Delayed segmental axial dystonia of the trunk on standing after lumbar disk operation

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Abstract

We report four patients with various degrees of chronic, tonic, mildly painful, or non-painful, kyphoscolioses in orthostatism, which developed weeks, or months, after one or several laminectomies for lumbar disk hernia, in the absence of recurring radicular pain or acute lumbar pain. No family history or personal antecedent, of focal or generalized dystonia was found and the dystonia was not seen in any of the four patients pre-operatively, or during the immediate post-operative period. Only ill-defined lumbar `discomfort', unlike their pre-operative lumbago, was reported by the patients, before and during the occurrence of the pathologic trunk posture on standing. Asymmetric lumbar muscle tonic contraction and hypertrophy was found on physical examination. In all patients, the kyphoscoliosis was maximal when standing, partially disappeared when seated, and completely when lying down. One patient responded well to clonazepam, but the other three showed no improvement with either clonazepam or local injections of botulinum toxin; l-dopa was ineffective in all cases, and trihexiphenidyle in three.

Introduction

Acute lumbar syndrome is a common clinical condition characterized by severe lumbar pain and paravertebral muscle spasm, with limitation of antero–posterior and lateral movement of the trunk, antalgic scoliosis and a cautious gait (Abbot and Mattis, 1970, Sinclair et al., 1948, Murphey, 1968, Paine and Huang, 1972). This syndrome is transient and disappears at the same time as the lumbar pain or as the radicular syndrome improves. Marked `sciatic scoliosis', or `bayonet deformity' are entities well-known to neurosurgeons, seen during the acute phase following laminectomy for lumbar disc hernia (Murphey, 1968). However, persistent or delayed kyphoscolioses after lumbar laminectomy, occurring after an interval, free of recurring lumbago or acute radicular pain, has not as yet received much attention.

In our Movement Disorder Unit, we have seen four such patients, who presented with various degrees of orthostatic abnormal posture of the trunk in the absence of acute pain or recurring painful radiculopathy. This condition became apparent several weeks, or even months, after lumbar laminectomy, and shared many features with post-traumatic focal dystonic syndromes.

Section snippets

Patient 1

A 38-year-old worker, without any family history of dystonia or previous neuroleptic treatment, had complained of chronic back pain for ten years. In 1989, he had an acute episode of lumbar pain and stopped work for several months. In August 1990, he was hospitalized for two weeks for conservative treatment of another episode of acute lumbar syndrome. In August 1991, he presented, for the first time, with an acute right L5 sensory deficit, with acute lumbar syndrome, but no scoliosis. Because

Discussion

All four patients presented with chronic, non-painful, or mildly painful, tonic orthostatic kyphoscoliosis, with grotesque anteflexion (camptocormia) in one patient; this abnormal posture disappeared partially when seated and completely when lying down. These features were not accompanied by a painful radicular syndrome, which appeared only a few weeks, or months, after single or multiple laminectomies for lumbar disk hernia, and in the absence of any instability on functional X-rays of the

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