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Side effects of morphine are common when it is given in titrated doses to control severe pain in advanced cancer. We describe a case of severe back pain resistant to parenteral morphine accompanied by muscle spasm, in which the addition of diazepam both had an opioid-sparing effect and provided superior symptomatic relief. Diazepam appears to have a specific role as an adjuvant analgesic for pain due to skeletal muscle spasm associated with painful vertebral metastases.

Twelve patients underwent 17 endoscopic injections of botulinum toxin type A in the cricopharyngeus muscle for the treatment of dysphagia and cricopharyngeal spasm over a 3-year period. The patient's charts were reviewed. Preoperative and postoperative symptoms, examination, and swallowing studies were reviewed. Eleven of the 12 patients had improvement in their symptoms, which lasted for a mean of 3.8 months. Two patients elected cricopharyngeal myotomy for permanent correction of their dysphagia. There was 1 case of postoperative neck cellulitis in an immunocompromised patient undergoing simultaneous excision of a thyroglossal duct cyst. We conclude that endoscopic injection of botulinum toxin is a relatively safe and viable technique for the treatment of dysphagia associated with cricopharyngeal spasm. It requires simple tools readily available to otolaryngologists. Larger, prospective controlled studies are necessary to establish its effectiveness and role in the management of this condition.

A maxillary alveolar mucosal inflammation, demonstrated by local tenderness and increased temperature, is present in migraine, tension-type headache and facial pain patients even when the patient is asymptomatic. Research is presented showing effective treatment of these conditions with fewer side effects than with standard medication by local anti-inflammatory methods. These alternative methods include: chilling, application of anti-inflammatory gel and low-level (non-cutting) laser. Local treatment also mediates cervical muscle spasm, adding to its overall effectiveness.

Satoyoshi syndrome is a rare, slowly progressive disorder of unknown etiology with a poor long-term prognosis. The syndrome consists of the following clinical features: (1) painful, intermittent muscle spasms; (2) alopecia; (3) diarrhea; and (4) skeletal abnormalities in cases of juvenile onset. The age of onset is typically less than 20 years of age, although three adult onset cases had been reported. There had been no case report of Satoyoshi syndrome with strict unilateral presentation. We present a 25-year-old man with progressive unilateral hair loss and muscle spasms. Although previous literature had postulated malabsorption and autoimmune mechanism as pathogenic for Satoyoshi syndrome, the presence of a strictly unilateral presentation argues against those hypotheses. However, these hypotheses should still be considered, as our patient did not fit a typical Satoyoshi syndrome. Therefore, more research is needed to understand the pathophysiology and develop an effective treatment to prevent the progression of the disease.

Supracondylar fractures (SF) of the humerus are the third most common type of fractures in childhood. The highest rate of pulselessness fracture of the distal humerus is the extension-type. The aim of our treatment is to minimize potential complications. Our management of pulselessness supracondylar fracture is more aggressive compared with other dpts. 223 (100%) patients with SF were treated at the dpt. of Paediatric Surgery, University Children's Hospital in Bratislava, in the 5-year period of (1995-1999). 11 (4.93%) patients remained pulseless after reposition of bone fragments. These patients underwent surgical revision of the brachial artery. Spasms of the brachial artery (BA) occurred in six patients, a lesion of BA in three patients and thrombosis of BA in two patients. We performed revision of the brachial artery by a Fogarthy catheter in six patients--in four cases with thrombectomy. In two cases we released the vessel from bone fragments. In two patients was replaced the injured segment of the brachial artery by a venous allotransplant. Peroperative angiography was performed in six patients. We reoperated three patients with early postoperative complications. We did not record any case of Volkmann's contracture.

Study Design: Epidemiological review., Objective: To evaluate sleep disturbances in the spinal cord injured., Setting: The Clinic for Para- and Tetraplegia, Hornbaek/Copenhagen, Copenhagen University hospital, Denmark., Methods: All patients admitted with traumatic SCI during the 20-year period 1968-1987 were reviewed. The normal population consisted of 339, 222 men and 117 women. These groups were asked to fill in the self-administered Nordic Sleep Questionnaire (NSQ) containing 21 questions. Questions were added regarding employment, smoking, alcohol, coffee or tea consumption, height and weight. The questionnaire for SCI individuals included questions about bladder emptying method, mobility, and spasms. For the SCI population age at injury, cause of injury, neurological level, and functional class were retrieved., Results: Four hundred and eight SCI individuals, 331 men and 77 women, answered the NSQ corresponding to a response rate of 83.8%. Forty-seven per cent had a cervical cord lesion and about half of the population had a complete motor lesion. In comparison with the normal population the SCI individuals had greater difficulty in falling asleep, described more frequent awakenings, slept subjectively less well, were more often prescribed sleeping pills, slept more hours, took more and longer naps, and snored more and for more years. In particular, spasms, pain, paraesthesia, and troubles with voiding were claimed to be part of the sleep problems., Conclusion: In spite of the same average age and a higher body mass index in the normal than the SCI population, the SCI individuals showed significantly more sleep problems than the normal population.

Background: Accommodative spasm (AS) has been reported to be a rare cause of an acquired unilateral visual loss. We describe a unique case of acquired visual loss due to an apparent unilateral AS triggered by occlusion of the contralateral eye. Clinical examination and photorefraction techniques were performed during the acute phase of the disorder and in the follow-up evaluations., Case Report: An otherwise healthy 27-year-old woman presented with a 2-month decrease of vision in her left eye. Unaided visual acuity in the right eye was 20/20 and in the left eye was finger counting. Orthophoria existed at distance and near. The decrease in vision in the left eye was attributed to an apparent unilateral AS of 5 D, which occurred only when the right eye was occluded. Under the occluder, the right eye also manifested an AS. With the left eye occluded or with binocular viewing, the right eye and left eye accommodated normally. With a 5 D convex lens before the right eye, the visual acuity in the left eye was 20/20. Refractive error with cycloplegia revealed low hyperopia in each eye., Conclusion: AS can be the cause of acquired unilateral visual loss. To our knowledge, this is the first documented report of an apparent unilateral AS triggered by occlusion of the contralateral eye.

Background: Although many patients complain of eye fatigue caused by accommodative spasm, there have been no reports of a good objective examination method to diagnose it., Purpose: The spectral power of the high frequency component of the accommodative microfluctuation (spectral power of HFC) differs according to the constrictive degree of the accommodation. In this paper, we expatiated upon our previously reported analyzing processes of the spectral power of HFC, and we investigated the relationship between normal subjects and subjects with asthenopia., Method: The accommodative microfluctuation were recorded when the subjects were looking at a stable target. The waves of the accommodative microfluctuation were analyzed by FFT., Results: The spectral power of HFC for the distant target was 50-60 in the subjects with normal vision, but it was higher in the subjects with asthenopia., Conclusion: Our results suggested that the ciliary muscle was also actively working in asthenopia caused by accommodative spasm even if the patient was looking at a distant target.

Objectives: To investigate the efficacy of botulinum toxin A in chronic low back pain and associated disabilities., Methods: Thirty-one consecutive patients with chronic low back pain who met the inclusion criteria were studied: 15 received 200 units of botulinum toxin type A, 40 units/site at five lumbar paravertebral levels on the side of maximum discomfort, and 16 received normal saline. Each patient's baseline level of pain and degree of disability was documented using the visual analogue scale (VAS) and the Oswestry Low Back Pain Questionnaire (OLBPQ). The authors reevaluated the patients at 3 and 8 weeks (visual analogue scale) and at 8 weeks (OLBPQ)., Results: At 3 weeks, 11 of 15 patients who received botulinum toxin (73.3%) had >50% pain relief vs four of 16 (25%) in the saline group (p = 0.012). At 8 weeks, nine of 15 (60%) in the botulinum toxin group and two of 16 (12.5%) in the saline group had relief (p = 0.009). Repeat OLBPQ at 8 weeks showed improvement in 10 of 15 (66.7%) in the botulinum toxin group vs three of 16 (18.8%) in the saline group (p = 0.011). No patient experienced side effects., Conclusion: Paravertebral administration of botulinum toxin A in patients with chronic low back pain relieved pain and improved function at 3 and 8 weeks after treatment.

We attempted to prove the occurrence of generalized vasospasms in cases with eclampsia/preeclampsia and HELLP syndrome and to suggest the existence of an angiospastic syndrome of pregnancy. Sixteen cases with severe preeclampsia were evaluated. Among them, three cases were complicated by eclampsia and one case with HELLP syndrome. Cranial magnetic resonance angiography (MRA) was performed in 15 cases, and celiac angiography was performed in one case. Vasospasms were observed in 12 cases (75.0%), including all cases involving eclampsia and HELLP syndrome, and cerebral infarction was observed in one case. Typical vasospasms were found by MRA in the middle and posterior cerebral arteries with peripheral ischemic changes in cases with severe preeclampsia and eclampsia. Vasospasms of the hepatic arteries were observed by celiac angiography in a case with HELLP syndrome. Vasospasms are characteristic for patients with eclampsia/preeclampsia and HELLP syndrome, and the existence of an angiospastic syndrome of pregnancy is proposed.

Background: Sphincter of Oddi dysfunction has been implicated as a cause of various forms of acute pancreatitis. However, there is no direct evidence to show that sphincter of Oddi dysfunction can cause obstruction of trans-sphincteric flow resulting in acute pancreatitis., Aims: To determine if induced sphincter of Oddi spasm can produce trans-sphincteric obstruction and, in combination with stimulated pancreatic secretion, induce acute pancreatitis., Methods: In anaesthetised possums, the pancreatic duct was ligated and pancreatic exocrine secretion stimulated by cholecystokinin octapeptide/secretin to induce acute pancreatitis. In separate animals, carbachol was applied topically to the sphincter of Oddi to cause transient sphincter obstruction. Sphincter of Oddi motility, trans-sphincteric flow, pancreatic duct pressure, pancreatic exocrine secretion, plasma amylase levels, and pancreatic tissue damage (histology score) were studied and compared with variables in ligation models., Results: Acute pancreatitis developed following stimulation of pancreatic exocrine secretion with peptides after pancreatic duct ligation (p<0.05). Neither pancreatic duct ligation nor stimulation of pancreatic exocrine secretion with cholecystokinin octapeptide/secretin alone resulted in acute pancreatitis. Topical carbachol stimulated sphincter of Oddi motility abolished trans-sphincteric flow, and increased pancreatic exocrine secretion (p<0.05) and pancreatic duct pressure to levels comparable with pancreatic duct ligation (p<0.001). Carbachol application (with or without combined peptide stimulation) elevated plasma amylase levels (p<0.01) and produced pancreatic tissue damage (p<0.05). Decompression of pancreatic duct ameliorated these effects (p<0.05)., Conclusion: Induced sphincter of Oddi dysfunction when coupled with stimulated pancreatic secretion causes acute pancreatitis. This may be an important pathophysiological mechanism causing various forms of acute pancreatitis.

Spasmodic dysphonia (SD), a disabling focal dystonia involving the laryngeal musculature, is most commonly treated by the intramuscular injection of botulinum toxin (BTX). Although the treatment is well tolerated and generally produces clinical voice improvement, it has never been statistically shown to alter the patient's perception of voice quality or general health. Declining resources for medical care mandate that treatment outcomes be documented. A prospective analysis of the effects of BTX on the patient's perception of voice and general health was undertaken. The Voice Handicap Index (VHI) and Short Form 36 (SF-36) surveys were administered to patients before treatment and 1 month after. Pretreatment and posttreatment scores were analyzed with a Student's t-test. On the VHI, improvements in the patients' perception of their functional, physical, and emotional voice handicap reached statistical significance (p < or = .0005). On the SF-36, patients had statistically significant improvements in mental health (p < or = .03) and social functioning (p < or = .04). Treatment of SD with BTX significantly lessened the patients' perception of dysphonia. In addition, it improved their social functioning and their perception of their mental health. These outcome measures justify the continued treatment of SD with BTX.

Orofacial sensory changes are uncommon complaints that can coexist with temporomandibular dysfunction (TMD). The location, character, and intensity vary greatly with each individual and symptom fluctuation is not unusual for any patient. The etiology of orofacial sensory changes may be related to either local or systemic factors. Several investigators have reported that muscle entrapment of branches of the third division of the trigeminal nerve may result in orofacial sensory disruption. Different theories have been suggested to illustrate how TMD and trauma might be associated with these neurological changes. Additionally, several mechanisms exist to explain how muscle spasms may be responsible for nerve compression in individuals with normal anatomy and in those with anatomical variations. In this study, thirty subjects from a group of 282 TMD patients were found to have coexisting orofacial sensory disturbances and TMD. Subjects presenting with any neurological complaints should alert the clinician to the possibility that these symptoms may be the early clinical signs of serious disease.

Dysphagia secondary to primary cricopharyngeal achalasia (PCA) is infrequently seen in paediatric patients. Two female children with PCA who had recurrent attacks of aspiration pneumonia are presented. A cricopharyngeal myotomy was successfully performed in both cases, confirming its efficacy. Investigation and management of this rare condition are reviewed.

Objective: This study was conducted to evaluate, subjectively and objectively, the diagnostic and therapeutic effects of botulinum toxin (Botox) in patients with dysphagia caused by cricopharyngeus (CP) muscle spasm and/or hypertonicity., Methods: A retrospective chart review was done of 5 patients with normally functioning larynges treated with CP Botox injection for dysphagia caused by perceived spasm. Subjective measures of swallowing function after injection were obtained with a patient questionnaire. Objective data were obtained both before and after surgery by one or more of the following tests: modified barium swallow study, manometry, videostroboscopy, and fiberoptic endoscopic evaluation of swallowing. Quality-of-life measures were obtained with a swallowing rating scale., Results: Overall, all patients had initial improvement in swallowing after Botox injection. The duration of benefit was from 2 to 14 months. There were no complications. Four of 5 patients had long-term benefits, as evidenced by decreased or eliminated aspiration symptoms, removal of tracheotomy, ability to eat solid foods, and weight gain. One patient continues to have poor swallowing function., Conclusion: Botox injection of the CP muscle to treat dysphagia is effective in patients with underlying muscle spasm or hypertonicity. A positive response to Botox can also help confirm the diagnosis of CP muscle spasm.

Myofascial pain syndrome (MPS) is a common illness, characterised by acute or chronic focal pain, muscle stiffness and fatigue. The pathophysiology of MPS remains unclear. Previous preliminary studies have demonstrated therapeutic efficacy of the muscle relaxant botulinum toxin type A (BTX-A) in the treatment of MPS. A single-centre, randomised trial compared the effects of BTX-A with the steroid methylprednisolone (both administered intramuscularly with 0.5% bupivacaine), in 40 patients suffering from chronic myofascial pain in the piriformis, iliopsoas or scalenus anterior muscles. Thirty days after receiving an injection of either BTX-A or steroid followed by post-injection physiotherapy, pain severity had decreased significantly from baseline in both treatment groups, with no significant difference between the two treatment groups. However, the baseline pain score was significantly higher in the BTX-A treatment group compared with the steroid group (7.9 vs. 7.3), and the reduction in pain score between baseline and 30 days post-injection was greater in the BTX-A group compared with the steroid group (-3.9 vs. -3.5; P=0.06). At 60 days post-injection, the pain severity score for the BTX-A-treated patients was statistically significantly lower than the pain score for the steroid-treated population (2.3 vs. 4.9). Furthermore, the reduction in pain score in the BTX-A group at 60 days post-injection was greater than at 30 days (-5.5 vs. -3.9), whereas the effect of the steroid had begun to wane. These results indicate the superior efficacy of BTX-A over conventional steroid treatment in patients suffering from MPS, when combined with appropriate physiotherapy.

Three patients with Sjogren's syndrome are presented in whom frequent tonic/dystonic spasms of the limbs developed during the course of the illness. These patients' clinical findings suggested spinal cord involvement, a localization that was confirmed by magnetic resonance imaging in two patients. In one patient the painful movements responded to treatment with phenytoin and in one other to baclofen. Sjogren's syndrome should be considered in the differential diagnosis of conditions that produce tonic/dystonic limb spasms.

The initial assumption that sudden acute chest pain may be of cardiac origin is justifiable, but when this proves not to be the case the patient is left with little explanation of the cause. It is suggested here that diaphragmatic cramp may be a cause of some undiagnosed noncardiac chest pains associated with mandibular referred pain. The phrenic nerve provides both motor and sensory innervation to the diaphragm, while the trigeminal nerve carries sensation from the mandibular teeth. Both nerves originate in separate nuclei close together in the lower medulla. Interconnections between these nuclei and others higher up in the brain may provide one explanation for this problem.

Previously, we demonstrated that patients with adductor spasmodic dysphonia (ADSD) have a disinhibition of laryngeal responses to sensory input. In this study, sensorimotor responses to stimulation of the superior laryngeal nerve were compared between 10 subjects with abductor spasmodic dysphonia (ABSD) and 15 normal volunteers. The groups had similar latency and frequency characteristics of their unconditioned adductor responses (p>.05). The conditioned R1 (early) responses of the subjects with ABSD were greater and more variable in amplitude than those of the normal volunteers (p< or =.008). Similar R2 (late) conditioning effects were found in both groups, with a nonsignificant trend toward reduced inhibition of contralateral R2 responses at lower interstimulus intervals (p = .01) in the patient group. Thus, inhibitory mechanisms that modulate the R1 laryngeal sensorimotor pathway in the brain stem may be abnormal in subjects with ABSD. Abnormal modulation of laryngeal sensorimotor responses seems present in both types of spasmodic dysphonia.

It is generally believed that injury of the vessel wall is an important condition for the development of atherosclerosis. The nature of this injury and its relationship to lesion origin, however, are not clearly understood. Based on early work by the author and a selective review of the literature, evidence is presented to show how a common cardiovascular event, vasospasm, may be one of the factors responsible for this tissue damage, because it produces a substantial arteriopathy in the very vessel in which it occurs.

We report on a 3-year-old girl with West syndrome and with focal hypsarrhythmia. The left hemisphere of the patient was virtually completely defective and continuous hypsarrhythmia was only seen in the residual right frontal cortex, where an interictal single photon emission computed tomography (SPECT) showed hyperperfusion. Despite a focal epileptic pattern, the tonic spasms were quite symmetrical. In our patient, spasms might not require the sensorimotor cortex, but the brainstem containing the descending pathways that control spinal reflexes and other infratentorial structures seem to be essential for the occurrence of spasms. This is in accordance with the result of an ictal SPECT that showed hyperperfusion of the brainstem and cerebellum. These findings suggest that hypsarrhythmia originates from cortical lesions, while subcortical structures may be primarily responsible for the tonic spasms in this patient.

Acoustic phonatory events were identified in 14 women diagnosed with ADSD and compared to those of 14 women age-matched (+/-2 years) with no evidence of vocal pathology/dysfunction. The three acoustic parameters examined during sustained vowel production and reading included phonatory breaks, aperiodicity, and frequency shifts. Intra- and intermeasurer correlations showed high reliability for the measures. Findings indicated that those with ADSD produced a greater frequency of aberrant acoustic events than the controls during both tasks. For the group with ADSD, the amount and type of each event also varied with utterance type. The sustained vowel sample produced by those with ADSD consisted of a greater percentage of aperiodic segments followed by phonatory breaks and frequency shifts. During reading, frequency shifts were the predominant acoustic event, followed by phonatory breaks and aperiodicity. The advantage of segmenting the acoustic waveform into these measures and the relevancy of examining intertask performances by those with ADSD is discussed.

The purpose of this study was to determine if phonatory air flow characteristics differed among women with adductor spasmodic dysphonia (AdSD), muscle tension dysphonia (MTD), and normal phonation. Phonatory air flow signals were gathered during [pa] syllable repetitions. Mean phonatory air flow, coefficients of variation, and the presence of large air flow perturbations (75 ml/s or more) were examined for the three groups of speakers. There was no significant difference in mean phonatory air flow across groups, and very large intersubject variation in mean phonatory air flow occurred for both the AdSD and MTD groups. Coefficients of variation were similar for the groups of women with MTD and normal phonation but were significantly larger for the group with AdSD. Air flow perturbations were common with AdSD and rare with MTD. Relatively large coefficients of variation and air flow perturbations of at least 75 ml/s did occur for some women with normal voices who were 70 years of age or older. It appears that intrasubject variability in phonatory air flow may aid in the differentiation of AdSD and MTD when used in conjunction with other elements of a thorough voice evaluation. However, the potential contribution of aging to increased intrasubject variability in phonatory air flow must be considered when interpreting findings.

Background: Voluntary nystagmus has been recognized as a pendular, rapid, conjugate, primarily horizontal, benign eye movement initiated and maintained by voluntary effort., Case: A 10-year-old Japanese girl presented with voluntary nystagmus associated with accommodation spasms. Her chief complaints, intermittent blurred vision, headache, and soreness of the eyes, were thought to be related to the voluntary nystagmus and accommodation spasms., Findings: The waveform of the nystagmus appeared pendular, the frequency was 13-15 Hz, and the amplitude was 3-5 degrees. Scanning laser ophthalmoscopic video images clearly demonstrated vertical and torsional components in addition to the horizontal eye movements. Her refraction was unstable, varying between -0.5 diopters (D) and -5.5 D, and the recording of the accommodometer increased to -12.0 D when nystagmus was initiated., Conclusions: This may be a unique form of voluntary nystagmus that consists of horizontal, vertical, and rotational components associated with accommodation spasms. Observation of this patient continues, without any further treatment or examination.

Our objective in this study was summing up of results of clinical studies on effectiveness of a selective alpha-adrenoblocker doxazosine in the pharmacotherapy of reflex and spastic disorders of outflow of urine. Doxazosine ("Cardura", Pfizer Inc.) was prescribed per os once per day in the morning after meal in a dose of 2-4 mg. The drug can be used not only as a hypotensive agent but also in conservative treatment of patients with prostate hyperplasia. It was found to be very effective in attempts to bring the disordered outflow of urine back to normal in patients presenting with calculi in the lower third of ureters as well as those with prior prostata resection; in affections of and injuries to the brain and spinal cord.

Injection of botulinum toxin (Botox) into the laryngeal muscles has become the treatment of choice for controlling the symptoms of spasmodic dysphonia (SD). Currently, no specific battery of objective tests to assess the outcome is universally accepted. The purpose of this study was to investigate demographic, clinical, and treatment factors with voice outcome following Botox injection. Sixty-eight patients with adductor SD who underwent at least one Botox injection during a 5-year period were studied. Voice outcome measures were made from patient self-reporting scales and included overall vocal quality, length of response, and duration of breathiness. Vocal quality was significantly correlated with the underlying severity of vocal symptoms prior to treatment, incidence of breathiness and unilateral versus bilateral injection. The length of response was greater in males and following bilateral injections. An increased period of breathiness significantly correlated with bilateral injections.

Objective: To investigate the effect of C8 nerve root division on the treatment of spastic cerebral palsy in the upper limbs., Methods: Two patients were treated with division of the C8 never root. Supraclavicular incision was made to expose the C5-T1 nerve roots. The intraoperative electromyographic recording technique was used to monitor the responses from the flexor digitorum and flexor carpi ulnaris muscle groups simultaneously. The C5-T1 nerve roots were stimulated and the evoked muscle amplitude potentials (EMAP) were recorded from the muscle groups. The EMAP of the muscle groups obtained during electrical stimulation of the C8 nerve root was the largest, which was used as the basis for C8 nerve root division., Results: Division of the C8 nerve root slightly affected the function of the upper limb, and reduced the muscle tone of the flexor wrist and digitorum., Conclusion: Division of the C8 nerve root can reduce the muscle tone of the flexor wrist and digitorum in a short time. The long-term effects need to be followed up further.

Hyperemesis gravidarum is associated with nausea and vomiting during the 1st trimester of pregnancy. We report 2 cases of hyperemesis gravidarum associated with vasospasms of cerebral arteries recognized by magnetic resonance imaging angiography. The hyperemetic condition of the patients improved after fluid and electrolyte replacement therapy.

The aims of this study were to evaluate the emotional status and life quality of the patients with spasmodic dysphonia (SD) before and after botulinum toxin treatment, and to ascertain whether SD is a somatoform disorder. Ten patients with spasmodic dysphonia were injected unilaterally into the vocal cord with botulinum toxin. Before botulinum toxin treatment, two clinician's rating scales--Hamilton Depression Rating Scale (HDRS) and Hamilton Anxiety Rating Scale (HARS), and three self-rating psychometrics--Zung's Self-Rating Depression Scale (SDS), Life Quality Scale (GHQ/QL-12), and Symptom Distress Checklist (SCL-90) were applied. Self-rating scales were also administered in 20 matched normal controls. The patients were reevaluated 1 month after botulinum toxin treatment. The Clinical Global Impression Scale (CGI) was also rated by the patients themselves and a speech pathologist. The mean scores of SD patients were significantly higher than that of controls in SDS, and subscales of somatization, obsessive-compulsive symptoms, depression, anxiety, and psychoticism in SCL-90. The mean score of GHQ/QL-12 was significantly higher in the control group. The scores of HDRS, SDS, GHQ/QL-12 and subscales of somatization, depression, and anxiety in SCL-90 showed significant improvement after botulinum treatment. In CGI, seven patients were rated as improved by patients themselves and the speech pathologist. The patients with SD had more anxiety, depression and somatization symptoms, and poor life quality than normal controls. Their emotional status and life quality improved after botulinum toxin treatment. The results suggest that the emotional symptoms of patients with SD are mainly secondary to voice disorder.

Background: The etiology of cerebral ischemic accidents in young adults often remains unclarified., Case Description: A 32-year-old woman presented after multiple episodes of left monocular visual impairment and right-sided focal signs. MRI revealed a low-flow infarction on the left; color-coded duplex sonography (CCDS), however, showed normal vascular findings. During the inpatient rehabilitation, a renewed visual impairment occurred; an immediate CCDS examination now demonstrated a filiform stenosis of the left internal carotid artery (ICA) 4 cm above the origin and indirect signs of a severe stenosis of the right ICA. Results of a follow-up examination 18 hours later were again normal. Six weeks later, on reoccurrence of visual impairment, a reversible stenosis of the left ICA was again demonstrated. A search for possible causes of vasospasm was unsuccessful. After treatment with calcium antagonists the patient was free of complaints (with the exception of 3 very short attacks of visual impairment) during the following 12 months., Conclusions: Cervical carotid artery vasospasms can apparently occur spontaneously without a mechanical trigger. Because their detection is difficult, vasospasms may go undetected.

We analyzed frequency and duration parameters of voice and speech in two men with adductor spasmodic dysphonia (SD). One was treated with botulinum toxin injection; the other received acupuncture therapy. Improvement after acupuncture therapy in terms of standard deviation of fundamental frequency, acoustic perturbation measurements, durational measurements of voice and speech, and spectrographic analysis was comparable to the results achieved with botulinum toxin injection. Voice and speech parameters were stable 1 year after acupuncture therapy.

Purpose: The purpose of the study is to analyze the effectiveness and side effects of botulinum toxin using four different treatment site applications to determine the most successful treatment regime with the least side effects., Methods: In a prospective trial, 92 patients (50 blepharospasm and 42 hemifacial spasm) were assigned randomly to 1 of 4 different treatment groups (standard [S], brow [B], inner orbital [IO], or outer orbital [OO]). Each treatment group had a different pattern of injection sites in the orbicularis. A total of 285 treatments were given, and the mean follow-up time was 16.4 months., Results: In the blepharospasm group, patients assigned to the standard group had a significantly longer duration of effect than for those in the brow, inner orbital, and outer orbital groups (8.1 weeks compared with 4.5, 4.2, and 3.1 weeks, respectively; P < 0.001). In the hemifacial spasm group, patients in the outer orbital group had significantly shorter duration of effect than those in standard, brow, or inner orbital group (7.2 weeks compared with 12.6, 12.8 and 10.4 weeks, respectively; P < 0.001). The four major complications of botulinum toxin treatment were epiphora, ocular irritation, ptosis, and diplopia. The inner orbital treatment produced significantly more episodes of ptosis (13% of treatments). However, the standard treatment produced the most epiphora and ocular irritation (18% of treatments)., Conclusions: The position of the injection sites around the orbicularis influences the effectiveness and side effects of botulinum toxin treatment for patients with blepharospasm and hemifacial spasm. The further the treatment is away from the eyelid margin, the lower the risk of ocular side effects. The standard treatment produces the longest duration of effect in the blepharospasm group but with the most transient ocular irritation and epiphora. In the hemifacial spasm group, the brow treatment has an equally long duration of effect as that of the standard treatment with fewer side effects.

Description and quantification of the symptoms of adductor spasmodic dysphonia often reflect the clinician's knowledge of the disorder, ideas about the cause of the disorder, and personal experience. No reliable instrument that identifies and quantifies the spectrum of perceptual symptoms has been available. Therefore, we developed a standardized measure called the Unified Spasmodic Dysphonia Rating Scale (USDRS) in cooperation with a team of 118 experienced voice judges. Consensual validations of content validity guided the incremental development of the scale. Using the USDRS allows more consistent and complete data collection, both clinically and in research clinical trials.

A 66-year-old woman underwent elective cardiac catheterization for investigation of periodic attacks of chest pain at rest. During the examination, a chest pain attack occurred unexpectedly, resulting in ST elevation in the precordial leads on electrocardiography. Immediate coronary arteriography demonstrated no organic stenosis but markedly delayed contrast medium perfusion in the mild to distal portion of the left anterior descending artery. These phenomena spontaneously disappeared about 3 min later, and the patient was diagnosed as having angina pectoris due to microvascular spasm. The demonstration of angina pectoris due to microvascular spasm by coronary arteriography during a spontaneous attack is very rare.

We report a large right occipital falcine meningioma, the main presenting feature of which was ipsilateral hemifacial spasm. The patient was relieved of the hemifacial spasm after the supratentorial tumour was resected. The pathogenesis of hemifacial spasm is reviewed in light of this unusual case and the treatment of hemifacial spasm secondary to a tumour is discussed.

We described a 60-year-old man with 5-year history of insulin dependent diabetes mellitus who developed continuous rigidity of truncal muscle and painless, rhythmic muscular spasm of trunk and proximal lower and upper extremities. The rigidity continued even in sleep. The painless muscle spasm was often precipitated by volitional movement and emotional stimuli. Intravenous administration of diazepam strongly attenuated the muscle spasm as well as truncal rigidity. Surface electromyography showed the continuous contraction of abdominal and paraspinal muscles. The rhythmic, clonic spasm of shoulder, triceps brachii, intercostal, abdominal, paraspinal and quadriceps femoris muscle induced by voluntary neck flexion was not compatible with typical stiff-man syndrome. Antibody against glutamic acid decarboxylase (GAD) was detected in the serum and cerebrospinal fluid of this patient. His condition was getting well with oral intake of sodium valproate. While painless, rhythmic spasm and persistent rigidity during sleep ruled out the patient from typical stiff-man syndrome, he was supposed to have the same pathophysiological mechanism as the anti-GAD autoantibody positive stiff-man syndrome.

Dystonia and particularly spasmodic torticollis are neuromuscular disorders that are extremely resistant to most therapies (physical, medical, or surgical). Torticollis is a unilateral spasm of the neck muscles, particularly of the sternocleidomastoid, that produces violent, tonic turning of the head to one side. The etiology remains uncertain, although the role of psychogenic factors has been emphasized. This article reviews the literature and reports four cases of spasmodic torticollis treated successfully with hypnosis. In all four cases, psychogenic causes were involved. Postural hypnosis (i.e., hypnosis in the standing position) was employed to counteract and minimize muscle spasms due to postural reflexes. A hypnobehavioral approach was adopted along with hypnotic strategies that included hierarchical desensitization, sensory-imaging conditioning, ego-boosting suggestions, and hypnosis-facilitated differential muscle retraining. In two cases, a combined hypnosis and electromyographic-biofeedback approach was used to equilibrate and retrain affected neck muscles. Although the hypnotherapeutic process took several months to induce and stabilize significant changes, outcome results were good to excellent in all cases, with marked reduction of the torticollis and the hypertrophy of the neck muscles as well as a reduced interference of symptoms in daily living.