Tsui Scale Research Articles

Selective peripheral denervation: comparison with pallidal stimulation and literature review

Patients with cervical dystonia who are non-responders to Botulinum toxin qualify for surgery. Selective peripheral denervation (Bertrand's procedure, SPD) and deep brain stimulation of the globus pallidus (GPi-DBS) are available surgical options. Although peripheral denervation has potential advantages over DBS, the latter is nowadays more commonly performed. We describe the long-term outcome of selective peripheral denervation as compared with GPi-DBS, along with the findings of literature review. Twenty patients with selective peripheral denervation and 15 with GPi-DBS were included. Tsui scale, a visual analogue scale, and the global outcome score of the Toronto Western Spasmodic Torticollis Rating Scale were used to define a "combined global surgical outcome". The "combined global surgical outcome" for patients with selective peripheral denervation or pallidal stimulation was respectively "bad" for 65 and 13.3%, "fair-to-good" for 30 and 26.7%, and "marked" improvement for 5 and 60% (p<0.001). Improvement on visual analogue scale (p<0.002), global outcome score (p<0.002), and Tsui score (p<0.000) was larger for the pallidal stimulation group. Seventy-five percent of patients with selective peripheral denervation and 60% of patients with pallidal stimulation reported side effects. Seven patients with selective peripheral denervation successively underwent GPi-DBS, with a further significant improvement in the Tsui score (-48.6±17.4%). GPi-DBS is to be preferred to selective peripheral denervation for the treatment of cervical dystonia because it produces larger benefit, even if it can have more potentially severe complications. GPi-DBS is also a valid alternative in case of failure of SPD.

Botulinum Toxin Type a in Cervical Dystonia

Cervical dystonia is a syndrome characterized by anomalous postures and unintentional repetitive movements of the head and the neck. Aim of this study is to show the effectiveness of the combined treatment botulinum toxin-FKT through the use of a recent methodic of investigation, myoton, and of the classical clinical evaluations, such as Tsui and VAS scales. 15 patients (9 females, 6 males) have been selected. During the initial visit and in the following controls, performed every month, patients have been submitted to physiatric examination, clinical evaluation of the dystonia through the Tsui scale, clinical evaluation of the pain through the VAS scale, myometric evaluation. We obtained a statistical reduction of muscular tone values in passive elongation (t0=16,34&#x00B1;1,23) until 4 month (t4 =16,11&#x00B1;1,23), when we performed a second infiltration. After 4 months from the second infiltration (t8=15,99&#x00B1;1,11) value did not present more some statistical correlation and was necessary to perform a new infiltration. Values of elasticity, stiffness, Tsui and VAS scale followed the same course of the tone. Our study demonstrates that combined treatment botulinum toxin-FKT is effective. It emerges that if to the treatment with botulinum toxin follows a suitable FKT treatment, the effect of the drug lasts 4 months and not 3 months as described by the literature. Our study has underlined that using myometric measurement we can consider least changes in muscular tone, elasticity and stiffness; we have a broader view of the spastic muscle, and we can better plan appropriate rehabilitative care for each patient.

Bilateral deep brain stimulation for cervical dystonia in patients with previous peripheral surgery

There are no data available concerning whether patients with cervical dystonia who have recurrent or new symptoms after peripheral denervation surgery benefit similarly from pallidal deep brain stimulation compared with patients who receive primarily pallidal stimulation. Data on 7 cervical dystonia patients with recurrent or progressive dystonia after peripheral denervation who underwent pallidal stimulation were prospectively collected. Deep brain stimulation was performed in Mannheim/Hannover, Germany, or in Umea, Sweden. To the subgroup from Mannheim/Hannover, a second group of patients without previous peripheral surgery was matched. Assessments included the Toronto Western Spasmodic Torticollis Rating Scale and the Burke-Fahn-Marsden dystonia rating scale, as well as the Tsui scale in the Swedish patients. The 4 patients from Mannheim/Hannover experienced sustained improvement from pallidal stimulation by a mean of 57.5% according to the Toronto Western Spasmodic Torticollis Rating Scale (P < .05) and by a mean of 69.5% according to the Burke-Fahn-Marsden dystonia rating scale (P < .05) at long-term follow-up of 40.5 months. The patients from Umea had a mean Tsui score of 7 prior to surgery and a mean score of 3 at the mean follow-up of 8 months (62.5%). In the matched group the Toronto Western Spasmodic Torticollis Rating Scale improved by 58.8% and the Burke-Fahn-Marsden dystonia rating scale by 67% (P < .05) at long-term follow-up (mean, 41.5 months). Patients who had prior peripheral surgery for cervical dystonia experience improvement from subsequent pallidal stimulation that is comparable to that of de novo patients.

Riluzole therapy in cervical dystonia.

We conducted a 6-week open-label pilot study with blinded video rating of riluzole (50 mg twice a day) in six patients with cervical dystonia (CD) refractory to botulinum toxin A and oral pharmacological treatment. The Tsui rating scale served as primary efficacy measure and improved significantly under riluzole (P = 0.002). In three of six patients, the Tsui score improved by more than 30% with a greater 50% reduction in the head tremor/jerk subscore of the Tsui scale. These data suggest that riluzole may be helpful in a subgroup of patients with disabling CD refractory to other therapies.

Quantification of sensory trick impact on tremor amplitude and frequency in 60 patients with head tremor.

Head tremor with an obvious head deviation is the typical clinical picture of tremulous cervical dystonia (TCD), whereas head tremor without any significant head deviation allows for the differential diagnosis of dystonic head tremor (DHT) as well as essential head tremor (EHT). Clinical and polyelectromyographic (poly-EMG) studies have shown a suppression of dystonic muscle activity in patients with TCD performing a maneuver called geste antagonistique. The effect of these trick maneuvers on head tremor has not been investigated in patients with DHT and EHT. We studied the impact of sensory trick maneuvers on head tremor amplitude and frequency clinically by using the tremor subscore of the Tsui scale and by means of computer-based accelerometry in 60 patients with head tremor as their major disorder. Based on clinical data (modified Tsui scale: rating of spontaneous head deviation [rotation + lateroflexion + ante-/retroflexion]), pharmacologic response of tremor (propranolol, primidone, or alcohol), family history (postural hand tremor in first-degree relatives), and poly-EMG findings (reciprocal inhibition in neck muscles during voluntary head rotation), 34 patients were diagnosed as having TCD, 14 were classified as having DHT, and 12 patients were diagnosed as having EHT. Using a clinical rating scale, head tremor amplitudes showed a significant decrease compared with baseline during the performance of sensory trick maneuvers in patients with TCD and DHT, but not in patients with EHT. This clinically observed effect was accompanied by a significant reduction in the mean peak power of the dominant frequency in patients with TCD (decrease by 83%, p = 0.0001) and DHT (decrease by 90%, p = 0.01), but not in patients with EHT (decrease by 6%, p = 0.6). Head tremor frequencies showed no significant changes in relation to the trick maneuvers. We conclude that a significant reduction of head tremor amplitude during a sensory trick maneuver is a useful quantitative criterion to distinguish TCD and DHT from EHT.

Transcranial magnetic stimulation and silent period in spasmodic torticollis.

Our objective was to study the corticobulbar projections to neck muscles in cervical dystonia. We compared both the motor evoked potentials and the electromyographic silent period after transcranial magnetic stimulation from sternocleidomastoid and trapezius muscles in a group of 13 patients with spasmodic torticollis with those of 20 healthy volunteers. With the target muscle at rest, no changes of motor threshold, motor evoked potentials latency, and amplitude were observed in dystonic patients. With facilitation, the mean amplitude of the motor evoked potentials was increased in patients compared with controls, the significant difference being for the trapezius muscle, whereas the latency did not differ between groups. The cortical silent period was significantly shorter in dystonic patients than in healthy subjects in both muscles. The duration of the cortical silent period recorded from the sternocleidomastoid muscle showed a positive correlation with the degree of neurologic disability assessed by Tsui's scale. No abnormalities of both nerve conduction velocity and peripheral silent period by stimulation of accessory nerve were found. These results indicate an impairment of the mechanisms of inhibitory motor control in patients with spasmodic torticollis, which could be the result of a decrease of the basal ganglia inhibitory output over the motor cortex.

What is the optimal dose of botulinum toxin A in the treatment of cervical dystonia? Results of a double blind, placebo controlled, dose ranging study using Dysport®

OBJECTIVESBotulinum toxin injections have become a first line therapeutic approach in cervical dystonia. Nevertheless, published dosing schedules, responder rates, and frequency of adverse events vary widely. The present prospective multicentre...

Botulinum toxin in cervical dystonia: low dosage with electromyographic guidance

Sixty patients with idiopathic cervical dystonia were treated a total of 240 times with botulinum toxin type A (BTA). Selected muscles were injected with BTA under electromyographic (EMG) guidance. The clinical effect was measured on the Tsui scale and a 10-point anchored visual analogue scale. A dosage of 150-300 mouse units was used in 77% of the treatments (mean 204 mouse units). Based on the Tsui scale, 45% of 240 treatments were still effective at the moment of reinjection (median improvement 2 points). Based on the 10-point anchored visual analogue scale, 73% of treatments were successful (median improvement 3 points). Forty-eight patients (80%) responded favourably to the treatment. Side-effects were mild and transient. Dysphagia occurred in 9% of treatments. Antibody production was investigated in 41 patients and was negative in all. A striking difference from previous reports is the lower dosage used in this study. The clinical response, however, was similar to that of other studies. We conclude that a dosage of 200-400 mouse units BTA (Dysport) may also be effective in the treatment of cervical dystonia, but with fewer side effects. EMG guidance and application of BTA into deep cervical muscles may further improve the clinical effect.