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Should We Treat Musician's Dystonia with Thalamotomy?

Summary and Comment |
September 3, 2013

Should We Treat Musician's Dystonia with Thalamotomy?

  1. Michael S. Okun, MD

Long-term follow-up data suggest the technique is useful but perhaps best reserved for when other options have failed.

  1. Michael S. Okun, MD
Figure 1: Ventro-Oral Thalamotomy for Musician's Dystonia Brain surgery for musician's dystonia at Tokyo Women's Medical University
Reprinted with permission from John Wiley and Sons
Figure 1: Ventro-Oral Thalamotomy for Musician's Dystonia Brain surgery for musician's dystonia at Tokyo Women's Medical University Reprinted with permission from John Wiley and Sons

Researchers present long-term follow-up data on the use of unilateral ventro-oral thalamotomy in 15 patients with musician's dystonia operated on over a 7-year period. All patients had medically intractable focal hand dystonia specific to playing a musical instrument. Brain lesions were placed in the hemisphere contralateral to the musician's dystonia. (Photo)

The Tubiana musician's dystonia scale was the main outcome variable.

Fourteen of 15 patients had improvement, reported as immediate and sustained for a mean of 31 months (range, 4–108 months). The mean Tubiana scale score was 2.7 preoperatively and 4.6 both immediately and ultimately postoperatively. One patient had postoperative weakness, and four patients had at least transient dysarthria. Two of three patients who had given up professional careers were able to resume their profession.

Comment

Dystonia is a movement disorder that results in cocontraction of muscles. The movements frequently cause difficulties, especially with intentional tasks. Certain dystonias curiously occur only when performing specific tasks, not during daily activities. This study involved mostly professional musicians who experienced dystonia almost exclusively when playing their musical instruments. These patients have few treatment options. Botulinum toxin and, occasionally, pharmacotherapy are effective. Botulinum toxin was not available to the Japanese patients in this case series; it would be practical to attempt toxin therapy prior to deep brain stimulation.

These authors elected not to use advanced imaging or physiological target guidance for placement of the brain lesions; they used an indirect targeting approach instead. In this old-fashioned method, the target was a predefined region 15 mm from the midline of the anterior commissure–posterior commissure line. In modern practice, and especially when placing brain lesions, direct targeting with high-quality imaging should be performed, especially given the risk of lesioning the internal capsule. In addition, surgical groups may consider the merits of further refining the target with microelectrode mapping techniques. This report provides long-term evidence that thalamotomy may be an option for musicians who are willing to undergo the risks of brain surgery.

  • Disclosures for Michael S. Okun, MD at time of publication Grant / research support NIH; National Parkinson Foundation; Michael J. Fox Foundation Editorial boards Parkinsonism and Related Disorders; Tremor and Hyperkinetic Disorders Leadership positions in professional societies National Parkinson Foundation (Medical Director and Ask the Doctor Director); Tourette Syndrome Association (Medical Advisory Board)

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