The surgical injury increased the passive stiffness of the multifidus fiber bundles. Increased collagen content in the extracellular matrix is the likely reason and these changes may be important in the postoperative compensation of the spine.Level of Evidence: N/A.

Lumbar muscle atrophy and increased relative intramuscular lipid concentration are not mitigated by daily artificial gravity after 60-day head-down tilt bed rest

Exposure to axial unloading induces adaptations in paraspinal muscles, as shown after spaceflights. This study investigated whether daily exposure to artificial gravity (AG) mitigated lumbar spine flattening and muscle atrophy associated with 60-day head-down tilt (HDT) bed rest (Earth-based space analog). Twenty-four healthy individuals participated in the study: 8 received 30-min continuous AG; 8 received 6 × 5-min AG interspersed with rest periods; and 8 received no AG exposure (control group). Magnetic resonance imaging (MRI) of the lumbopelvic region was conducted at baseline (BDC) and at day 59 of HDT (HDT59). Longitudinal relaxation time (T1)-weighted images were used to assess morphology of the lumbar spine (spinal length, intervertebral disk angles, disk area) and volumes of the lumbar multifidus (LM), lumbar erector spinae (LES), quadratus lumborum (QL), and psoas major (PM) muscles from L₁/L₂ to L₅/S₁ vertebral levels. A chemical shift-based two-point lipid/water Dixon sequence was used to evaluate muscle composition. Results showed that spinal length and disk area increased (P < 0.05); intervertebral disk angles (P < 0.05) and muscle volumes of LM, LES, and QL reduced (P < 0.01); and lipid-to-water ratio for the LM and LES muscles increased (P < 0.01) after HDT59 in all groups. Neither of the AG protocols mitigated the lumbar spinae deconditioning induced by HDT bed rest. The increase in lipid-to-water ratio in LM and LES muscles indicates an increased relative intramuscular lipid concentration. Altered muscle composition in atrophied muscles may impair lumbar spine function after body unloading, which could increase injury risk to vulnerable soft tissues. This relationship needs further investigation.NEW & NOTEWORTHY This study presents novel insights into the morphological adaptations occurring in the lumbar spine after 60-day head-down bed rest and the potential role of artificial gravity (AG) to mitigate them. Results demonstrated no protective effect of AG protocols used in this study. In atrophied paraspinal muscles, the ratio of lipids versus intramuscular water increased in the postural lumbar muscles, which could impair muscle function during upright standing. These findings have relevance for future space explorations.

Camptocormia in an Adolescent: A Case Report and Review of the Literature

Camptocormia, or bent-spine syndrome, is an entity with a long history and many etiologies. We discuss below both the history of this diagnosis in light of a rare case of psychogenic camptocormia and the recent changes in nosology regarding this disorder.

Camptocormia: Etiology, diagnosis, and treatment response

Background

We sought to determine the etiologies, diagnostic testing, and management of a retrospective cohort of patients with camptocormia evaluated at a single center.

Methods

We reviewed medical records of all adult patients evaluated at Mayo Clinic Rochester with a diagnosis of camptocormia from 2000 to 2014. Demographic and clinical data were abstracted and analyzed.

Results

There were 276 patients (58.0% male), with mean age at presentation of 68.6 (±12.7) years. An etiology was identified in 98.2%. The most common etiologies were idiopathic Parkinson disease (22.5%), idiopathic axial myopathy (14.1%), and degenerative joint disease without fixed deformity (13.0%). We also identified several rare causes of camptocormia. Investigations included spine imaging, needle and surface EMG, and muscle biopsy. Most patients received physical therapy and orthotic support with limited benefit. Limited improvement of camptocormia was seen where a treatable etiology was identified.

Conclusions

An etiology can be identified in almost all cases of camptocormia. Most cases are due to 3 common disorders: Parkinson disease, axial myopathy, and degenerative joint disease. A diagnostic and treatment algorithm is proposed.

Case Studies in Neuroscience: A dissociation of balance and posture demonstrated by camptocormia

Upright stance in humans requires an intricate exchange between the neural mechanisms that control balance and those that control posture; however, the distinction between these control systems is hard to discern in healthy subjects. By studying balance and postural control of a participant with camptocormia - an involuntary flexion of the trunk during standing that resolves when supine - a divergence between balance and postural control was revealed. A kinematic and kinetic investigation of standing and walking showed a stereotyped flexion of the upper body by almost 80° over a few minutes, and yet the participant's ability to control center of mass within the base of support and to compensate for external perturbations remained intact. This unique case also revealed the involvement of automatic, tonic control of the paraspinal muscles during standing and the effects of attention. Although strength was reduced and MRI showed a reduction in muscle mass, there was sufficient strength to maintain an upright posture under voluntary control and when using geste antagoniste maneuvers or "sensory tricks" from visual, auditory, and haptic biofeedback. Dual tasks that either increased or decreased the attention given to postural alignment would decrease or increase the postural flexion, respectively. The custom-made "twister" device that measured axial resistance to slow passive rotation revealed abnormalities in axial muscle tone distribution during standing. The results suggest that the disorder in this case was due to a disruption in the automatic, tonic drive to the postural muscles and that myogenic changes were secondary. NEW & NOTEWORTHY By studying an idiopathic camptocormia case with a detailed biomechanical and sensorimotor approach, we have demonstrated unique insights into the neural control of human bipedalism 1) balance and postural control cannot be considered the same neural process, as there is a stereotyped abnormal flexed posture, without balance deficits, associated with camptocormia, and 2) posture during standing is controlled by automatic axial tone but "sensory tricks" involving sensory biofeedback to direct voluntary attention to postural alignment can override, when required.

Lumbar Spinal Surgery in Patients With Parkinson Disease: A Multicenter Retrospective Study

STUDY DESIGN

A multicenter, retrospective study.

OBJECTIVE

To identify the factors that affect surgery-related complications and to clarify the surgical strategy for treating lumbar disorders in Parkinson disease (PD).

SUMMARY OF BACKGROUND DATA

Previous studies have reported a high complication rate for spinal surgery in patients with PD. Because of the limited number of studies, there are no guidelines for spinal surgery for PD patients.

METHODS

We retrospectively reviewed the records for 67 PD patients who underwent lumbar spinal surgery. The patients were divided into 3 groups: 12 patients underwent laminectomy (Laminectomy), 24 underwent fusion surgery (Fusion) for lumbar canal stenosis, and 31 underwent corrective surgery for spinal deformity (Deformity). We assessed surgery-related complications in each group. The Cox proportional hazards model was used to identify the factors that predicted surgical failure.

RESULTS

The percentages of patients who experienced failure of the initial surgery were 33.3% in the Laminectomy group, 45.8% in the Fusion group, and 67.7% in the Deformity group. The rates of implant failure were high in the Fusion and Deformity groups (33.3% and 38.7%, respectively). The Deformity group had a high rate of postoperative fracture (41.9%). These complications occurred at the most caudal site within a year after surgery and resulted in progression of kyphotic deformity. Multivariate analysis revealed that preoperative lumbar lordosis angle (LL) (per -1 degree) was associated with a failure of the initial surgery (hazard ratio, 1.024; 95% confidence interval, 1.008-1.04; P=0.003).

CONCLUSIONS

We have demonstrated that a small preoperative LL increases the risk for failure of the initial surgery. Attaining and maintaining the proper lumbar lordosis with rigid fixation may be necessary in PD patients with a small preoperative LL.

Pathophysiological Concepts and Treatment of Camptocormia

Camptocormia is a disabling pathological, non-fixed, forward bending of the trunk. The clinical definition using only the bending angle is insufficient; it should include the subjectively perceived inability to stand upright, occurrence of back pain, typical individual complaints, and need for walking aids and compensatory signs (e.g. back-swept wing sign). Due to the heterogeneous etiologies of camptocormia a broad diagnostic approach is necessary. Camptocormia is most frequently encountered in movement disorders (PD and dystonia) and muscles diseases (myositis and myopathy, mainly facio-scapulo-humeral muscular dystrophy (FSHD)). The main diagnostic aim is to discover the etiology by looking for signs of the underlying disease in the neurological examination, EMG, muscle MRI and possibly biopsy. PD and probably myositic camptocormia can be divided into an acute and a chronic stage according to the duration of camptocormia and the findings in the short time inversion recovery (STIR) and T1 sequences of paravertebral muscle MRI. There is no established treatment of camptocormia resulting from any etiology. Case series suggest that deep brain stimulation (DBS) of the subthalamic nucleus (STN-DBS) is effective in the acute but not the chronic stage of PD camptocormia. In chronic stages with degenerated muscles, treatment options are limited to orthoses, walking aids, physiotherapy and pain therapy. In acute myositic camptocormia an escalation strategy with different immunosuppressive drugs is recommended. In dystonic camptocormia, as in dystonia in general, case reports have shown botulinum toxin and DBS of the globus pallidus internus (GPi-DBS) to be effective. Camptocormia in connection with primary myopathies should be treated according to the underlying illness.

Posterior and anterior spinal fusion for the management of deformities in patients with Parkinson's disease

Introduction. Spinal scoliosis and kyphosis in elderly people sometimes cause severe low back pain. Surgical methods such as osteotomy are useful for correcting the deformity. However, complications during and after surgery are associated with the osteotomy procedure. In particular, it is difficult to manage deformity correction surgery for patients with Parkinson's disease. Here, we present two cases of combined anterior and posterior surgery for deformity in patients with adult scoliosis and kyphosis due to Parkinson's disease. Case Presentation. Two 70-year-old women had spinal scoliosis and kyphosis due to Parkinson's disease. They had severe low back pain, and conservative treatment was not effective for the pain. Surgery was planned to correct the deformity in both patients. We performed combined posterior and anterior correction surgery. At first, posterior fusions were performed from T4 to the ilium using pedicle screws. Next, cages and autograft from the iliac crest were used in anterior lumbar surgery. The patients became symptom free after surgery. Bony fusion was observed 12 months after surgery. Conclusions. Combined posterior and anterior fusion surgery is effective for patients who show scoliosis and kyphosis deformity, and symptomatic low back pain due to Parkinson's disease.

Myofibrillar disorganization characterizes myopathy of camptocormia in Parkinson's disease

Camptocormia is a highly disabling syndrome that occurs in various diseases but is particularly associated with Parkinson's disease (PD). Although first described nearly 200 years ago, the morphological changes associated with camptocormia are still under debate and the pathophysiology is unknown. We analyzed paraspinal muscle biopsies of 14 PD patients with camptocormia and compared the findings to sex-matched postmortem controls of comparable age to exclude biopsy site-specific changes. Camptocormia in PD showed a consistent lesion pattern composed of myopathic changes with type-1 fiber hypertrophy, loss of type-2 fibers, loss of oxidative enzyme activity, and acid phosphatase reactivity of lesions. Ultrastructurally, myofibrillar disorganization and Z-band streaming up to electron-dense patches/plaques were seen in the lesions. No aberrant protein aggregation, signs of myositis or mitochondriopathy were found, but the mitochondrial content of paraspinal muscles in patients and controls was markedly higher than known from limb biopsies. Additionally, we were able to demonstrate a link between the severity of the clinical syndrome and the degree of the myopathic changes. Because of the consistent lesion pattern, we propose criteria for the diagnosis of camptocormia in PD from muscle biopsies. The morphological changes show obvious parallels to the muscle pathology of experimental tenotomy reported in the 1970s, which depend on an intact innervation and do not occur after interruption of the myotactic reflexes. A dysregulation of the proprioception could be part of the pathogenesis of camptocormia in Parkinson's disease, particularly in view of the clinical symptoms of rigidity and loss of muscle strength.

Pisa syndrome in Parkinson's disease: clinical, electromyographic, and radiological characterization

Abnormal postures of the trunk are a typical feature of Parkinson's disease (PD). These include Pisa syndrome (PS), a tonic lateral flexion of the trunk associated with slight rotation along the sagittal plane. In this study we describe clinical, electromyographic (EMG), and radiological features of PS in a group of 20 PD patients. All patients with trunk deviation underwent EMG and radiological (RX and CT scan) investigation. Clinical characteristics of patients with PS were compared with a control group of PD patients without trunk deviation. PD patients with PS showed a significantly higher score of disease asymmetry compared with the control group. In the majority of patients with PS, trunk bending was contralateral to the side of symptom onset. EMG showed abnormal tonic hyperactivity on the side of the deviation in the paravertebral thoracic muscles and in the abdominal oblique muscles. CT of the lumbar paraspinal muscles showed muscular atrophy more marked on the side of the deviation, with a craniocaudal gradient. PS may represent a complication of advanced PD in a subgroup of patients who show more marked asymmetry of disease and who have detectable hyperactivity of the dorsal paravertebral muscles on the less affected side. This postural abnormality deserves attention and proper early treatment to prevent comorbidities and pain.

Fatty involution of the gluteus medius muscles: a late-onset girdle myopathy?

BACKGROUND

Involvement of the gluteus medius muscle has been reported in girdle myopathies or facioscapulohumeral myopathies. Camptocormia, or Bent spine syndrome, characterized by involuntary forward flexion of the trunk in the standing position, may be secondary to a late-onset myopathy essentially involving the spinal erector muscles. In this article, we report the observations of patients with severe deficiency of the gluteus medius, suggesting a late-onset myopathy.

METHODS

Computed tomography and magnetic resonance imaging (MRI) were performed in 17 patients, with a mean age 76 years, 3 men and 14 women, presenting a Trendelenburg limp related to fatty infiltration of the gluteus medius muscles. Eight of these patients also had camptocormia.

RESULTS

Computed tomographic scan and MRI appearance differed from that of age-matched controls and suggested myopathy. MRI excluded an inflammatory disorder or disinsertion of the gluteus medius muscle. Biopsies of gluteus medius and paravertebral muscles showed marked septal fibrosis and adiposis, whereas control biopsies were normal. Creatine phosphokinase was moderately increased in two thirds of patients.

CONCLUSIONS

Involvement of the gluteus medius muscles, like involvement of the paravertebral muscles with which it is frequently associated, may be a form of late-onset girdle myopathy.

Bent spine syndrome (camptocormia): a retrospective study of 63 patients

OBJECTIVES

Bent spine syndrome (BSS) is characterized by involuntary forward flexion of the trunk in the standing position but not in the recumbent position. We assessed the causes of BSS based on findings in 63 patients.

METHODS

We retrospectively reviewed the records of all patients with BSS evaluated at a teaching hospital in Toulouse, France, between 1995 and 2006. For each patient, we recorded the findings from the following investigations: physical examination, electromyogram (EMG), creatine phosphokinase (CPK) assay, computed tomography (CT), and surgical muscle biopsy.

RESULTS

We identified 63 patients, 46 females and 17 males, with a mean age of 70 ± 6.9 years. Among them, 40 had delayed-onset paraspinal myopathy, with fatty infiltration predominantly affecting the paraspinal muscles. In 40% of these patients, CT disclosed mild fatty infiltration of the gluteal and posterior thigh and leg muscles in addition to the paraspinal muscle abnormalities. Paraspinal muscle histology showed lobular endomysial fibrosis, as previously described and ruled out other forms of muscle dystrophy. The remaining 23 patients (14 females and nine males) had either another neurological disease or myopathic involvement of other muscles, with a definite diagnosis; nevertheless, forward bending of the trunk was the most prominent symptom and the reason for the initial physician visit.

CONCLUSION

In our case-series, delayed-onset paraspinal myopathy accounted for 64% of cases of BSS. The most informative investigation was CT, which showed a patchy decrease in paraspinal muscle density.

Facioscapulohumeral muscular dystrophy presenting with isolated axial myopathy and bent spine syndrome

Several subtypes of facioscapulohumeral muscular dystrophy (FSHD) with atypical clinical presentation have been described. We report a new, distinct phenotype with progressive bent spine syndrome solely affecting the paraspinal muscles. Magnetic resonance imaging study of the lumbar spine revealed marked atrophy of the paraspinal muscles. The diagnosis was confirmed by DNA testing, which revealed shortened restriction fragments of the D4Z4 repeat on haplotype A in connection with a positive family history.

Myopathy causing camptocormia in idiopathic Parkinson's disease: a multidisciplinary approach

Extreme forward flexion of the spine, named camptocormia (CC), and head drop syndrome (HD) may be among the most disabling symptoms in Parkinson's disease (PD). This study aims to eludicate the etiology of PD-associated CC and HD via a multidisciplinary approach (clinical examination, electromyography, MRI, genetic analysis, muscle morphology) centering on the histology of the paraspinal muscles. We studied 17 patients with the clinical diagnosis of PD and CC or head drop syndrome and six controls. We performed muscle biopsies of paraspinal muscles and deep neck extensor muscles. Mean age at onset of postural abnormality was 66 years and mean latency between onset of parkinsonian symptoms to first signs of CC or head drop was 7 years. The electromyogram of paraspinal muscles was abnormal in 13-14 patients. Histopathology revealed chronic myopathic changes in 14 of 17 biopsies, consisting of abnormal variation in fiber size, increase in internal nuclei, and increase in connective tissue, myofibrillar disarray and similarities to protein surplus myopathies. Interestingly, heterozygous variants in the Parkin gene were found in 2 of 9 investigated patients. We conclude that CC and HD in PD are predominantly myopathic. Aberrant protein aggregation may link PD and CC.

Camptocormia in idiopathic Parkinson's disease: a focal myopathy of the paravertebral muscles

The objective of our study was to describe the clinical features of camptocormia, an involuntary, marked flexion of the thoracolumbar spine in idiopathic Parkinson's disease (PD) and to understand its etiology. In a prospective, cross-sectional study, we examined 15 patients with PD and camptocormia using laboratory parameters, EMG, muscle magnetic resonance imaging, and biopsy of the paravertebral muscles. The clinical data were compared with a matched control group of PD patients without camptocormia, and the biopsies were compared with muscles from age-matched autopsies. Almost all the patients (median age, 68.0 years; 7 women) with camptocormia suffered from advanced PD. Camptocormia occurred at a median of 9.0 years after the PD diagnosis. Compared with our clinical control group, back pain was more frequent and less dopa-sensitive in the patients with camptocormia who suffered more often from additional diseases of the back. On EMG, we found mainly a myopathic pattern. The MRI of the paravertebral muscles showed localized changes ranging from edema with contrast enhancement, which are considered to be early signs, to atrophy and/or fatty degeneration, interpreted as late degenerative changes. Early signs were seen mainly during the first year and degenerative changes after 1.5 years. Biopsies revealed consistently myopathic changes and in some cases fatty degeneration. Clinical or electromyographic features favoring dystonia were absent. Camptocormia is a major disabling, non-fluctuating and levodopa-resistant complication of advanced PD. The cause of camptocormia in idiopathic PD is a focal myopathy. Our findings suggest that the myopathy has a progressive course, which finally leads to degeneration of the paravertebral muscles.

Acute camptocormia induced by olanzapine: a case report

Introduction

Camptocormia refers to an abnormal posture with flexion of the thoraco-lumbar spine which increases during walking and resolves in supine position. This symptom is an increasingly recognized feature of parkinsonian and dystonic disorders, but may also be caused by neuromuscular diseases. There is recent evidence that both central and peripheral mechanisms may be involved in the pathogenesis of camptocormia. We report a case of acute onset of camptocormia, a rare side effect induced by olanzapine, a second-generation atypical anti-psychotic drug with fewer extra-pyramidal side-effects, increasingly used as first line therapy for schizophrenia, delusional disorders and bipolar disorder.

Case presentation

A 73-year-old Caucasian woman with no history of neuromuscular disorder, treated for chronic delusional disorder for the last ten years, received two injections of long-acting haloperidol. She was then referred for fatigue. Physical examination showed a frank parkinsonism without other abnormalities. Routine laboratory tests showed normal results, notably concerning creatine kinase level. Fatigue was attributed to haloperidol which was substituted for olanzapine. Our patient left the hospital after five days without complaint. She was admitted again three days later with acute back pain. Examination showed camptocormia and tenderness in paraspinal muscles. Creatine kinase level was elevated (2986 UI/L). Magnetic resonance imaging showed necrosis and edema in paraspinal muscles. Olanzapine was discontinued. Pain resolved quickly and muscle enzymes were normalized within ten days. Risperidone was later introduced without significant side-effect. The camptocormic posture had disappeared when the patient was seen as an out-patient one year later.

Conclusions

Camptocormia is a heterogeneous syndrome of various causes. We believe that our case illustrates the need to search for paraspinal muscle damage, including drug-induced rhabdomyolysis, in patients presenting with acute-onset bent spine syndrome. Although rare, the occurrence of camptocormia induced by olanzapine must be considered.

Spinal surgery in patients with Parkinson's disease: experiences with the challenges posed by sagittal imbalance and the Parkinson's spine

Only a few reports exist concerning biomechanical challenges spine surgeons face when treating Parkinson's disease (PD) patients with spinal deformity. We recognized patients suffering from spinal deformity aggravated by the burden of PD to stress the principles of sagittal balance in surgical treatment. Treatment of sagittal imbalance in PD is difficult due to brittle bone and (the neuromuscular disorder) with postural dysfunction. We performed a retrospective review of 23 PD patients treated surgically for spinal disorders. Mean ASA score was 2.3 (2-3). Outcome analysis included review of medical records focusing on failure characteristics, complications, and radiographic analysis of balance parameters to characterize special risk factors or precautions to be considered in PD patients. The sample included 15 female and 8 male PD patients with mean age of 66.3 years (57-76) at index surgery and 67.9 years (59-76) at follow-up. 10 patients (43.5%) presented with the sequels of failed previous surgery. 18 patients (78.3%) underwent multilevel fusion (C3 level) with 16 patients (69.6%) having fusion to S1, S2 or the Ilium. At a mean follow-up of 14.5 months (1-59) we noted medical complications in 7 patients (30.4%) and surgical complications in 12 patients (52.2%). C7-sagittal center vertical line was 12.2 cm (8-57) preoperatively, 6.9 cm postoperatively, and 7.6 cm at follow-up. Detailed analysis of radiographs, sagittal spinal, and spino-pelvic balance, stressed a positive C7 off-set of 10 cm on average in 25% of patients at follow-up requiring revision surgery in 4 of them. Statistical analysis revealed that patients with a postoperative or follow-up sagittal imbalance (C7-SVL >10 cm) had a significantly increased rate of revision done or scheduled (p = 0.03). Patients with revision surgery as index procedure also were found more likely to suffer postoperative or final sagittal imbalance (C7-SPL, 10 cm; p = 0.008). At all, 33% of patients had any early or late revision performed. Nevertheless, 78% of patients were satisfied or very satisfied with their clinical outcome, while 22% were either not satisfied or uncertain regarding their outcome. The surgical history of PD patients treated for spinal disorders and the reasons necessitating redo surgery for recalcitrant global sagittal imbalance in our sample stressed the mainstays of spinal surgery in Parkinson's: If spinal surgery is indicated, the reconstruction of spino-pelvic balance with focus on lumbar lordosis and global sagittal alignment is required.

Restoration of erect posture in idiopathic camptocormia by electrical stimulation of the globus pallidus internus

The authors report on 2 young patients who developed drug-resistant idiopathic dystonic camptocormia (bent spine) and were treated successfully by deep brain stimulation (DBS) of the globus pallidus internus (GPi). The first patient, a 26-year-old woman, suffered for 3 years from such severe camptocormia that she became unable to walk and was confined to bed or a wheelchair. The second patient, a 21-year-old man, suffered for 6 months from less severe camptocormia; he was able to walk but only for short distances with a very bent spine, the arms in a parallel position to the legs, and the hands almost approaching the floor to potentially support him in case of a forward fall. Within a few days following DBS, both patients experienced marked clinical improvement. At most recent follow-up (44 months in one case and 42 in the other), the patients' ability to walk upright remained normal. Similar findings have only been reported recently in a few cases of camptocormia secondary to Parkinson disease or tardive dyskinesia. On the basis of the experience of these 2 idiopathic cases and the previously reported cases of secondary camptocormia with a favorable response to GPi DBS, the authors postulate that specific patterns of oscillatory activity in the GPi are vital for the maintenance of erect posture and the adoption of bipedal walking by humans.

Camptocormia: the bent spine syndrome, an update

Camptocormia, also referred to as bent spine syndrome (BSS) is defined as an abnormal flexion of the trunk, appearing in standing position, increasing during walking and abating in supine position. BSS was initially considered, especially in wartime, as a psychogenic disorder. It is now recognized that in addition to psychiatric syndromes, many cases of reducible BSS have a somatic origin related to a number of musculo-skeletal or neurological disorders. The majority of BSS of muscular origin is related to a primary idiopathic axial myopathy of late onset, appearing progressively in elderly patients. Diagnosis of axial myopathy first described by Laroche et al. is based upon CT/MRI examination demonstrating massive fatty infiltration of paravertebral muscles. The non-specific histological aspect includes an extensive endomysial fibrosis and fat tissue with irregular degenerated fibers. Weakness of the paravertebral muscles can be secondary to a wide variety of diseases generating diffuse pathologic changes in the muscular tissue. BSS can be the predominant and sometimes revealing symptom of a more generalized muscular disorder. Causes of secondary BSS are numerous. They must be carefully assessed and ruled out before considering the diagnosis of primary axial myopathy. The principal etiologies include on the one hand inflammatory myopathies, muscular dystrophies of late onset, myotonic myopathies, endocrine and metabolic myopathies, and on the other hand neurological disorders, principally Parkinson's disease. Camptocormia in Parkinsonism is caused by axial dystonia, which is the hallmark of Parkinson's disease. There is no specific pharmacologic treatment for primary axial myopathy. General activity, walking with a cane, physiotherapy, and exercises should be encouraged. Treatment of secondary forms of BSS is dependent upon the variety of the disorder generating the muscular pathology. Pharmacologic and general management of camptocormia in Parkinson's disease merge with that of Parkinsonism. Levodopa treatment, usually active on tumor rigidity and akinesia, has poor or negative effect on BSS.

Camptocormia as a presentation of generalized inflammatory myopathy

Camptocormia is an abnormal truncal flexion posture that occurs while walking or standing. It is usually caused by various hypokinetic movement disorders such as Parkinson disease and multiple system atrophy. Myopathy or motor neuron disease can also be infrequent causes of camptocormia. Paraspinous muscle biopsy usually reveals focal myositis, regardless of the etiology of camptocormia. We describe the first case of generalized inflammatory myopathy with prominent camptocormia and proximal muscle weakness. Muscle biopsy of the quadriceps confirmed the diagnosis of polymyositis, and the posture showed modest improvement in response to steroid treatment.

Painful camptocormia: the relevance of shaking your patient's hand

Camptocormia is an abnormal posture with marked flexion of thoracolumbar spine that abates in the recumbent position. Camptocormia has been described in various neurological (Parkinsonism), muscular (myopathy), psychogenic or orthopedic disorders. There are several hypotheses that can explain this impaired posture but they are usually related to the concomitant pathologies. We report the first case of a patient with confirmed myotonic dystrophy addressed to our medical center for impaired posture who underwent extensive medical exams and explorations because of a myotonic hand. Axial weakness and muscle atrophy, validated by CT-scan imaging, are discussed independent of the concomitant pathology (Parkinson, myopathy).

Disorders of paravertebral lumbar muscles: from pathology to cross-sectional imaging

Paravertebral lumbar muscles are important for spine stabilization and mobility. They may be abnormal in several disorders that may be associated with pain or functional impairment. Special attention should be paid to the paravertebral muscles during imaging, so that a possible muscular disease is not overlooked, especially in patients with low back pain. This article reviews such imaging abnormalities.

Camptocormia and Parkinson's disease: MR imaging

Camptocormia is characterized by an excessive anterior flexion of the spine that appears only when standing or walking. The origin of this symptom remains unknown, but recent clinical reports of camptocormia associated with Parkinson's disease (PD) suggest cerebral involvement in the pathogenesis of camptocormia. This study was undertaken to investigate the hypothesis that camptocormia in PD has a central origin. Seventeen PD patients with camptocormia were prospectively enrolled and were compared to 10 matched PD patients without camptocormia and 12 normal controls. The normalized volumes of the brain, striatal nuclei, and the cross-sectional areas of the midbrain and pons were measured on three-dimensional magnetic resonance imaging. Data were correlated with the severity of the symptoms. The normalized axial surface of the midbrain was statistically smaller in PD patients with camptocormia than in normal controls (P = 0.01). The normalized volumetric data were not statistically different in PD patients with camptocormia. There was a significant negative correlation between the severity of camptocormia and the normalized brain volume (P < 0.009; R = -0.649) and sagittal pons area (P < 0.01; R = -0.642). The results suggest that PD with camptocormia may represent a selective form of PD in which a specific neuronal dysfunction possibly occurs within the brainstem.

Joint and skeletal deformities in Parkinson's disease, multiple system atrophy, and progressive supranuclear palsy

The objective of this study is to characterize clinical features of joint and skeletal deformities in Parkinson's disease (PD), multiple system atrophy (MSA), and progressive supranuclear palsy (PSP). Clinical information including age, gender, presence of deformity, initial symptom side, neuropsychological and motor features, family history, and treatment with levodopa/dopamine agonists was collected on consecutive patients with PD, MSA, and PSP evaluated at the Movement Disorders Clinic at Baylor College of Medicine. In this series of 202 patients, 36.1% had deformities of the limbs, neck, or trunk, including 33.5% of PD, 68.4% of MSA, and 26.3% of PSP patients. "Striatal" hand and foot deformities were present in 13.4%, involuntary trunk flexion in 12.9%, anterocollis in 9.4%, and scoliosis in 8.4% of all patients. Patients with these joint and skeletal deformities had higher mean Unified Parkinson's Disease Rating Scale scores (57.4 vs. 46.6; P < 0.01) and were more often treated with levodopa (69.9% vs. 50.4%; P < 0.01) than patients without deformity, independent of disease duration. Patients with striatal deformity were younger than patients without deformity (mean 60.4 vs. 68.6 years; P < 0.01), and they tended to have an earlier age of onset of initial parkinsonian symptoms (mean 54.7 vs. 62.5 years; P < 0.01). Furthermore, the side of striatal deformity correlated with the side of initial parkinsonian symptoms in all patients (100%) with striatal hand and in 83.3% of patients with striatal foot. Joint and skeletal deformities are common and frequently under-recognized features of PD, MSA, and PSP that often cause marked functional disability independent of other motor symptoms.

Camptocormia in a Patient with Parkinson Disease and a Myopathy with Nemaline Rods

Camptocormia, also referred to as bent spine, is a gait disorder characterized by hyperflexion of the thoracolumbar spine that develops in recumbent position while walking and that disappears in supine position. Myopathy is one of the frequent causes of camptocormia. A 77-yr-old male patient who was followed up with the diagnosis of rheumatoid arthritis for 2 yrs was admitted with progressive gait deterioration. Hyperflexion of trunk, disappearing in supine position, was detected and diagnosed as camptocormia. He also exhibited the signs of parkinsonism. A paraspinal muscle biopsy showed myopathy with rods in many muscle fibers. Camptocormia in this patient may be attributable to the myopathic weakness of thoracolumbar paraspinal muscles. The normal biceps brachii muscle biopsy refers to the isolated affection of paraspinal muscles in this patient. A camptocormia (bent spine) case of myopathy with nemaline rods associated with Parkinson disease is presented.

A specific clinical pattern of camptocormia in Parkinson's disease

BACKGROUND

Camptocormia, characterised by extreme forward flexion of the thoracolumbar spine and severe stooping in the supine position, seems to be prevalent in Parkinson's disease.

OBJECTIVE

The aim of this study was to identify features of parkinsonian camptocormia and to describe the main clinical characteristics of patients with Parkinson's disease who develop the condition.

METHODS

An extensive range of clinical, biochemical and imaging data were gathered for 23 patients with Parkinson's disease with camptocormia, notably including magnetic resonance imaging (MRI) of the brain and spine, electromyographic recordings of the paravertebral muscles and muscle biopsies.

RESULTS

Camptocormia occurred in severe Parkinson's disease with axial predominance, motor fluctuations and dysautonomic symptoms. The condition was often associated with spondyloarthritic changes and pain. MRI showed paraspinal muscle signal abnormalities in five patients and fatty involution in seven patients. The seven patients had motor unit reductions on the spinal erector electromyogram. The MRI results for the girdle muscles were normal. Cranial MRI showed signal abnormalities for the basal ganglia in three patients.

DISCUSSION

Various mechanisms may contribute to the development of parkinsonian camptocormia: dopaminergic depletion in Parkinson's disease induces functional changes in the organisation of the corticospinal and reticulospinal tracts, where dysfunction could contribute to axial rigidity. Furthermore, rigidity of the spinal flexion muscles could lead to under-use of the spinal extension muscles, which become progressively atrophic. Rigidity may also induce spinal deformations, leading to a neurogenic syndrome via compression of the spinal nerves.

CONCLUSION

The screening and early management of camptocormia in Parkinson's disease is likely to be important for preventing axial disorders and spinal deformations.

Parkinson's disease with camptocormia

BACKGROUND

Camptocormia is defined as an abnormal flexion of the trunk that appears when standing or walking and disappears in the supine position. The origin of the disorder is unknown, but it is usually attributed either to a primary or a secondary paravertebral muscle myopathy or a motor neurone disorder. Camptocormia is also observed in a minority of patients with parkinsonism.

OBJECTIVE

To characterise the clinical and electrophysiological features of camptocormia and parkinsonian symptoms in patients with Parkinson's disease and camptocormia compared with patients with Parkinson's disease without camptocormia.

METHODS

Patients with parkinsonism and camptocormia (excluding patients with multiple system atrophy) prospectively underwent a multidisciplinary clinical (neurological, neuropsychological, psychological, rheumatological) and neurophysiological (electromyogram, ocular movement recording) examination and were compared with age-matched patients with Parkinson's disease without camptocormia.

RESULTS

The camptocormia developed after 8.5 (SD 5.3) years of parkinsonism, responded poorly to levodopa treatment (20%) and displayed features consistent with axial dystonia. Patients with camptocormia were characterised by prominent levodopa-unresponsive axial symptoms (ie, axial rigidity, gait disorder and postural instability), along with a tendency for greater error in the antisaccade paradigm.

CONCLUSION

We suggest that (1) the salient features of parkinsonism observed in patients with camptocormia are likely to represent a specific form of Parkinson's disease and camptocormia is an axial dystonia and (2) both camptocormia and parkinsonism in these patients might result from additional, non-dopaminergic neuronal dysfunction in the basal ganglia.

Camptocormia associated with focal myositis in multiple-system atrophy

Camptocormia (CC) or pronounced forward flexion of the trunk is a common symptom of Parkinson's disease. We describe 2 patients with probable, respectively possible multiple-system atrophy and CC. Magnetic resonance imaging of the erector trunci showed focal patchy hyperintensities with gadolinium enhancement and muscle biopsy was indicative of variably pronounced focal myositis. CC was progressive and the major handicap for both patients after 1 and 1.5 years of follow-up, respectively. The therapeutic response was poor. Similarities with the dropped-head syndrome suggest that the muscle pathology may be either the primary cause of CC, a focal reaction to the CC posture, or a coincident syndrome of old age.

Response of the dropped head/bent spine syndrome to treatment with intravenous immunoglobulin

Weakness of neck extension causing a dropped head may result from many neuromuscular disorders. One etiology is isolated neck extensor myopathy. A similar focal myopathy of the lower axial muscles may cause the bent spine syndrome, which manifests as flexion of the trunk and inability to stand upright. Combination of both dropped head and bent spine myopathies is uncommon. Inflammation is usually not pronounced in these conditions and response to immunosuppressive treatment is rare. We present an 81-year-old man who developed progressive weakness of neck and trunk extension over several months, with a prominent inflammatory process in the thoracic paraspinal muscles, which responded dramatically to treatment with intravenous immunoglobulin (IVIg). This case, together with other rare reports, suggests that the presence of inflammation in the biopsy of an affected muscle may predict treatment response.

Camptocormia as a clinical manifestation of mitochondrial myopathy

Camptocormia is an unusual condition characterized by a progressive weakness of the extensor muscles of the spine that cause an involuntary truncal flexion. Occasionally, camptocormia can be the clinical manifestation of an underlying myopathy, including inflammatory or metabolic myopathies. We present a case of a 78-year-old female with camptocormia associated with a mitochondrial myopathy. Additionally, we review the clinical characteristics of three similar, previously reported cases.

The bent spine syndrome: myopathy + biomechanics = symptoms

BACKGROUND CONTEXT

The bent spine syndrome, which mimics spinal stenosis, is thought to be a focal paraspinal myopathy, but because paraspinal fatigue with ambulation is not a feature of more severe myopathies, the cause of symptoms is not clear.

PURPOSE

To evaluate electromyographic and biomechanical aspects of the bent spine syndrome.

STUDY DESIGN/SETTING

University spine clinic.

METHODS

A patient with severe disability from the bent spine syndrome was compared with a fortuitously discovered asymptomatic research subject with the syndrome, in terms of physical examination, magnetic resonance imaging, and electrodiagnostic testing.

RESULTS

Both subjects had fatty paraspinal replacement on magnetic resonance imaging and electromyography. More detailed electromyography of the patient showed abnormalities medially and caudally, but changes including apparent myopathic motor units up to the high thoracic region. The research subject had no hip flexion contracture, whereas the patient had severe contracture. Correction of contracture increased ambulation from 20 to 300 meters.

CONCLUSIONS

Bent spine syndrome is likely a paraspinal myopathy, but symptoms do not occur unless there is also a hip flexion contracture.

[Parkinson's disease, progressive lumbar kyphosis and focal paraspinal myositis]

INTRODUCTION

The camptocormia (bent spine) is characterized by a severe forward flexion of the thoracolumbar spine which disappears in the supine position. Clinical case. We describe a typical case observed in a parkinsonian patient. The MRI, electromyogram and biopsy of the paraspinal muscles revealed a typical myositis pattern.

DISCUSSION

This case, the sixth published to our knowledge, confirms that focal myositis is associated with the camptocormia in Parkinson's disease. Typically it is observed in male subjects, appearing 4 to 6 years after the onset of Parkinson's disease, in fluctuating patients treated by an association of L-Dopa and agonist. It appears quickly and becomes the most important symptom. Antiparkinsonian drugs are useless.

CONCLUSION

This exceptional picture raises original pathophysiological and therapeutic questions. Systematic studies should be performed in order to detail the pathophysiological link between these 3 entities: Parkinson's disease, focal myositis and camptocormia.

Camptocormia or Pisa syndrome in multiple system atrophy

Although a mild stooped posture is a hallmark of parkinsonism, extreme trunk forward flexion is not common. This phenomenon was described in different etiological entities and called camptocormia. Other similar presentations called Pisa syndrome and antecollis were described mainly in extrapyramidal disorders. Authors present two cases of probable multiple system atrophy (MSA) with predominant parkinsonism and Pisa syndrome (or camptocormia). Both of them were previously misdiagnosed as idiopathic Parkinson's disease (PD) and one was reported 1 year earlier. The typical clinical presentation fulfilling the diagnostic criteria for multiple system atrophy, rapid progression with lack of responsiveness to L-DOPA and apomorphine and typical MRI putaminal pathology observed in both cases allowed us to make a diagnosis. Accuracy of clinical diagnosis in multiple system atrophy is still very poor. Therefore, unusual or rare clinical presentations may support the final diagnosis. The camptocormia, Pisa syndrome and antecollis may represent the continuum of the same motor phenomenon and most of the authors refer them to unusual form of axial dystonia. According to many clinical presentations on different forms of camptocormia/Pisa syndrome authors conclude that not etiology, but the localization of specific lesion, probably within putamen is responsible for that form of dystonia. In cases of parkinsonism and severe forward flexion of trunk multiple system atrophy, diagnosis should be considered.

Spinal surgery in patients with Parkinson's disease: construct failure and progressive deformity

STUDY DESIGN

Retrospective case series review of patients with Parkinson's disease undergoing elective spine surgery at a single tertiary referral center.

OBJECTIVES

To assess the rate of complications of spine surgery in the population with Parkinson's disease and characterize the causes of failure and special needs of this unique population.

SUMMARY OF BACKGROUND DATA

Patients with Parkinson's disease experience a combination of poor bone quality and a severe neuromuscular disorder. There is little information in the literature about outcomes of spine surgery in this population. Preliminary review suggests that these patients have a high rate of instrument-related complications that has not been reported previously.

METHODS

A computerized search using diagnostic and procedural codes identified 14 patients with Parkinson's disease who underwent spine surgery from January 1993 through December 2000. Their charts and radiographs were reviewed, and those not examined within twelve months were invited for follow-up review. The remaining patients were being followed on a regular basis by their spine surgeon, the Movement Disorders Clinic, or both and were seen and examined during their routine follow-up observation. INDICATIONS AND EXTENT OF INDEX SURGERY VARIED: Complications, revisions, and radiographic evidence of loosening were assessed. Causes of failure were sought with respect to surgical and clinical factors. All patients underwent surgical care by a fellowship-trained spine surgeon.

RESULTS

The mean follow-up period from index procedure was 66.8 months; the median follow-up period was 38 months. Of 14 patients, 12 (86%) required additional surgery, undergoing a total of 31 reoperations. Eleven patients (79%) underwent 22 additional procedures at the same or adjacent level for instability, including four patients (29%) who had hardware failure or pullout, necessitating 10 reoperations. The one other patient who required additional surgery had a successful index procedure but underwent another operation to address instability at a remote spinal segment. Of five patients whose index procedure involved only one spinal level, three (60%) required additional procedures, all at that level. Two patients (14%) developed wound infections during the course of treatment but not as the cause of initial treatment failure. The primary mechanisms of failure were relentless kyphosis or segmental instability at the operated-on or adjacent levels.

CONCLUSION

Patients with Parkinson's disease undergoing spine surgery in a single tertiary referral center had a very high reoperation rate associated with technical complications. Patients should be appropriately counseled regarding the increased risk of operative complications and closely followed for incipient failure.

Dropped head presentation of mitochondrial myopathy

Dropped head secondary to weakness of the neck extensors has been reported in a wide assortment of neuromuscular disorders. Infrequently, dropped head can be the first sign of disease. We describe two patients with dropped head as the presenting manifestation of mitochondrial myopathy. In both patients, serum lactate was elevated and muscle biopsy showed mitochondrial proliferation. Mitochondrial myopathy should be considered in the differential diagnosis of dropped head syndrome, particularly when other, more common causes such as myasthenia gravis, polymyositis, and amyotrophic lateral sclerosis have been excluded by appropriate laboratory and electrophysiological studies.