Professional Documents
Culture Documents
Dr Marieta Anca-Herschkovitsch
Movement Disorder Clinic
Edith Wolfson Medical Center
Israel
Post-traumatic cervical dystonia :a subject of debate
The development of abnormal posturing of the neck or shoulder after
local injury has been termed posttraumatic cervical dystonia (PTCD).
FIRST DESCRIPTION IN 1888 BY GOWERS
Features to distinguish this disorder as a distinct clinical entity from those
of typical idiopathic cervical dystonia are :
onset and maximum disability occur very quickly after injury(hours
to days), severe pain and a fixed abnormal posture(Lang ,2003),not
influenced by sleep,poor response to BTX (Frei et al ,2004 )
In order to establish a consistent causal relationship between peripheral trauma
and movement disorder, Jankovic (1994) proposed the following criteria :
1. The injury should be severe enough to cause local symptoms persisting or
requiring medical attention for at least two weeks after the trauma;
2. The onset of involuntary movements must have occurred within one year after
the trauma;
3. The abnormal movements should be anatomically related to the site of the
injury. Moreover, the causal relationship should be supported by the absence of
other causes capable of producing the same symptoms, presence of reflex
sympathetic dystrophy and poor response to conventional treatment.
The mechanism by which dystonia may be related to post-
traumatic movement disorders and CRPS is poorly understood .
*-mediated through the sympathetic nervous system- view recently called into
question (Schott, 1995 ; Baron et al., 1999 )
* -Inflammation might be involved in the development of CRPS following injury, at
least in the early stages (Birklein et al., 2001 ).
* -Peripheral mechanisms ( sensitization of peripheral nociceptors, or
ectopic or ephaptic transmission of nerve impulses) are suggested as a
possible mechanism of CRPS and post-traumatic movement disorders (Jankovic,
1994 ; Schott, 1986b , 2001 ).
However, spread to ipsilateral, axial, and contralateral muscles may occur in fixed
dystonia, as in CRPS and post-traumatic dystonia, in these cases, such peripheral
mechanisms are unlikely to explain the development of abnormal movements after
injury.
*-Impairment of interneuronal circuits at the spinal/ brainstem level and central
synaptic reorganization analogous to that following amputation could be a
possible mechanisms leading to such sequelae even after a minor peripheral injury
(van Hilten et al., 2001 ).
Controversy:
*-A retrospective study of the clinical characteristics of the 16 patients with early
post-traumatic CD (CD-PT) in comparison with the 52 patients reporting no
antecedent trauma (CD-NT) was performed( O’Riordan,2004 ).
In this comparison the CD-PT group had a significantly increased
frequency of laterocollis, significantly more reported pain and more reported
depression. Non-significant trends were noted for less responsiveness to
botulinum toxin and less use of gestes antagonistes in the CD-PT group
WHIPLASH ASSOCIATED DISORDER
• The term "whiplash" has been used to describe a mechanism of injury, and the
clinical manifestations as a consequence of the injury.
• In 1995, the Quebec Task Force on Whiplash Associated Disorders (WAD)
defined: "whiplash is an acceleration-deceleration mechanism of energy
transfer to the neck. It may result from rear-end or side-impact motor vehicle
collisions, but can also occur during diving or other mishaps. The impact may
result in bony or soft-tissue injuries (whiplash-injury), which in turn may lead
to a variety of clinical manifestations called Whiplash Associated Disorders
• The incidence of whiplash injury :between 70–200 per 100,000 inhabitants
no consensus about the natural course of the whiplash injuries .
• It was concluded that 14 - 42 %of patients could develop chronic
complaints (over six month duration), and that 10 percent of those patients
had constant severe pain.
• The common symptoms are: neck pain (88–100%), headache (54–
66% ),neck stiffness, shoulder pain, arm pain/numbness, paraesthesia,
weakness, dysphagia, visual and auditory symptoms and dizziness
Mechanics of Whiplash
Hyperextension HyperFlexion