Wise Young
11-17-2006, 03:32 AM
ABU,
Here is what I have found so far. De Salles (1996) reported use of stereotaxic lesions of the ventrolateral nucleus or ventroposterior pallidium (globus pallidus) may reduce or eliminate motor dysfunction. It may be also possible to place stimulating electrodes into either of these two structures and ascertain whether these structures are active when you are undergoing choreoathetotic movements and inject local anesthesia (to stop the activity in those areas) to see if it reduces or stops the movement. This is to avoid the possibility of unnecessary trial-and-error in the lesioning process.
From what I know about choreoathetosis, it is not solely something that arises from the basal ganglia or thalamus. There have been some reports of choreoathetosis that results from cerebellar degeneration (Usui, et al. 1988). Also, neck muscles are very strong and I have not been able to find any reports of using botox to used for this purpose. I will keep adding to this, as I find more information:
De Salles AA (1996). Role of stereotaxis in the treatment of cerebral palsy. J Child Neurol 11 Suppl 1: S43-50. There is a renewed interest in basal ganglia surgery for improvement of motor symptoms in cerebral palsy. Rigidity, choreoathetosis, and tremor can be improved or abolished by a well-placed radiofrequency lesion, either in the ventrolateral nucleus of the thalamus or ventroposterior pallidum. The target is chosen based on the predominance of the symptoms in a given patient. A review of the main reports on surgery of the basal ganglia for cerebral palsy, as well as the author's data, shows that the surgery can have a remarkable impact on patients' quality of life when motor dysfunction is improved. An update of the physiopathology of cerebral palsy motor symptoms related to anatomic findings on experimental work, magnetic resonance imaging, and autopsy is used to rationalize surgery of the basal ganglia. Modern stereotactic technique based on exquisite demonstration of the basal ganglia anatomy by magnetic resonance imaging is described and supported by intraoperative electricophysiologic studies. The author stresses the importance of a multidisciplinary approach to provide the cerebral palsy patient with a comprehensive treatment plan before stereotactic surgery. Division of Neurosurgery, University of California Los Angeles School of Medicine 90024-6975, USA. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=8959461
Usui S, Beppu H, Hirose K, Tanabe H and Tsubaki T (1988). [A family of spino-cerebellar degeneration with disturbance of ocular movement, choreoathetosis, amyotrophy and dementia--a consideration in clinical features]. No To Shinkei 40: 953-61. Seven cases in a family of hereditary spino-cerebellar degeneration (SCD) similar to dentatorubro-pallido-Luysian atrophy (DRPLA) were reported. The clinical features of these cases were disturbance of ocular movement (limitation of ocular movement and slow eye movement (SEM], remarkable amyotrophy, choreoathetosis, dementia and sleep apnea. The brain CT's revealed marked atrophy in pons and cerebellum. Amyotrophy had been reported in the case of DRPLA, particular ataxo-choreoathetoid form (by Hirayama). Muscle biopsy was performed in these cases, which showed scattered small angulated fiber, severe atrophic fiber with pyknotic nuclear clump, fiber type grouping and small rounded fiber were mixed. These findings indicates neurogenic change of radiculoneuropathy type (by Tanabe). In many reported cases of DRPLA and SCD with amyotrophy, this type of muscle biopsy had not been recognized. In SCD with amyotrophy, a main lesion had existed on peripheral nerve. In this case, there was no definite clinical findings (sensory disturbance, delay of conduction nerve velocity, peripheral neuropathy in nerve biopsy). In recent years, several unclassified cases of SCD with amyotrophy had been reported, which had multi-system degeneration involving peripheral neuropathy. This case is similar to these cases, which is speculates multi-systemic lesions, not only DRPLA but also peripheral nerve involvement. On neuro-otological study, velocity of saccade was slow and persuit was reserved in proband case. In younger onset case, disturbance of saccade and pursuit was mild. In older progressive case, disturbance of saccade and pursuit was progressive and accompanied with severe limitation of ocular movement. Several autopsy cases of SEM had been reported.(ABSTRACT TRUNCATED AT 250 WORDS) Department of Neurology, Tokyo Metropolitan Neurological Hospital, Japan. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=3196499
Wise Young
11-17-2006, 10:05 AM
ABU,
Here is more about pallidotomy. Fujimoto, et al. (1997) reported a case of a 41-year old man with severe choreoathetosis in all limbs, neck, face, and tongue. Bilateral lesions of the the globus pallidus apparently reduced his movements. This is surprising because lesions of the globus pallidus is commonly used to treat people with immobility due to Parkinson's disease. Therefore, one would have expected that pallidotomy would have produced increasd movement. In fact, Aizawa, et al. (1991) had reported that pallidal degeneration is associated with choreoathetosis, torsion dystonia, and progressive rigidity.
Regarding use of botox, it turned out that I was searching under the wrong term. Botox has been used extensively to treat torticollis of the neck, particularly in children. Do (2006) describes the use of botox to treat the sternocleidomastoid muscle. Apparently, botox is frequently used to treat cervical dystonia, as suggested by 139 cases reported by Comella, et al. (2005) at 19 centers. Oleszek, et al. (2005) and Slawek, et al. (2005) had previously suggested that Botox A is better but Comella, et al.'s study did not confirm this. Anyway, the list of complications is useful.
Botox, of course, needs to be injected repeatedly. There is one study of patient satisfaction with Botox treatment of idiopathic cervical dystonia, suggesting that about two thirds of the patients had a "good outcome" (Skogseid & Kerty, 2005). Costa, et al. (2005) did a Cochrane database analysis of Botulinum toxin A treatment versus anti-cholinergic treatment of cervical dystonia. It is clear that Botulinum A has been very widely used and provides more subjective and objective benefits than anti-cholinergics. It is interesting that Costa, et al. are from the same Lisbon hospital that Carlos Lima is doing his operations.
Hakkinen, et al. (2004) reported that decreased muscle strength is high associated with neck pain in cervical dystonia patients treated with botulinum toxin A. According to Frei, et al. (2004), posttraumatic cervical dystonia and pain occurs after spinal cord injury but Zesiewicz, et al. (2004) reported that side effects are mild and that most patients experienced pain reduction in patients treated with Botox A for idiopathic cervical dystonia. Slawek & Reclawowicz (2004) did not find any evidence of central damage of the brainstem or other central nervous system structures after Botox A treatment of neck muscles. Apparently, Botox is better than selective denervation (Braun & Richter, 2002).
Thus, it would seem that Botox A may be a treatment that you might want to consider.
Wise.
Fujimoto Y, Isozaki E, Yokochi F, Yamakawa K, Takahashi H and Hirai S (1997). [A case of chorea-acanthocytosis successfully treated with posteroventral pallidotomy]. Rinsho Shinkeigaku 37: 891-4. We described a 41-year-old man with chorea-acanthocytosis, who presented severe choreoathetosis in all the limbs, neck, face and tongue. Especially, the oral area was affected most strikingly. He had difficulty in eating, because he pushed foods out of the mouth with the tongue. He received left posteroventral pallidotomy (PVP). His involuntary movements became much less enough for the patient to eat with a spoon in a sitting position by himself. Six months after the first operation, although involuntary movement on the right hand remained reduced, choreoballistic movement appeared on the left side. He received PVP on the right side. The choreoballistic movement was remarkably improved after the right PVP. No neurological aggravation has been found for 7 months after the second PVP. Bilateral PVP was fully effective as for the improvement of the activity of daily life. The output from the internal globus pallidus (GPi) is well-known to be inhibitory. Therefore, it is understandable that the coagulation of GPi results in improvement of hypokinesia and rigidity in patients with Parkinson's disease. However, some clinical reports, including ours, have described the significant reduction of hyperkinetic choreoballistic movement after PVP. The exact mechanism of these surgical effects has not been elucidated yet, and further clinical and basic studies are needed to answer this question. Department of Neurology, Tokyo Metropolitan Neurological Hospital. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=9490899
Aizawa H, Kwak S, Shimizu T, Goto J, Nakano I, Mannen T and Shibasaki H (1991). A case of adult onset pure pallidal degeneration. I. Clinical manifestations and neuropathological observations. J Neurol Sci 102: 76-82. We present a case of adult onset progressive neurodegenerative disease with a selective involvement in the globus pallidus (GP). The main symptom was extreme slowness in motion without rigidity, which was distinct from akinesia of parkinsonism. Dystonic posture developed in neck and fingers and mild rigidospasticity appeared in a later stage. Neuropathological examination shows a selective neuronal loss with gliosis in GP and degeneration of the efferent fibers. Although the subthalamic nucleus is slightly atrophic with minimal gliosis, there is no neuronal loss in the nucleus. The rest of the structures are pathologically insignificant. Because the pathological change is confined to GP neurons and their efferent fibers, we think that the marked slowness in motion and dystonic posture are ascribable to the selective GP lesion. A degenerative neurological disorder preferentially involved in GP was reported as pure pallidal degeneration (PPD). The onset of the PPD was in the first or second decades and the main symptoms were choreoathetosis, torsion dystonia and progressive rigidity. These distinct clinical features seemed to distinguish the present case from the previously described PPD. Therefore, we would like to call our case "adult onset" PPD. Clinicopathological correlation is discussed. National Institute of Neuroscience, National Center of Neurology and Psychiatry, Tokyo, Japan. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=1856734
Do TT (2006). Congenital muscular torticollis: current concepts and review of treatment. Curr Opin Pediatr 18: 26-9. PURPOSE OF REVIEW: The purpose of this review is to better understand the spectrum of disease in torticollis, which is the third most common pediatric orthopaedic diagnosis in childhood. Besides the benign muscular tightness of the sternocleidomastoid muscle leading to the classic head position, the differential diagnosis of the wry neck include sequelae to inflammatory, ocular, neurologic or orthopedic diseases. Patients present with a stiff and tilted neck, and therefore require a thorough and systematic work-up, including a complete physical and neurologic examination and cervical spine radiographs. RECENT FINDINGS: Recent findings show that magnetic resonance imaging of the brain and neck is no longer considered cost-effective, or necessary, in congenital muscular torticollis. Observation and physical therapy, with or without bracing, is usually an effective treatment in most cases, especially if instituted within the first year of life. Botox has recently been shown to be an effective intermediate method of treatment for more resistant cases of congenital muscular torticollis. In those presenting after the age of 1 year, there is an increased rate of sternocleidomastoid muscle lengthening. The lengthening may improve the range of motion, but not necessarily the plagiocephaly, facial asymmetry, or cranial molding. SUMMARY: It is important to differentiate muscular from nonmuscular torticollis. Congenital muscular torticollis is benign; missing a case of nonmuscular torticollis could be potentially life threatening. Division of Orthopaedic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio 45229, USA. twee.do@cchmc.org http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=16470158
Comella CL, Jankovic J, Shannon KM, Tsui J, Swenson M, Leurgans S and Fan W (2005). Comparison of botulinum toxin serotypes A and B for the treatment of cervical dystonia. Neurology 65: 1423-9. OBJECTIVE: To directly compare two serotypes of botulinum toxin (BoNTA and BoNTB) in cervical dystonia (CD) using a randomized, double-blind, parallel-arm study design. METHODS: Subjects with CD who had a previous response from BoNTA were randomly assigned to BoNTA or BoNTB and evaluated in a blinded fashion at baseline, 4 weeks, 8 weeks, and 2-week intervals thereafter until loss of 80% of clinical effect or completion of 20 weeks of observation. CD severity was measured with the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS), and adverse events were assessed by structured interview. Statistical analysis included Wilcoxon rank sum test, log rank tests, and Kaplan-Meier survival curves for duration of effect. RESULTS: A total of 139 subjects (BoNTA, n = 74; BoNTB, n = 65) were randomized at 19 study sites. Improvement in TWSTRS score was found at 4 weeks after injection and did not differ between serotypes. Dysphagia and dry mouth were more frequent with BoNTB (dysphagia: BoNTA 19% vs BoNTB 48%, p = 0.0005; dry mouth (BoNTA 41% vs BoNTB 80%, p < 0.0001). In clinical responders, BoNT A had a modestly longer duration of benefit (BoNTA 14 weeks, BoNTB 12.1 weeks, p = 0.033). CONCLUSION: Both serotypes of botulinum toxin (BoNTA and BoNTB) had equivalent benefit in subjects with cervical dystonia at 4 weeks. BoNTA had fewer adverse events and a marginally longer duration of effect in subjects showing a clinical response. Rush University Medical Center, Chicago, IL 60612, USA. ccomella@rush.edu http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=16275831
Comella CL, Jankovic J, Shannon KM, Tsui J, Swenson M, Leurgans S and Fan W (2005). Comparison of botulinum toxin serotypes A and B for the treatment of cervical dystonia. Neurology 65: 1423-9. OBJECTIVE: To directly compare two serotypes of botulinum toxin (BoNTA and BoNTB) in cervical dystonia (CD) using a randomized, double-blind, parallel-arm study design. METHODS: Subjects with CD who had a previous response from BoNTA were randomly assigned to BoNTA or BoNTB and evaluated in a blinded fashion at baseline, 4 weeks, 8 weeks, and 2-week intervals thereafter until loss of 80% of clinical effect or completion of 20 weeks of observation. CD severity was measured with the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS), and adverse events were assessed by structured interview. Statistical analysis included Wilcoxon rank sum test, log rank tests, and Kaplan-Meier survival curves for duration of effect. RESULTS: A total of 139 subjects (BoNTA, n = 74; BoNTB, n = 65) were randomized at 19 study sites. Improvement in TWSTRS score was found at 4 weeks after injection and did not differ between serotypes. Dysphagia and dry mouth were more frequent with BoNTB (dysphagia: BoNTA 19% vs BoNTB 48%, p = 0.0005; dry mouth (BoNTA 41% vs BoNTB 80%, p < 0.0001). In clinical responders, BoNT A had a modestly longer duration of benefit (BoNTA 14 weeks, BoNTB 12.1 weeks, p = 0.033). CONCLUSION: Both serotypes of botulinum toxin (BoNTA and BoNTB) had equivalent benefit in subjects with cervical dystonia at 4 weeks. BoNTA had fewer adverse events and a marginally longer duration of effect in subjects showing a clinical response. Rush University Medical Center, Chicago, IL 60612, USA. ccomella@rush.edu http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=16275831
Oleszek JL, Chang N, Apkon SD and Wilson PE (2005). Botulinum toxin type a in the treatment of children with congenital muscular torticollis. Am J Phys Med Rehabil 84: 813-6. This is a retrospective case series describing the use of botulinum toxin type A in the treatment of children with congenital muscular torticollis who fail to progress with conservative management. A total of 27 children with congenital muscular torticollis, 6-18 mos of age, received 30 botulinum toxin type A injections into their sternocleidomastoid or upper trapezius muscle, or both, at a pediatric tertiary care center between 1995 and 2001. Three children received repeat injections. Twenty of 27 children (74%) had improved cervical rotation or head tilt after the injections, and 2 of 27 (7%) experienced transient adverse events, specifically, mild dysphagia and neck weakness. This series suggests that botulinum toxin type A may be a safe and effective treatment option for children with congenital muscular torticollis who are unresponsive to a traditional regimen of physical therapy and a home program. A prospective, randomized controlled trial is necessary to definitively assess the role of botulinum toxin type A in this population. Department of Physical Medicine and Rehabilitation, Children's Hospital, Denver, Colorado 80218, USA. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=16205437
Slawek J, Madalinski MH, Maciag-Tymecka I and Duzynski W (2005). [Frequency of side effects after botulinum toxin A injections in neurology, rehabilitation and gastroenterology]. Pol Merkur Lekarski 18: 298-302. Botulinum toxin type A is one of the most potent biological toxins, recently used clinically (Botox, Dysport) for wide range of indications. THE AIM OF THE STUDY was to assess the frequency and severity of side effects during BTX-A therapy for different indications and underlying possible mechanisms. MATERIAL AND METHODS: Material consisted of 327 patients (F202, M125) who underwent 1043 sessions of BTX-A injections for: cervical dystonia--CD (n=58), blepharospasm--BLP (n=31), hemifacial spasm--HFS (n=39), spasticity due to cerebral palsy--CP (n=96), chronic anal fissure--CAF (n=96), esophageal achalasia--AE (n=7). RESULTS: In CD the following side effects were observed: dysphagia (27% of patients and 7% of sessions), weakness of neck muscles (6.7% and 1.3%), pain during swallowing (5.1% and 1%), flu-like syndrome (3.4%, 0.7%). Dysphagia appeared 8.2 days after injection and lasted 14.9 days on average. In BLP authors noticed: unilateral ptosis (22%, 6.3%), bilateral ptosis (3%, 1.9%), haematoma (3%, 0.6%) and in HFS: excessive weakness resulting in asymmetry of face--mild (28.2% and 20%) and moderate (46% and 26.7%). In spasticity due to CP authors noticed: excessive weakness of lower limbs which lasted 13.8 days on average (6.2% and 1.9%), pain (5.2% and 1.6%), flu-like syndrome (4.1% and 1.3%). In CAF: mild incontinence of the flatus and faeces (9% and 5% of sessions), haematoma (5%), flu-like syndrome (3%), inflammation of external anal varices (2%), epididymitis (1%). In AE: chest pain in 6 (at the day of injection and lasted 2-4 days) and reflux in 2 patients (4-8 weeks after injection, lasted 2-3 weeks) were observed. CONCLUSION: Therapy with BTX-A is a very safe procedure, especially when compared with high rate of effectiveness of injections. The side effects are transient, mostly local and completely reversible. Klinika Neurochirurgii, Oddzial Neurochirurgii Czynnosciowej i Chorob Ukladu Pozapiramidowego Akademii Medycznej w Gdansku. jaroslawek@amg.gda.pl http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=15997637
Skogseid IM and Kerty E (2005). The course of cervical dystonia and patient satisfaction with long-term botulinum toxin A treatment. Eur J Neurol 12: 163-70. In 78 patients with idiopathic cervical dystonia (CD), we studied the course of the disease and the patients' satisfaction with long-term botulinum toxin A (BTX) treatment (median 5.5 years, range 1.5-10). On a seven-point scale ranging from excellent to worsening, the effect of treatment was scored as excellent or good by 52% of patients and moderate by 33%. The independent scores of the treating neurologists were excellent or good in 65% and moderate in 27%, respectively, and correlated well with the patients' scores. The 'Global Burden of Disease', as expressed on Visual Analog Scales (VAS, 0-10) before and at evaluation of treatment, was reduced by a median of 4 in individual patients. By combining these outcome measures, 67% of the patients were characterized as having a good effect, and 33% an unsatisfactory effect. This outcome (good or unsatisfactory effect) was independent of the severity of head deviation or complexity pattern of CD prior to treatment, the delay from onset to start of BTX treatment, or the number of treatments. The complexity pattern remained stable during treatment in 64% of the patients, became less complex in 19%, whereas 17% of the patients developed more complex patterns. Department of Neurology, Rikshospitalek University Hospital, University of Oslo, Oslo, Norway. i.m.skogseid@klinmed.uio.no http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=15693803
Costa J, Borges A, Espirito-Santo C, Ferreira J, Coelho M, Moore P and Sampaio C (2005). Botulinum toxin type A versus botulinum toxin type B for cervical dystonia. Cochrane Database Syst Rev CD004314. BACKGROUND: Cervical dystonia is the most common form of focal dystonia. It is characterized by involuntary posturing of the head and frequently is associated with neck pain. Disability and social withdrawal are common. Most cases are idiopathic, and generally it is a life-long disorder. In recent years, botulinum toxin type A (BtA) has become first line therapy for cervical dystonia. However, not all patients respond well to BtA, and 5 to 10% become resistant to it. Botulinum toxin B (BtB) is an alternative to BtA and offers the potential to help patients who do not respond to BtA. At present there is no compelling theoretical reason why it should not be as effective as, or even more effective than, BtA. OBJECTIVES: To compare the clinical efficacy and safety of BtA versus BtB in cervical dystonia. SEARCH STRATEGY: Studies for inclusion in the review were identified using the Cochrane Movement Disorders Group trials register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, by handsearching the Movement Disorders Journal and abstracts of international congresses on movement disorders and botulinum toxin, by communication with other researchers in the field, by searching reference lists of papers found using the above search strategies, and by contact with authors and drug manufacturer. SELECTION CRITERIA: Studies were considered eligible for inclusion in the review if they evaluated the efficacy of BtA versus BtB for the treatment of cervical dystonia. Trials must have been randomised and placebo-controlled. DATA COLLECTION AND ANALYSIS: A paper pro-forma was used to collect data from the included studies using double extraction by two independent reviewers. Each trial was assessed for internal validity by each of the two reviewers. Differences were settled by discussion. The outcome measures used included improvement in symptomatic rating scales, subjective evaluation by patients and clinicians, changes in pain scores, changes in quality of life assessments, and frequency and severity of adverse events. MAIN RESULTS: We cannot give any results since we have only identified two ongoing trials and there are no preliminary results or interim analyses available for them. The full results of these trials are expected in late 2004 or 2005. AUTHORS' CONCLUSIONS: It is currently not possible to make definitive comparisons between BtA and BtB for the treatment of cervical dystonia; uncontrolled comparisons should be regarded with suspicion. Instituto de Farmacologia e Terapeutica Geral, Faculdade de Medicina Lisboa, Av. Prof. Egas Moniz, Lisboa, Portugal, 1649-028. movementdisord@mail.telepac.pt http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=15674940
Costa J, Espirito-Santo C, Borges A, Ferreira JJ, Coelho M and Sampaio C (2005). Botulinum toxin type A versus anticholinergics for cervical dystonia. Cochrane Database Syst Rev CD004312. BACKGROUND: Cervical dystonia is the most common form of focal dystonia. It is characterized by involuntary posturing of the head and frequently is associated with neck pain. Disability and social withdrawal are common. Most cases are idiopathic and generally cervical dystonia is a life-long disorder. Botulinum toxin Type A (BtA) is now the first line therapy. Before BtA, anticholinergics were the most widely accepted treatment, so it is important to understand how these two treatments compare. OBJECTIVES: To compare the clinical efficacy and safety of BtA versus anticholinergic drugs in the treatment of cervical dystonia. SEARCH STRATEGY: We searched the Cochrane Movement Disorders Group trials register (June 2003), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 2, 2003), MEDLINE 1977 to June 2003), EMBASE (1977 to June 2003) and reference lists of articles. We also contacted manufacturers and researchers in the field. SELECTION CRITERIA: Randomised studies comparing BtA versus any anticholinergic drug for the treatment of cervical dystonia. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed trial quality and extracted data. Study authors were contacted for additional information. Adverse effects information was collected from the trials. MAIN RESULTS: We found only one trial suitable for inclusion and accordingly no meta-analysis was performed. It compared BtA versus trihexyphenidyl in 66 patients with cervical dystonia. Although this was a relatively small trial with short duration, the results can probably be generalized for the population, since the trial appears to be unbiased and produced clear clinically significant results. The results favoured BtA, and the difference was similar in size to that obtained in a systematic review comparing BtA with placebo. BtA was better tolerated. AUTHORS' CONCLUSIONS: The available evidence suggests that BtA injections provide more objective and subjective benefit than trihexyphenidyl to patients with cervical dystonia. We could not draw any conclusions about other anticholinergic drugs. Future trials should explore the role of anticholinergic drugs in patients that do not get benefit with BtA. Instituto de Farmacologia e Terapeutica Geral, Faculdade de Medicina Lisboa, Av. Prof. Egas Moniz, Lisboa, Portugal, 1649-028. movementdisord@mail.telepac.pt http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=15674939
Hakkinen A, Ylinen J, Rinta-Keturi M, Talvitie U, Kautiainen H and Rissanen A (2004). Decreased neck muscle strength is highly associated with pain in cervical dystonia patients treated with botulinum toxin injections. Arch Phys Med Rehabil 85: 1684-8. OBJECTIVES: To compare the isometric neck muscle strength of cervical dystonia patients treated with botulinum toxin injections with that of healthy control subjects and to evaluate the association between neck strength, neck pain, and disability in these patients. DESIGN: Clinical cross-sectional study. SETTING: Outpatient rehabilitation and neurology clinics in a Finnish hospital. PARTICIPANTS: Twenty-three patients with cervical dystonia with botulinum toxin-treated neck muscles and 23 healthy control subjects. INTERVENTIONS: Not applicable.Main outcome measures Isometric neck strength was measured by a special neck strength measurement system. Disability was measured by the Neck Disability Index, and pain and symptoms of cervical dystonia by a visual analog scale. RESULTS: Isometric neck strength in all directions measured was significantly lower (25%-44%) in the cervical dystonia patients than in the healthy controls. Neck pain levels reported during the strength tests (r range, -.36 to -.70) and neck pain experienced during the preceding week (r range, -.52 to -.63) were inversely associated with isometric strength results. The difference between sides in rotation strength was 35% in the patient group (P<.001), whereas no significant difference between sides was found in the healthy controls. Fifty-one percent of the patients reported moderate or severe disability. Pain, stiffness, and incorrect position of the head were the most prominent symptoms. CONCLUSIONS: Cervical dystonia patients with botulinum toxin-treated neck muscles showed significantly lower maximal neck strength than healthy controls. The patients also had a statistically significant difference between sides in neck rotation strength. Thus, strength measures may be useful to detect disturbance in the function of the neck muscles. Department of Physical Medicine, Central Hospital, Jyvaskyla, Finland. arja.hakkinen@ksshp.fi http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=15468031
Frei KP, Pathak M, Jenkins S and Truong DD (2004). Natural history of posttraumatic cervical dystonia. Mov Disord 19: 1492-8. We studied a case series of 9 patients with posttraumatic cervical dystonia, in whom involuntary muscle spasms and abnormal head postures occurred within 7 days after cervical injury. Patients were examined, treated with botulinum toxin as necessary, and were followed up to 5 years. Based on our observations of these cases, we propose that complex regional pain syndrome (CRPS) could represent a variant of posttraumatic cervical dystonia that may develop over time after the initiation of dystonia. The Parkinson's and Movement Disorder Institute, Fountain Valley, California 92708, USA. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=15390063
Zesiewicz TA, Stamey W, Sullivan KL and Hauser RA (2004). Botulinum toxin A for the treatment of cervical dystonia. Expert Opin Pharmacother 5: 2017-24. Idiopathic cervical dystonia (ICD) is the most common adult-onset focal dystonia. It is characterised by relatively sustained, involuntary contractions of neck muscles. Injections of botulinum toxin (BTX)-A are safe and effective for the treatment of ICD, and have substantially improved its treatment. BTX-A is manufactured by Allergan Pharmaceuticals in the US and Ireland, and is distributed as Botox. In Europe, BTX-A is manufactured and distributed by Ipsen Pharmaceuticals as Dysport. Success rates for BTX-A injections for ICD ranges 64-90%, with 76-93% of injected patients experiencing pain reduction. Side effects are generally mild and include dysphagia and neck weakness. University of South Florida, Parkinson's disease and Movement Disorders Center, 4 Columbia Drive, Suite 410, Tampa, Florida 33606, USA. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=15330738
Slawek J and Reclawowicz D (2004). [The central action of botulinum toxin type A assessed by brain auditory and somatosensory evoked potentials]. Neurol Neurochir Pol 38: 93-9. BACKGROUND AND PURPOSE: Botulinum toxin type A (BTX-A) acts as a neuromuscular blocker in the release of acetylcholine. Nevertheless, some clinical effects and side effects are difficult to explain only due to the peripheral mode of action. The aim of the study was to assess the central effects of BTX-A by measuring the two modalities of evoked potentials (somatosensory and brain-stem auditory). MATERIAL AND METHODS: In 23 patients (13 females, 10 males, mean age of 46, range of 25-71) with idiopathic cervical dystonia (never treated with BTX-A) brainstem auditory evoked responses (BAER) and somatosensory evoked potentials from upper extremities (SEP) were performed before and 4-6 weeks after BTX-A administration. BTX-A (Botox in 14 patients, Dysport in 9 patients) was injected into neck muscles: sternocleidomastoideus, splenius capitis, trapezius and levator scapulae. RESULTS: The authors did not find any statistically significant differences in basic parameters (latency and interlatency of I, III, V in BAER and N9, N13, N20 and P25 responses in SEP) before and after BTX-A administration. CONCLUSIONS: It seems that BTX-A does not have any direct central effect or the methods are not sensitive enough to detect them. Remote (anatomically distant) clinical effects seen by other authors or side effects may be explained by indirect mechanism due to deafferentation of stimuli from muscle spindles after BTX-A injection and thus modifying the central loops of reflexes or due to unpredictable hematogenous spread of BTX-A to distant muscles. Oddzial Neurochirurgii Czynnosciowej i Chorob Ukladu Pozapiramidowego, Klinika Neurochirurgii, Akademia Medyczna w Gdansku. jaroslawek@amg.gda.pl http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=15307601
Braun V and Richter HP (2002). Selective peripheral denervation for spasmodic torticollis: 13-year experience with 155 patients. J Neurosurg 97: 207-12. OBJECT: Botulinum toxin injections are the best therapeutic option in patients with spasmodic torticollis. Although a small number of patients do not benefit from such therapy, the majority respond well but may develop antibodies to the toxin after repeated applications. In those termed primary nonresponders, no improvement related to botulinum toxin has been shown. In patients in whom no response was shown and those in whom resistance to the therapy developed, selective peripheral denervation is a neurosurgical option. METHODS: Between June 1988 and August 2001, 155 patients underwent selective peripheral denervation. Surgery was performed at a mean of 8.5 years after the onset of symptoms (range 0.5-37 years). The mean age of the patients at the onset of dystonia was 39.7 years (range 17-77 years). For evaluation of results, patients' responses were assessed. Results were obtained in 140 patients in whom the follow-up period ranged from 3 to 124 months (mean 32.8 months): 18 reported complete relief of their symptoms, 50 significant relief, and 34 moderate relief; 19 noted only minor relief and the remaining 19 no improvement. The results differ substantially when compared with those previously demonstrated in patients who received botulinum toxin injections. Although 80% of the secondary nonresponders were satisfied with the result of surgery, only 62% of the primary nonresponders considered the operation helpful. There were no major side effects. The recurrence rate was 11%. CONCLUSIONS: The injection of botulinum toxin should be the first-choice treatment. If surgery is required, selective peripheral denervation provides the best results and has the fewest side effects compared with all surgical options. Department of Neurosurgery, University of Ulm, Gunzburg, Germany. veit.braun@medizin.uni-ulm.de http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=12296680
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