Introduction: Movement disorder includes a variety of disorders such as cervical dystonia (also known as spasmodic torticollis) athetoid cerebral palsy3, and Tourette’s syndrome.These patients display unique, unusual movements that are repetitive, and may include involuntary cervical motion, which has been well established to cause cervical radiculopathy, myelopathy or both.The findings of this study demonstrated that neurological and orthopedic complications in this unique group of patients can be effectively managed with the use of botulinum toxin injection, although the application of our therapeutic strategy during the pre- and post-operative periods posed a considerable challenge. The literature on movement disorders is discussed herein.

Methods: In this retrospective study, there were 6 patients during the period from 2003 to 2010 who suffered from cervical spondylosis secondary to movement disorder. Each patient received botulinum toxin injection one week before operation. In our protocol, botulinum toxin was injected at both sides of sternocleidomastoid, trapezius, splenius capitis and levator scapulae one week prior to surgery.

Results: All the patients were assessed preoperatively by neurologists.The surgical procedures were anterior cervical discectomies and interbody fusion plus segmental fixation. None of our patients underwent posterior decompression/fusion. The most common levels that needed decompression were C3-4 and C4-5. At the mean follow-up of 56.5 months, all patients showed an improvement in their daily activities, and the average percentage improvement was 41% (according to the modified Rankin Scale scores). Cervical spine X-ray series showed no evidence of implant failure in any of the patients.

Conclusions: Movement disorders cause chronic, repetitive and involuntary neck movements that can initiate degenerative cervical spine disease. The most frequently involved levels are C3-4 and C4-5. Surgical decompression and rigid internal fi xation are strongly recommended. Intramuscular injection of botulinum toxin aids post-operative immobilization of the neck and should be used as an important adjunct in the treatment of this disorder. These patients need to be closely followed because they are at risk of developing adjacent segmental degeneration.

Patient Care: The findings of this study demonstrated that neurological and orthopedic complications in this unique group of patients can be effectively managed with the use of botulinum toxin injection, although the application of our therapeutic strategy during the pre- and post-operative periods posed a considerable challenge.

Learning Objectives: The purpose of this study was to investigate the management of neurological and orthopedic complications in patients with movement disorder induced cervical spondylosis by botulinum toxin injection to provide immobilization of neck.

References: 1. Chawda SJ, M?nchau A, Johnson D, Bhatia K, Quinn NP, Stevens J, Lees AJ, Palmer JD. Pattern of premature degenerative changes of the cervical spine in patients with spasmodic torticollis and the impact on the outcome of selective peripheral denervation. J Neurol Neurosurg Psychiatry. 2000;68:465-471. 2. Polk JL, Maragos VA, Nicholas JJ. Cervical spondylotic myeloradiculopathy in dystonia. Arch Phys Med Rehabil. 1992;73:389-392. 3. Nishihara N, Tanabe G, Nakahara S, Imai T, Murakawa H. Surgical treatment of cervical spondylotic myelopathy complicating athetoid cerebral palsy. J Bone Joint Surg Br. 1984;66:504-508. 4. Krauss JK, Jankovic J. Severe motor tics causing cervical myelopathy in Tourette’s syndrome. Mov Disord. 1996;11:563-566. 5. Ben Shlomo Y, Camfi eld L, Warner T. What are the determinants of quality of life in people with cervical dystonia? J Neurol Neurosurg Psychiatry 2002;5:608- 614. 6. Claypool DW, Duane DD, Ilstrup DM, Melton LJ 3rd. Epidemiology and outcome of cervical dystonia (spasmodic torticollis) in Rochester, Minnesota. Mov Disord 1995;5:608-614. 7. Nutt JG, Muenter MD, Aronson A, Kurland LT, Melton LJ 3rd. Epidemiology of focal and generalized dystonia in Rochester, Minnesota. Mov Disord 1988;3:188-194. 8. The Epidemiological Study of Dystonia in Europe (ESDE) Collaborative Group. A prevalence study of primary dystonia in eight European countries. J Neurol 2000;10:787-92. 9. Wilson JL, Hareendran A, Hendry A. Reliability of the Modifi ed Rankin Scale Across Multiple Raters: Benefits of a Structured Interview. Stroke 2005;36:777- 781. 10. Anderson WW, Wise BL, ltabashi HH, Jones M. Cervical spondylosis in patients with athetosis. Neurology 1962;72:410-412. 11. Angelini L, Broggi G, Nardocci N, Savoiardo M. Subacute cervical myelopathy in a child with cerebral palsy. Secondary to torsion dystonia. Child‘s Brain 1982;9:354-357. 12. Fuji T, Yonenobu K, Fujiwara K, Yamashita K, Ebara S, Ono K, Okada K. Cervical radiculopathy or myelopathy secondary to athetoid cerebral palsy. J Bone Joint Surg Am 1987;69:815-821. 13. Levine RA, Rosenbaum AE, Waltz JM, ScheinbergLC. Cervical spondylosis and dyskinesias. Neurology 1970;20:1194-1199. 14. Reese ME, Msall ME, Owen S, Pictor SP, Paroski MW. Acquired cervical spine impairment in young adults with cerebral palsy. Dev Med Child Neurol 1991;33:153-166. 15. Hagenah JM, Vieregge A, Vieregge P. Radiculopathy and myelopathy in patients with primary cervical dystonia. Eur Neurol 2001;4:236-240. 16. Hirose G, Kadoya S. Cervical spondylotic radiculomyelopathy in patients with athetoid-dystonic cerebral palsy: clinical evaluation and surgical treatment. J Neurol Neurosurg Psychiatry 1984;47:775-780. 17. White AA, Panjabi MM. The basic kinematics of the human spine. A review of past and present knowledge. Spine. 1978;3:16-20. 18. Hanakita J, Suwa H, Nagayasu S, Nishi S, Ohta F, Sakaida H. [Surgical treatment of cervical spondylotic radiculomyelopathy with abnormal involuntary neck movements. Report of three cases]. Neurol Med Chir (Tokyo) 1989;12:1132-1136. 19. Dauer WT, Burke RE, Greene P, Fahn S. Current concepts on the clinical features, etiology and management of idiopathic cervical dystonia. Brain 1998;121:547-560. 20. Greene P, Shale H, Fahn S. Experience with high dosages of anticholinergic and other drugs in the treatment of torsion dystonia. Adv Neurol 1988;50:547- 556. 21. Weiner WJ, Lang AE. Movement disorders: a comprehensive survey. Mount Kisco, NY: Futura; 1989. 22. Jankovic J. Treatment of dystonia. In: Watts RL, Koller WC, editors. Movement disorders: neurologic priniciples and practice. New York: McGraw-Hill; 1997;p.443-454. 23. Adler CH, Zimmerman RS, Lyons MK, Simeone F, Brin MF. Perioperative use of botulinum toxin for movement disorder-induced cervical spine disease. Mov Disord 1996;1:79-81. 24. Racette BA, Lauryssen C, Perlmutter JS. Preoperative treatment with botulinum toxin to facilitate cervical fusion in dystonic cerebral palsy. Report of two cases. J Neurosurg 1998;2:328-330. 25. Traynelis VC, Ryken T, Rodnitzky RL, Menezes AH. Botulinum toxin enhancement of postoperative immobilization in patients with cervical dystonia. Technical note. J Neurosurg 1992;5:808-809. 26. Brefel-Courbon C, Simonetta-Moreau M, More C, Rascol O, Clanet M, Montastruc JL, Lapeyre-MestreM. A pharmacoeconomic evaluation of botulinum toxin in the treatment of spasmodic torticollis. Clin Neuropharmacol 2000;23:203-207. 27. Dodel RC, Kirchner A, Koehne-Volland R, K?nig G, Ceballos-Baumann A, Naumann M, Brashear A, Richter HP, Szucs TD, Oertel WH. Costs of treating dystonias and hemifacial spasm with botulinum toxin A. Pharmacoeconomics 1997;6:695-706. 28. Kao I, Drachman DB, Price DL: Botulinum toxin: mechanisms of presynaptic blockade. Science 1976;193:1256-1258. 29. NIH Consensus Statement: Clinical use of botulinum toxin. Arch Neuro 1991;148:1294-1298. 30. Speelman JD, Brans JW. Cervical dystonia and botulinum treatment: is electromyographic guidance necessary? Mov Disord 1995;10:802. 31. Rosales RL, Arimura K, Takenaga S, Osame M. Extra fusal and intrafusal effects in experimental botulinum toxin A injection. Muscle Nerve 1996;19:488-496. 32. Brashear A, Bergan K, Wojcieszek J, Siemers ER, Ambrosius W. Patients’ perception of stopping or continuing treatment of cervical dystonia with botulinum toxin type A. Mov Disord 2000;15:150-153. 33. Comella CL, Buchman AS, Tanner CM, Brown- Toms NC, Goetz CG. Botulinum toxin injection for spasmodic torticollis: increased magnitude of benefit with electromyographic assistance. Neurology 1992;42:878-882. 34. Greene P, Fahn S, Diamond B. Development of resistance to botulinum toxin type A in patients with torticollis. Mov Disord 1994;9:213-217. 35. Hsiung GY, Das SK, Ranawaya R, Lafontaine AL, Suchowersky O. Long-term efficacy of botulinum toxin A in treatment of various movement disorders over a 10-year period. Mov Disord 2002;17:1288-1293. 36. Münchau A, Palmer JD, Dressler D, O’Sullivan JD, Tsang KL, Jahanshahi M, Quinn NP, Lees AJ, Bhatia KP. Prospective study of selective peripheral denervation for botulinum-toxin resistant patients with cervical dystonia. Brain 2001;124:769-783. 37. The Deep-Brain Stimulation for Parkinson’s Disease Study Group: Deep-brain stimulation of the subthalamic nucleus or the pars interna of the globus pallidus in Parkinson’s disease. N Engl J Med 2001;345:956-963. 38. Kiss ZHT, Doig K, Eliasziw M, Suchowersky O. DBS for torticollis: preliminary results from the multicentre Canadian pilot study. Can J Neurol Sci 2004;31 (Suppl 1):S29. 39. Krauss JK, Loher TJ, Pohle T, Weber S, Taub E, Bärlocher CB, Burgunder JM. Pallidal deep brain stimulation in patients with cervical dystonia and severe cervical dyskinesias with cervical myelopathy. J Neurol Neurosurg Psychiatry 2002;72:249-256. 40. Krauss JK, Pohle T, Weber S, Ozdoba C, Burgunder JM. Bilateral stimulation of globus pallidus internus for treatment of cervical dystonia. Lancet 1999;354:837-838. 41. Parkin S, Aziz T, Gregory R, Bain P. Bilateral internal globus pallidus stimulation for the treatment of spasmodic torticollis. Mov Disord 2001;16:489-493.