Dystonic lateroflexion of the trunk, also referred to as Pisa syndrome, pleurothotonus or a lean to the side, was originally described in association with prior exposure to neuroleptics. However, axial deformities (Pisa syndrome, camptocormia and antecollis) are also well recognised but poorly understood features of multiple system atrophy or late-stage Parkinson’s disease. Here, we report on three patients with longstanding Parkinson’s disease who, 4–9 years after a left pallidotomy, developed a Pisa syndrome to the right.

Case histories

The first patient, now 72 years old, was diagnosed with Parkinson’s disease at age 44 years, after initially presenting with pain in his right arm and leg. The right side always remained the more affected and the dyskinesias that developed after 4 years of levodopa treatment were also more pronounced on the right side. Because of progressive motor fluctuations, a left-sided pallidotomy was performed after 17 years of disease, which resulted in abolition of the right-sided dyskinesias and an improvement in the tremor and rigidity on the right. Eight years after the pallidotomy, 25 years after disease onset, he gradually developed a lean to the right, which showed some diurnal fluctuation and responded modestly to dopaminergic treatment. When “on”, he still remains independent for most daily activities. Parkinson’s disease dementia has recently been diagnosed.

In the second patient, now 63 years old, Parkinson’s disease was diagnosed at the age of 47 years when he …