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Table of Contents    
COMMENTARY
Year : 2020  |  Volume : 68  |  Issue : 1  |  Page : 152-153

Musician's Dystonia - What a Neurosurgeon Can Offer!


Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication28-Feb-2020

Correspondence Address:
Dr. Manmohan Singh
715, 7th Floor, CN Centre, AIIMS, Ansari Nagar, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.279673

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How to cite this article:
Singh M, Garg K. Musician's Dystonia - What a Neurosurgeon Can Offer!. Neurol India 2020;68:152-3

How to cite this URL:
Singh M, Garg K. Musician's Dystonia - What a Neurosurgeon Can Offer!. Neurol India [serial online] 2020 [cited 2020 Mar 28];68:152-3. Available from: http://www.neurologyindia.com/text.asp?2020/68/1/152/279673




The authors in the article titled 'Importance of Lesioning in Focal Dystonia' describe about successful management of a patient with musician's dystonia by thalamotomy.

Dystonias are defined as diverse “group of movement disorders characterized by sustained or intermittent muscle contractions causing abnormal, often repetitive, movements, postures, or both”.[1] Focal task specific dystonias (FTSD) are a diverse group of focal dystonias affecting an isolated body part and are triggered, at least initially, by a specific action. FTSD was first described in 1830 in the British Civil Services clerks what was actually a 'writer's cramp'. Other forms of FTSD has been described in musicians, typists, hairdressers, painters, shoemakers and tailors.[2]

The focal hand dystonia in musicians, also known as musician's dystonia, is a task-specific movement disorder characterized by painless, involuntary muscle contractions occurring only while playing a musical instrument. It commonly affects the dominant hand and is limited to a specific movement in the early stage of disease before spreading to other tasks. Though it usually affects one hand, rarely (5%) both the hands may be involved.[3]

The estimated prevalence of musician's dystonia varies from 0.5% to 8% among the professional musicians over their lifetime.[4] It appears in the musicians in their fourth decade after prolonged repetitive and fine movements associated with playing musical instruments and men are affected four times as often as women.[5] There is evidence to suggest the role of genetic and environmental factors in MD. The severity of the disorder is assessed using the Tubiana's musician's dystonia scale.

Various non-surgical modalities of treatment used for the management of MD includes oral medications (anticholinergic drugs), chemo-denervation, (botulinum toxin injections), and sensory and motor rehabilitation. Other ways adopted by few of the musicians include altering the position of the instrument and use of relaxation techniques.

However, success is very limited with these treatment modalities and more than half of the patients have to give up their profession.[6] The recent advances in the field of surgical intervention in movement disorders have also shown some success in patients with MD. Most common target is nucleus ventro-oralis of thalamus. Surgical approaches include lesioning or deep brain stimulation. Various methods of lesioning have been described like thermal, radiofrequency and gamma knife.[3],[7]

Thalamotomy has been performed to treat tremors and rigidity in Parkinson's disease since 1950s.[8] It leads to immediate and marked resolution of musician's dystonia as well. However, it involves the creation of a permanent stereotactically targeted lesion inside the thalamus. Any error in target, can lead to hemiparesis/plegia due to damage to the internal capsule. Transient dysarthria and weakness is usually noted following thalamotomy even with the correct target as there is transient edema following lesioning. One study reported that the transient dysarthria and weakness typically disappears within 5 months.[9] Horisawa et al. described good results in 15 patients with MD with no recurrence of symptoms at a mean follow-up period of 30·8 months (range - 4-108 months).[10]

Recently Gamma Knife radiosurgery and MRI-guided focused ultrasound ventro-oral thalamotomy has also been reported.[7],[11] Gamma knife radiosurgery (GKRS) and MRI guided focused ultrasound are both non-invasive ways of lesioning. However, it is not possible to deliver a test dose to confirm the optimal position of the nucleus during the procedure in GKRS. Moreover, there is risk of unexpected lesion expansion with GKRS, which can lead to permanent motor/sensory deficits. Long term results of GKRS are available in movement disorders unlike MRI guided focused ultrasound.

DBS has promising results in MD in a recent series.[12] DBS has the advantage over thalamotomy as electrical stimulation is reversible and controllable and no permanent lesion is created. Another advantage of DBS over thalamotomy is that it can safely be done in patients requiring bilateral stimulation, as there are concerns of severe speech abnormalities with bilateral thalamotomy. Though there are reports suggesting that bilateral thalamotomy is well tolerated especially after the advent of CT and MRI and by limiting the size of lesioning to 100 mm3.[13] The limitations of DBS include risk of infection and hardware complications (lead fractures and migrations), implantable pulse generator malfunction, and the need to replace non-functioning batteries. Besides, DBS requires intensive post-surgical calibrations requiring multiple hospital visits.

Apart from these invasive lesioning surgical techniques, transcranial direct current stimulation has offered encouraging results. Good results have also been seen in patients with FTSD following motor retraining assisted by bi-hemispheric, non-invasive brain stimulation via transcranial direct current stimulation to the motor cortex and anodal transcranial direct current stimulation targeting the cerebellum.[14]



 
  References Top

1.
Albanese A, Bhatia K, Bressman SB, Delong MR, Fahn S, Fung VS, et al. Phenomenology and classification of dystonia: A consensus update. Mov Disord 2013;28:863-73.  Back to cited text no. 1
    
2.
Frucht SJ. Focal task-specific dystonia in musicians. Adv Neurol 2004;94:225-30.  Back to cited text no. 2
    
3.
Horisawa S, Goto S, Nakajima T, Kawamata T, Taira T. Bilateral stereotactic thalamotomy for bilateral musician's hand dystonia. World Neurosurg 2016;92:585.e21-5.  Back to cited text no. 3
    
4.
Altenmüller E, Jabusch HC. Focal dystonia in musicians: Phenomenology, pathophysiology, triggering factors, and treatment. Med Probl Perform Art 2010;25:3-9.  Back to cited text no. 4
    
5.
Jabusch HC, Zschucke D, Schmidt A, Schuele S, Altenmüller E. Focal dystonia in musicians: Treatment strategies and long-term outcome in 144 patients. Mov Disord 2005;20:1623-6.  Back to cited text no. 5
    
6.
Schuele S, Lederman RJ. Long-term outcome of focal dystonia in string instrumentalists. Mov Disord 2004;19:43-8.  Back to cited text no. 6
    
7.
Horisawa S, Tamura N, Hayashi M, Matsuoka A, Hanada T, Kawamata T, et al. Gamma knife ventro-oral thalamotomy for musician's dystonia. Mov Disord 2017;32:89-90.  Back to cited text no. 7
    
8.
Ohye C. Use of selective thalamotomy for various kinds of movement disorder, based on basic studies. Stereotact Funct Neurosurg 2000;75:54-65.  Back to cited text no. 8
    
9.
Tomlinson FH, Jack CR, Kelly PJ. Sequential magnetic resonance imaging following stereotactic radiofrequency ventralis lateralis thalamotomy. J Neurosurg 1991;74:579-84.  Back to cited text no. 9
    
10.
Horisawa S, Taira T, Goto S, Ochiai T, Nakajima T. Long-term improvement of musician's dystonia after stereotactic ventro-oral thalamotomy. Ann Neurol 2013;74:648-54.  Back to cited text no. 10
    
11.
Horisawa S, Yamaguchi T, Abe K, Hori H, Sumi M, Konishi Y, et al. A single case of MRI-guided focused ultrasound ventro-oral thalamotomy for musician's dystonia. J Neurosurg 2018;131:384-386.  Back to cited text no. 11
    
12.
Fukaya C, Katayama Y, Kano T, Nagaoka T, Kobayashi K, Oshima H, et al. Thalamic deep brain stimulation for writer's cramp. J Neurosurg 2007;107:977-82.  Back to cited text no. 12
    
13.
Hirabayashi H, Hariz MI, Wårdell K, Blomstedt P. Impact of parameters of radiofrequency coagulation on volume of stereotactic lesion in pallidotomy and thalamotomy. Stereotact Funct Neurosurg 2012;90:307-15.  Back to cited text no. 13
    
14.
Bradnam LV, Graetz LJ, McDonnell MN, Ridding MC. Anodal transcranial direct current stimulation to the cerebellum improves handwriting and cyclic drawing kinematics in focal hand dystonia. Front Hum Neurosci 2015;9:286.  Back to cited text no. 14
    




 

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