Pharmacological and surgical options for the treatment of cervical dystonia

Cervical dystonia (CD) is a condition in which patients experience involunt ary and abnormal head movements, such as tilting, twisting, or extension, o ften accompanied by pain. Although the exact pathologic mechanisms underlyi ng idiopathic CD have not yet been identified, a number of therapeutic stra tegies have been developed to alleviate the symptoms of this disorder. Oral medications include anticholinergic agents, dopamine receptor antagonists, and GABAmimetic agents. These drugs are employed in a trial-and-error mann er and have a low rate of efficacy. Localized therapy using botulinum toxin injections has revolutionized the treatment of CD, providing a high rate o f response with a low incidence of side effects. However, as with oral medi cations, neurotoxin therapy is palliative, not curative, and repeated injec tions are required. In patients who develop resistance to botulinum toxin t herapy and who do not achieve an adequate response to, or are intolerant of , oral medications, surgical approaches are appropriate. Among the options for peripheral surgery, the greatest experience and most consistent results have been achieved with selective dorsal ramisectomy. Recent developments in stereotactic surgery suggest that, for more complex forms of CD or when more widespread dystonia is present, bilateral pallidotomy or globus pallid us deep brain stimulation may be the treatment of choice.