UNASSIGNED: Transcranial Direct Current Stimulation (tDCS) of the cerebellum shows promise for the treatment of dystonia. Specific motor rehabilitation programs have also been developed in this context. However, the combination of these two approaches has not yet been evaluated to determine their therapeutic potential.
UNASSIGNED: We report a series of 5 patients with cervical dystonia (CD) poorly controlled by botulinum toxin injections. They were initially treated by a protocol of repeated daily sessions (for 3 or 5 days) of cerebellar anodal tDCS (cer-atDCS) applied alone. In a second time, additional protocols of cer-atDCS were performed in combination with a program of goal-oriented motor training exercises (Mot-Training), specifically developed for the treatment of CD. The clinical impact of the procedures was assessed on the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS).
UNASSIGNED: Compared to baseline, the maximum percentage of TWSTRS total score improvement was 37% on average after cer-atDCS performed alone (p = 0.147, not significant) and 53% on average after cer-atDCS combined with Mot-Training (p = 0.014, significant). The TWSTRS pain and functional handicap subscores also improved after the combined protocol. A score of (+3) to (+5) was rated on the TWSTRS response scale after cer-atDCS performed alone or the combined protocol, corresponding to a moderate to striking improvement on dystonia and pain. This improvement lasted longer after the combined protocol than after cer-atDCS alone (3.4 vs. 1.4 months on average, p = 0.011).
UNASSIGNED: The combination of cer-atDCS with Mot-Training produced a greater and more prolonged improvement than the application of cer-atDCS alone. Such a combined therapeutic procedure is easy to perform and opens important perspectives in the long-term treatment of CD. These results remain to be confirmed by a randomized sham-controlled trial on a larger sample.

BACKGROUND: Cervical dystonia (CD) is a type of muscle tone disorder that usually occurs in the neck muscles. Due to the intermittent or continuous involuntary contraction of the neck muscles, the head and neck are twisted and skewed and some postural abnormalities occur. Long-term abnormal posture or pain can cause negative emotions in patients, which can affect their quality of life.
METHODS: This case report included a 37-year-old woman who was diagnosed with CD associated with anxiety and depression; the accompanying symptoms were head and neck tilt of approximately 90° to the right and mental abnormality. After two courses of acupuncture treatment, the patient\'s head and neck can be maintained in a normal position, and the negative emotions can be relieved.
CONCLUSIONS: This case indicates that acupuncture can effectively improve CD and the emotional state and quality of life of patients, making it an effective alternative treatment for the condition.

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

Ataxia-telangiectasia-like disorder 1 (ATLD1) is a rare neurodegenerative disorder associated with early onset ataxia and oculomotor apraxia. The genetic determination of ATLD1 is a mutation in the MRE11 gene (meiotic recombination 11 gene), which causes DNA-double strand break repair deficits. Clinical features of patients with ATLD1 resemble those of ataxia telangiectasia (AT), with slower progression and milder presentation. Main symptoms include progressive cerebellar ataxia, oculomotor apraxia, cellular hypersensitivity to ionizing radiations. Facial dyskinesia, dystonia, dysarthria have also been reported. Here we present a 45-year old woman with cervical and facial dystonia, dysarthria and ataxia, who turned out to be the first case of ATLD without oculomotor apraxia, and with dystonia as a main manifestation of the disease. She had presented those non-specific symptoms for years, before whole exome sequencing confirmed the diagnosis.

OBJECTIVE: Non-motor symptoms, such as sleep disturbances, fatigue, neuropsychiatric manifestations, cognitive impairment, and sensory abnormalities, have been widely reported in patients with idiopathic cervical dystonia (ICD). This study aimed to clarify the autonomic nervous system (ANS) involvement in ICD patients, which is still unclear in the literature.
METHODS: We conducted a pilot case-control study to investigate ANS in twenty ICD patients and twenty age-sex-matched controls. The Composite Autonomic System Scale 31 was used for ANS clinical assessment. The laser Doppler flowmetry quantitative spectral analysis, applied to the skin and recorded from indices, was used to measure at rest, after a parasympathetic activation (six deep breathing) and two sympathetic stimuli (isometric handgrip and mental calculation), the power of high-frequency and low-frequency oscillations, and the low-frequency/high-frequency ratio.
RESULTS: ICD patients manifested higher clinical dysautonomic symptoms than controls (p < 0.05). At rest, a lower high-frequency power band was detected among ICD patients than controls, reaching a statistically significant difference in the age group of ≥ 57-year-olds (p < 0.05). In the latter age group, ICD patients showed a lower low-frequency/high-frequency ratio than controls at rest (p < 0.05) and after mental calculation (p < 0.05). Regardless of age, during handgrip, ICD patients showed (i) lower low-frequency/high-frequency ratio (p < 0.05), (ii) similar increase of the low-frequency oscillatory component compared to controls, and (iii) stable high-frequency oscillatory component, which conversely decreased in controls. No differences between the two groups were detected during deep breathing.
CONCLUSIONS: ICD patients showed ANS dysfunction at clinical and neurophysiological levels, reflecting an abnormal parasympathetic-sympathetic interaction likely related to abnormal neck posture and neurotransmitter alterations.

The current case report describes an uncommon insertion of the levator scapulae (LS), which broadly attaches to multiple structures, including the serratus posterior superior, ligamentum nuchae, and the 6th and 7th spinous processes of the cervical vertebrae. The most superior portion of this aponeurosis merged with the ligamentum nuchae at the C7 level. The middle and inferior portions of the head were inserted (or fused) into the tendon of the rhomboid minor as well as the fibers of the serratus posterior superior muscle. Consequently, recognizing this anatomical variation, characterized by an additional slip of the LS attaching to the 7th vertebra and other muscular structures, is crucial not only for anatomists but also for surgeons performing procedures on the posterior neck related to cervical or shoulder pain and cervical dystonia.

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.

UNASSIGNED: Reports on the long-term effects of pallidotomy for cervical dystonia remain scarce.
UNASSIGNED: We report a case of cervical dystonia successfully treated by unilateral pallidotomy. The patient was a 29-year-old man without past medical and family history of cervical dystonia. At the age of 28 years, neck rotation to the right with right shoulder elevation developed and gradually became worse. After symptoms failed to respond to repetitive botulinum toxin injections and oral medications, he underwent left pallidotomy, which resulted in significant improvement of cervical dystonia and shoulder elevation without surgical complications. At the 3-month evaluation, the symptoms completely improved. The Toronto Western Spasmodic Torticollis Rating Scale score dramatically improved from 39 points before surgery to 0 points at 7-year postoperative evaluation.
UNASSIGNED: This case suggests that unilateral pallidotomy can be an alternative treatment option for cervical dystonia.

Introduction Cervical dystonia (CD), a rare disorder, is the most common form of dystonia, a movement disorder. Impairments in activities of daily living and quality of life may result from chronic pain, perceived stigma, difficulty walking, and/or lack of control over movements. Studies of treatments for difficulty walking in CD have been inconclusive. Osteopathic manipulative medicine (OMM) has been used to improve gait biomechanics in other health conditions. Foot progression angle (FPA) while walking indicates functional gait abnormalities that increase the risk of knee injury and osteoarthritis. Objective The aim of this study is to test if five-weekly treatments using an OMM sequence designed for CD improved abnormal gait biomechanics in individuals with CD by identifying and addressing somatic dysfunctions. Methods In this prospective case series, independently ambulating individuals with CD symptom onset before the age of 40 years, not due to traumatic injury, were evaluated utilizing validated scales for severity (Toronto western spasmodic torticollis rating scale [TWSTRsI]) and symptoms affecting quality of life (Cervical Dystonia Impact Profile [CDIP-58]), physical examination, and FPA before and after five-weekly OMM treatments. Lower body joint range of motion and angles were captured in a clinical gait lab by nine cameras collecting three-dimensional Whole-body position data during three trials of one gait cycle at participant-selected walking speed. The FPA waveforms during the gait cycle were quantified by Vicon Nexus and Polygon applications. Pretreatment and posttreatment results were compared to established healthy gait waveforms and tested by repeated measures ANOVA (α=0.05). Results Pretreatment waveforms in CD had a mean 5.13° of excess FPA during gait cycle phases requiring lower-extremity pronation compared to previously published age-gender-matched healthy waveforms. There was 96% improvement in pronation after five treatments, with a mean 0.21° (p=0.041) of excess FPA. Mean TWSTRs and CDIP-58 scores improved. On physical examination, the rotational direction of C2 vertebrae was contralateral to neck muscle hypertonicity. Vertical sphenobasilar synchondrosis strains were present in those with anterotorticollis. Participants had ipsilateral anterolateral neck muscle and anterolateral abdominal wall muscle hypertonicity. All patients had pelvic somatic dysfunctions with left-side superior relative to right-side and restriction from lower-extremity pronation (i.e., supination dysfunctions). Conclusion The FPA was significantly improved after treatment. This OMM sequence was well tolerated and may be useful for improving gait kinematics in individuals with CD. Randomized, controlled, long-term studies are needed to determine effectiveness.

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).
METHODS: 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.
CONCLUSIONS: 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.