Objective: To test whether the reintroduction of Botulinum Toxin Injections (BTI) after Globus pallidus interna Deep Brain Stimulation (Gpi-DBS) for intractable cervical dystonia synergistically improves outcome.

Background: It is well established that Gpi DBS is an effective treatment for CD that is medically refractive to BTI. However, a proportion of patients will continue to struggle with pain and disabling dystonia. Currently there are no available treatment options for this group of patients. It is not known whether the reintroduction of BTI after DBS would be effective.

Method: We assessed the outcome of combined therapy in 14 patients with cervical dystonia recruited from two Neurology Centres (The Walton Centre [Liverpool, UK] and the Federico II University of Naples [Naples, Italy]. All patients underwent Gpi stimulation after being unresponsive to BTI. Because of persistence of pain and dystonia symptoms despite at least 2 years of stimulation, they were treated again with BTI. Patients were assessed by the Toronto Western Spasmodic Torticollis Rating Scale – severity (TWSTRS) at baseline, six months postoperatively and annually thereafter.

Results: Our CD patients showed an average improvement of 60 % on the TWSTRS after GPi-DBS + BTI compared to BTI therapy itself and of 75% on the TWISTR after GPi-DBS itself. Moreover, the amount of BT units used in the combined therapy was reduced of the 58%.

Conclusion: Our preliminary data suggest a promising, possibly synergistic effect of BTI and Gpi-DBS when individual therapies fail in patients with intractable cervical dystonia patients. There are currently no established guidelines in this area. These finding need further exploration with larger, ideally muti-centre studies.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/combined-botulinum-toxin-and-gpi-dbs-therapy-in-intractable-cervical-dystonia/