Botulinum Toxin for Axial Postural Abnormalities in Parkinson's Disease: A Systematic Review.

Axial postural abnormalities (APAs), characterized by their frequency, disabling nature, and resistance to pharmacological treatments, significantly impact Parkinson's disease and atypical Parkinsonism patients. Despite advancements in diagnosing, assessing, and understanding their pathophysiology, managing these complications remains a significant challenge. Often underestimated by healthcare professionals, these disturbances can exacerbate disability. This systematic review assesses botulinum toxin treatments' effectiveness, alone and with rehabilitation, in addressing APAs in Parkinson's disease, utilizing MEDLINE (PubMed), Web of Science, and SCOPUS databases for source material. Of the 1087 records retrieved, 16 met the selection criteria. Most research has focused on botulinum toxin (BoNT) as the primary treatment for camptocormia and Pisa syndrome, utilizing mostly observational methods. Despite dose and injection site variations, a common strategy was using electromyography-guided injections, occasionally enhanced with ultrasound. Patients with Pisa syndrome notably saw consistent improvements in APAs and pain. However, studies on the combined effects of botulinum toxin and rehabilitation are limited, and antecollis is significantly under-researched. These findings recommend precise BoNT injections into hyperactive muscles in well-selected patients by skilled clinicians, avoiding compensatory muscles, and underscore the necessity of early rehabilitation. Rehabilitation is crucial in a multidisciplinary approach to managing APAs, highlighting the importance of a multidisciplinary team of experts.

The Effects of Preoperative Steroid Therapy on Perioperative Morbidity and Mortality After Adult Spinal Deformity Surgery.

STUDY DESIGN: Retrospective cohort analysis. OBJECTIVES: To identify the effects of preoperative steroid therapy on 30-day perioperative complications after adult spinal deformity (ASD) surgery. SUMMARY OF BACKGROUND DATA: Chronic steroid therapy has demonstrated therapeutic effects in the treatment of various medical conditions but is also known to be associated with surgical complications. There remains a gap in the literature regarding the impact of chronic steroid therapy in predisposing patients to perioperative complications after elective surgery for ASD. METHODS: We performed a retrospective analysis of data from the 2008-2015 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Patients were divided into two groups based on preoperative steroid therapy. Differences in baseline patient characteristics, comorbidities, and operative variables were assessed. Univariate analysis was performed to compare the incidence of perioperative complications. Multivariate stepwise logistic regression models were then used to adjust for baseline patient and operative variables in order to identify perioperative complications that were associated with preoperative steroid therapy. RESULTS: We identified 7,936 patients who underwent surgery for ASD, of which 418 (5.3%) were on preoperative steroid therapy. Preoperative steroid therapy was an independent risk factor for four perioperative complications, including mortality (odds ratio [OR] 2.42, 95% confidence interval [CI] 1.30, 4.51; p = .005), wound dehiscence (OR 3.12, 95% CI 1.45, 6.70; p = .004), deep vein thrombosis (DVT) (OR 2.10, 95% CI 1.24, 3.55; p = .006), and blood transfusion (OR 1.34, 95% CI 1.08, 1.66; p < .007). CONCLUSIONS: Patients on preoperative steroid therapy are at increased risk of 30-day mortality, wound dehiscence, DVT, and blood transfusion after surgery for ASD. An interdisciplinary approach to the perioperative management of steroid regimens is critical. LEVEL OF EVIDENCE: Level III.

The influence of postural deformities on neck function and pain in patients with Parkinson's disease.

BACKGROUND: Trunk alignment is thought to contribute to neck function. However, this common assumption is not clear in patients with Parkinson's disease (PwPD) suffering from different postural deformities such as: Pisa syndrome (PS), Camptocormia & Antecollis (C&A). OBJECTIVES: to investigate the effect of different postural deformities including PS and C&A on neck function and pain in patient (PwPD). METHODS: Forty-five participants belonging to three groups: 15 PD patients without postural disorders (PD), 15 with PS, and 15 with C&A. The function, disability and pain were assessed by Neck Disability Index (NDI), and Brief Pain Inventory (BPI) which used to assess the pain severity (BPI-PS) and Pain Interference (BPI-PI). All groups completed clinical assessments by the Unified Parkinson's Disease Rating Scale (UPDRS), Modified Hoenh & Yahr (mH&Y) staging and the Levodopa Equivalent Daily Dose (LEDD). RESULTS: PD group compared with PS and C&A groups showed differences in NDI, BPI-PS, BPI-PI, LEDD and mH&Y staging (P < 0.001), but no differences found in PD duration, UPDRS-II and III in the same groups. Moreover, no differences were observed between PS and C&A groups in the mentioned scales. DISCUSSION AND CONCLUSION: These results demonstrated that PS and C&A are associated with severe impairment of neck functions, and pain in PwPD.

An Unusual Cause of Camptocormia.

Background: Camptocormia is defined as forward flexion of the spine that manifests during walking and standing and disappears in recumbent position. The various etiologies include idiopathic Parkinson's disease, multiple system atrophy, myopathies, degenerative joint disease, and drugs. Case Report: A 67-year-old diabetic female presented with bradykinesia and camptocormia that started 1 year prior to presentation. Evaluation revealed levosulpiride, a dopamine receptor blocker commonly used for dyspepsia, to be the culprit. Discussion: It is well known that dopamine receptor blockers cause parkinsonism and tardive syndromes. We report a rare and unusual presentation of camptocormia attributed to this commonly used gastrointestinal drug in the Asian population.

Effect of subthalamic deep brain stimulation on posture in Parkinson's disease: A blind computerized analysis.

INTRODUCTION: We sought to assess the effect of subthalamic deep brain stimulation (STN DBS) on Parkinson's disease (PD)-associated postural abnormalities. METHODS: A computerized analysis of posture was used to quantify the thoracolumbar, thoracic, and cervical-occipital ventral angles, as well as the thoracolumbar and cervical-occipital lateral angles from the video-repository of three specialized movement disorder centers (n = 158 patients). Data was extracted from frames from video-recordings in the pre-surgical medication-ON (dopaminergic therapy) and post-surgical stimulation-ON/medication-ON states (STN DBS plus dopaminergic therapy). The sum of the five postural angles (global postural angle) was used to compare pre-vs. post-surgical trunk posture alterations. A multivariate analysis was used to examine the association between changes in the postural angles and demographic or clinical variables. RESULTS: There was a 6.7% amelioration in the global postural angle between the pre- and post-surgical assessments (p = 0.031). Motor response to and pre-surgical dosage of levodopa, male gender, and shorter PD duration were identified as predictors for posture improvement after STN DBS. Cases meeting criteria for lower (n = 2) or upper (n = 1) camptocormia respectively improved by 48.1% in the ventral thoracolumbar angle (from 36.4 ±â€¯0.0° to 18.9 ±â€¯4.2°) and 13.8% in the ventral thoracic angle (from 49.1° to 42.3°). Cases meeting criteria for Pisa syndrome (n = 2) improved by 67.5% in the lateral thoracolumbar angle (from 16.9 ±â€¯2.0° to 5.5 ±â€¯4.7°). CONCLUSIONS: STN DBS has a relatively small but significant effect on PD-associated postural abnormalities, potentially enhancing the effect of dopaminergic medications alone.

Association of Patient-Reported Narcotic Use With Short- and Long-Term Outcomes After Adult Spinal Deformity Surgery: Multicenter Study of 425 Patients With 2-year Follow-up.

STUDY DESIGN: Retrospective analysis of a prospective registry OBJECTIVE.: To investigate associations of preoperative narcotic use with outcomes after adult spinal deformity (ASD) surgery. SUMMARY OF BACKGROUND DATA: We hypothesized that preoperative narcotic use would predict longer hospital stays, greater postoperative narcotic use, and greater disability 2 years after ASD surgery. METHODS: A multicenter database of surgical ASD patients was analyzed retrospectively for patients with self-reported data on preoperative narcotic use. Patients were categorized as using narcotics daily or non-daily (including those who used no narcotics), according to self-report. Outcomes were prolonged length of hospital stay (LOS) (>7 days); length of intensive care unit (ICU) stay; and daily narcotic use and Oswestry Disability Index (ODI) scores 2 years postoperatively. Groups were compared by demographic characteristics, pain, disability, radiographic deformity, and surgical invasiveness. Multivariate logistic and linear regression were used to determine associations between preoperative narcotic use and outcomes. RESULTS: Of 575 patients who met the inclusion criteria, 425 (74%) had complete 2-year follow-up data. Forty-four percent reported daily preoperative narcotic use. Compared with non-daily users, daily narcotic users were older, had more comorbidities, more severe back pain, higher ODI scores, longer operative times, and worse preoperative malalignment and were more likely to undergo 3-column osteotomy (all, P < 0.05). Daily narcotic use independently predicted prolonged LOS (odds ratio [OR] = 1.7, 95% confidence interval [CI] = 1.1-2.9), longer ICU stay (difference = 16 hours, 95% CI = 1.9-30 hours), and daily narcotic use 2 years postoperatively (OR = 6.9, 95% CI = 3.7-13), as well as worse 2-year ODI score (difference = 4.5, 95% CI: 0.7-8.3, P = 0.021). CONCLUSION: Daily narcotic use before ASD surgery was associated with prolonged LOS, longer ICU stays, and increased risk of daily narcotic use and greater disability 2 years postoperatively. LEVEL OF EVIDENCE: 3.

Metformin Inhibits Cyst Formation in a Zebrafish Model of Polycystin-2 Deficiency.

Autosomal dominant polycystic kidney disease (ADPKD) is a common kidney disease caused by mutations in PKD1 or PKD2. Metformin reduces cyst growth in mouse models of PKD1. However, metformin has not been studied in animal models of PKD2, and the cellular mechanism underlying its effectiveness is not entirely clear. This study investigated the effects of metformin on cyst formation in a zebrafish model of polycystin-2 deficiency resulting from morpholino knockdown of pkd2. We added metformin (2.5 to 20 mM) to the embryo media between 4 and 48 hours post fertilisation and observed pronephric cyst formation by using the wt1b promoter-driven GFP signal in Tg(wt1b:GFP) pkd2 morphants. Metformin inhibited pronephric cyst formation by 42-61% compared with the untreated controls. Metformin also reduced the number of proliferating cells in the pronephric ducts, the degree of dorsal body curvature, and the infiltration of leukocytes surrounding the pronephros. Moreover, metformin treatment increased the phosphorylation of adenosine monophosphate-activated protein kinase (AMPK) and enhanced autophagy in the pronephros. Our data suggest that metformin reduces cyst formation through activation of the AMPK pathway and modulation of defective cellular events such as proliferation and autophagy. These results also imply that metformin could have therapeutic potential for ADPKD treatment.

Treatment of Mild Camptocormia with Selegiline in Patients with Parkinson's Disease.

BACKGROUND: Camptocormia in Parkinson's disease (PD) is unresponsive to various therapies and induced difficulties in their day-to-day life. OBJECTIVE: This study, an open trial, was aimed at assessing the efficacy of selegiline in the treatment of mild camptocormia in PD patients. METHODS: Participants were administered 5 mg of selegiline for the first 8 weeks and 7.5 mg for the second 8 weeks. RESULTS: As primary endpoints, the degree of thoracolumbar anteflexion decreased from 23.2° (mean) (11.8° (SD)) at baseline to 18.3° (7.1°) at 16 weeks, and the area of postural sway measured using a Gravicorder increased. However, the differences were not significant. Thoracolumbar anteflexion improved in 60% of the participants. CONCLUSIONS: In this study, 60% of the participants showed an improvement in anteflexion of the thoracolumbar spine with selegiline, but the change in the degree of anteflexion was 5°, which was not statistically significant. Participants with significant improvement in thoracolumbar anteflexion had an increased postural sway. This change was induced by a decrease in truncal muscle tonus or change in the center of gravity. This study combined the study of anteflexion and stability, and provides information on the treatment of short-term or mild camptocormia.

Treatment of camptocormia with botulinum toxin.

Camptocormia is defined as an involuntary axial postural distortion of >45° flexion which occurs in the upright position, increases whilst walking and resolves when supine (Ashour and Jankovic, 2006). Unlike orthopaedic or age related kyphosis it is not a fixed structural deformity and produces kyphosis at predominantly lumbar and thoracic rather than cervical regions. Camptocormia has been reported due to a wide range of neurologic, psychiatric, muscular and orthopaedic conditions as well as rare reports of its emergence following the initiation of a number of medications (Finsterer and Strobl, 2010). Parkinson's disease (PD) includes prominent motor features of bradykinesia, rigidity and reduced postural balance responses in all those affected with this disease, but can also cause a range of other motor and non-motor features. Camptocormia is reported in a minority of patients with PD, and it is usually associated with longer disease duration and greater disease burden (Tiple et al., 2009). The aetiology of camptocormia in PD is debated, and responses to treatment have been generally poor and variable between studies. Recent studies have suggested the use of botulinum toxin may improve posture in some affected individuals.

Treatment of camptocormia with continuous subcutaneous infusions of apomorphine: 1-year prospective pilot study.

Camptocormia is defined as a marked dystonic flexion of the trunk in the sagittal plane. Camptocormia responds poorly to botulinum toxin injections, manipulation with dopaminergic treatment, and deep brain stimulation. We designed a prospective pilot study to assess the effect of apomorphine infusions on camptocormia. Five patients were enrolled. All five patients responded well to this treatment. The fact that camptocormia responds so well to apomorphine may be explained by the sustained stimulation of the ventrolateral striatal D1 receptors, alleviating this type of dystonia.

Unusual case of levodopa-responsive camptocormia in a patient with negative dopamine transporter scan and normal DYT 5 gene.

OBJECTIVE: To describe an unusual case of camptocormia responding to levodopa. METHODS: We present a case of camptocormia with a sustained excellent response to levodopa in a patient with negative dopamine transporter and no DYT 5 genetic mutations. RESULTS: We present a 52-year-old man with 2 years' history of progressive camptocormia, with nearly normal posture while standing and forward trunk flexion close to 90 degrees after walking for less than a minute. His posture completely resolved in the supine position. There were no pyramidal or extrapyramidal signs or dystonia in other locations. Family history was noncontributory except 1 paternal aunt with Parkinson disease. There was no history of antidopaminergic exposure. Workup, including brain, cervical, thoracic, and lumbar spine magnetic resonance imaging and paraspinal muscle electromyography, was unremarkable. Serum ceruloplasmin level was normal. Genetic testing for dopa-responsive dystonia, including GTP cyclohydrolase 1 (GCH 1) and tyrosine hydroxylase (TH) gene mutations (sequencing and deletion), was negative. DYT 6 (THAP1) gene mutation was not found, and dopamine transporter scan imaging obtained 4 years after onset of symptoms was normal. The patient has had an excellent response to levodopa sustained for the past 2 years. CONCLUSIONS: Levodopa should be considered in camptocormia even when not associated with neurodegenerative parkinsonism or DYT 5 gene mutation.

[Camptocormia in patients with Parkinson's disease].

Parkinson's disease (PD) is the most frequent among a broad spectrum of neurologic etiologies of саmptocormia. Camptocormia (CC) is characterized by an abnormal posture with involuntary forward flexion of the trunk, which appears in erect position, increases during prolonged standing or walking, and abates in supine position. CC leads to malposition, increasing postural instability and risk of falling. Treatment of CC in PD includes adjustment of antiparkinsonian medication, injections of botulinum toxin and orthopedical interventions. In this study, CC occurred in sitting position in 62.9% patients and in vertical position in 30% patients, however it disappeared in all patients in a dorsal position. CC was observed throughout the day in 77.1% patients. In 78.6% of PD patients with CC, the pose changed and encouraged with the various factors including weariness and stress; 37.1% patients used a walking stick; 5.7% used a walking aid. CC was accompanied with the painful syndrome in the majority of patients (88.6%). Moreover, 66% of patients had a history of vertebrogenic disorders. The association between CC and the start of dopaminergic treatment was found in 25.7% of patients.

Long-term effect of repeated lidocaine injections into the external oblique for upper camptocormia in Parkinson's disease.

BACKGROUND: Parkinson's disease (PD) is occasionally complicated by camptocormia. In a previous study, we classified camptocormia into upper and lower types based on the inflection point, and reported that lidocaine injection into the external oblique muscle, but not into the internal oblique or rectus abdomen, improved upper camptocormia in PD. The effect of a single lidocaine injection disappeared over a period of few days. In this study, we used repeated lidocaine injections into the external oblique for 4-5 days and evaluated the effects of such treatment for up to 90 days. METHODS: The study subjects were 12 patients with PD and upper camptocormia who were treated with repeated lidocaine injections into the bilateral external oblique followed by rehabilitation. The effect of treatment was evaluated by measuring the angle of truncal flexion before and after the injection. Patients who showed improvement with repeated injections were evaluated during a 90-day period. RESULTS: Eight out of 12 patients showed significant improvement in posture after a single lidocaine injection. However, the effect subsided several days after treatment. Repeated injections produced long-term improvement in 9 out of 12 patients, which was maintained during the 90-day observation period in eight of these patients. CONCLUSIONS: Our results showed that repeated lidocaine injections into the external oblique improved upper camptocormia, and that the effect was maintained in the majority of patients during the 90-day observation period, indicating that repeated lidocaine injections into the external oblique have therapeutic effect on upper camptocormia in patients with Parkinson's disease.