Objective: We sought to assess the clinical efficacy of Botulinum toxin (BoNT) injection for Pisa syndrome (PS) using a combined Magnetic Resonance Imaging (MRI)-, Ultrasonography (US)-, and Electromyography (EMG)-guided approach.

Background: Pisa syndrome (PS), defined as an acquired postural abnormality characterized by marked lateral trunk flexion ≥10° ameliorated by passive mobilization and supine positioning, may affect 7.4-10.3% of patients with Parkinson disease (PD).

Methods: Thirteen consecutively consenting patients with PD-associated PS were enrolled in a 3-month open label interventional study. Inclusion criteria were PS; idiopathic PD; and stable dose of dopaminergic medications. Exclusion criteria were previous treatment with BoNT, history of spine surgery, and severe orthopedic diseases. Spinal muscle atrophy was assessed using an MRI, while the pattern of muscular activity was analyzed with an US-guided EMG analysis in the standing and supine positions. US-assisted BoNT injections were delivered in muscles with asymmetric pattern of EMG activation when standing, in muscles not showing severe atrophy. As primary endpoint we evaluated the rate of patients improving by ≥ 5° in the lateral trunk flexion. As secondary endpoint, we evaluated the improvement in PS-associated pain/discomfort on a Visual Analogue Scale (VAS). Ancillary analyses included the association between demographic/clinical factors (age, lateral trunk flexion, PS duration, levodopa equivalent daily dose, and Movement Disorders Society Unified Parkinson’s Disease Rating Scale section-III) on the lateral trunk flexion and PS-associated pain/discomfort.

Results: There was a 84.6% rate of responders, who showed an average improvement on the lateral trunk flexion of 40% (p < 0.001). Pain/discomfort improved in all patients, with a 52.2% reduction in the VAS score (p < 0.001). No associations were detected between demographic/clinical factors and the extent of lateral trunk flexion or changes at the VAS score.

Conclusions: Our findings support the utility of a combined MRI-, US-, and EMG-guided BoNT injection for the symptomatic treatment of PD-associated PS. Randomized clinical trials are warranted to confirm these promising results.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/botulinum-toxin-injection-for-pisa-syndrome-in-parkinsons-disease/