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【每日动态】病例讨论：肉毒素有效治疗外伤后肌张力障碍一例
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动态跟踪版骨干站友
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Am J Phys Med Rehabil. ):246-9. doi: 10.1097/PHM.0245.Atypical posttraumatic dystonia treatedsuccessfully by botulinum toxin injection.Lee SY1, Lim JY.Author information
1From the Department of Physical Medicine and Rehabilitation,Soonchunhyang University, Bucheon Hospital, Gyeonggi, Korea (SYL); andDepartment of Rehabilitation Medicine, Seoul National University College of Medicine,Seoul National University Bundang Hospital, Gyeonggi, Korea (J-YL).AbstractThis study presents the case of a 39-yr-oldwoman who had atypical involuntary dystonic movements of the shoulder and back.Ten months earlier, she was involved in a motor vehicle collision. Involuntarymovements developed abruptly 3 wks before her first visit to the clinic. Herinvoluntary movements had some atypical features, such as continuous, bizarre,and rhythmic or semirhythmic characteristics, and showed mixed symmetric andasymmetric patterns. She was treated successfully with electromyography-guidedbotulinum toxin type A injection. Involuntary dystonic movements may be due toposttraumatic dystonia, a relatively uncommon diagnosis. Atypical posttraumaticdystonia may be managed effectively with botulinum toxin type A injections.PMID: Dystonia is a neurologic movement disorderin which sustained muscle contractions cause twisting and repetitive movementsor abnormal postures.1 Posttraumatic dystonia is an uncommon nonprimary dystonia,and its pathophysiology is not well understood. Patients with posttraumaticdystonia have poor responses to conventional medications or botulinum toxincompared with other focal dystonia.2The authors report the case of a woman whoexperienced abnormal involuntary movements that developed after an accident andwere treated successfully with botulinum toxin injection. She had unusualmovement patterns of the shoulder girdle muscles, which were bizarre,continuous, and rhythmic or semirhythmic. These involuntary movements are rareand atypical in posttraumatic dystonia. The details of the atypical patternsand treatment experience in the case may help physicians pay more attention todiverse features and outcomes in posttraumatic dystonia.CASE REPORTA 39-yr-old female patient visited theclinic for evaluation of continuous, involuntary dystonic movements of hershoulder and back, which developed 3 wks earlier. Approximately 10 mos beforethis visit, she had been involved in a motor vehicle collision. She underwentcervical spine magnetic resonance imaging for evaluation of posterior neck painwith radiating pain to both upper extremities that developed after theaccident. Themagnetic resonance imaging showed right central C4/5 diskextrusion with inferior migration. No spinal cord compression or abnormal cordsignals were found.She was treated with physical therapy andmedications, including nonsteroidal anti-inflammatory drugs and gabapentin.However, her symptoms did not resolve. Subsequently, a cervical epiduralsteroid injection helped her pain somewhat but not substantially. A deep achingpain with tingling and a cold sensation remained in both upper extremities. Involuntarymovements of her shoulder and upper back developed suddenly 3 wks before her firstvisit to the clinic and were especially aggravated at night. However, sleepdisturbance was not severe. She had no psychiatric history before the accident.No possible work or personal stressors related to her dystonic movements weredetected.Evaluation revealed consistent involuntarydystonic movements of the upper and middle trapezius muscles bilaterally at amean frequency of approximately 0.5 Hz. During more severe episodes, the abnormalmovements continued for 10 mins without a break. Overall, the bilateralscapular movements showed mixed symmetric and asymmetric patterns. When theseinvoluntary dystonic movements were symmetric, they presented as simultaneous bilateralscapular retraction, with the medial scapular border on both sides moving closeto the thoracic spinous process line and at a frequency of up to 1 Hz. Theasymmetric movement patterns occurred randomly and were characterized byinitial movement on either side, followed by movement on the opposite side andat a rate slower than that of the symmetric movement pattern. The scapula wasfirst elevated, mildly upwardly rotated, and then depressed and retractedexcessively, in sequence (video 1 [/PHM/A87]; Fig. 1). The strengthof the shoulder girdle muscle, by a manual muscle test, was normal, and therange of motion of the shoulder joints was also normal in all directions. Focaltenderness was present at the bilateral upper trapezius muscles. No definitehypertrophy of the shoulder girdle muscles was found.Although no definite abnormality in theperipheral nervous system such as radiculopathy was found in theelectrodiagnostic study, the authors observed semirhythmic continuous abnormalmotor activity in the shoulder girdle muscles regardless of the patient’sefforts. This involuntary motor activity was examined by needleelectromyography (EMG) analysis (video 2, ),and abnormal activity was much more distinct in the upper and middle trapeziusmuscles than in the other shoulder girdle muscles. Together, these findings weresuggestive of focal dystonia.After obtaining consent for botulinum toxintype A (BTA) (BOTOX; Allergan, Inc) as a treatment, EMG-guided BTA injectionswere performed. Because abnormal EMG activities of both sides were similar, 25units of BTA was injected at two different points in each muscle (i.e., 50units of BTA per muscle). In total, 200 units of BTA was injected in the upperand middle trapezius muscles bilaterally. At 2 wks after the BTA injections,although the pain had not improved significantly, the frequency of dystonicmovements was reduced to approximately 20% of the initial frequency. At1 mo after treatment, the abnormal dystonicmovements had almost completely disappeared (video 3,/PHM/A89). Follow-up needle EMG showed that the abnormalmotor activity previously present in the shoulder girdle muscles wassignificantly reduced and similar to the other muscles.After this treatment, only mild neck painremained. Another 4 mos later, similar involuntarydystonic movements occurred again in thesame region, but compared with the first outpatient visit, the frequency ofmovements was approximately 20%Y30% lower. The longest duration was less than 10secs. A second BTA injection was administered as before. Two months after thesecond injection, the involuntary dystonic movements had resolved. No seriouscomplication was observed after BTA injection. Written informed consent forthis case report was obtained from the patient.DISCUSSIONPosttraumatic dystonia is a rare and poorlyunderstood condition. Diagnostic criteria include (1) onset within at least 1yr of injury, (2) anatomic correlation between the site of injury and dystonic symptoms,and (3) symptoms persisting for more than 2 wks.2 The present case may havebeen a type of posttraumatic dystonia, as distinguished from primary dystoniasuch as idiopathic cervical dystonia, that developed with no definite etiology.Abnormal features previously reported in posttraumatic dystonia, however, suchas hypertrophy, limited range of motion, and the presence of complex regional painsyndrome,2 were not found. The patient had distinguishing features that are notcommon in posttraumatic dystonia,
bizarre, continuous,rhythmic, or semirhythmic involuntary movements of the bilateral sh and the inability to sustain any posture even for a short time.Regarding these specific features, the patient may have had an atypical type ofposttraumatic focal or segmental dystonia with continuous involuntary movementsin the bilateral shoulder girdle muscles.Various types of movement disorderrepresenting dystonia aswell asmyoclonus, tremor, and others can be mimicked bypsychogenic movement disorder. 3 Differentiating between psychogenic and organicnature of movement disorders is quite complicated. 4 Abrupt onset,inconsistency over time, and multiple somatizations are features frequentlydocumented in patients with psychogenic movement disorders.5 They more oftenhave fixed dystonia and coexisting tremor.6 Conversion or somatization disorderis a common psychiatric diagnosis in these cases, sometimes accompanied by apsychiatric illness such as depression, anxiety, or personality disorder.3 Generally,patients with psychogenic movement disorder have tendencies toward chronicprogressive conditions and poor prognoses.4This patient had several suspiciousfeatures suggesting a psychogenic movement disorder (abrupt onset, presence ofa precipitating event, unusual movement patterns). However, she also hadextremely mobile dystonia and consistent movement patterns. She did not havetremor, symptoms, or a history of psychiatric illness or distraction. Her symptomswere not affected by others’ attention. Moreover, her condition was alleviatedwith botulinum toxin injections. Although underlying psychogenic movementdisorders could not be completely excluded, atypical posttraumatic dystoniaseems more likely, supported in this patient by the lack of features suggestingpsychogenic movement disorders, symptom consistency, and clinical outcome afterBTA injections.BTA injection has been widely used for the treatmentof focal or segmental dystonia. Previous studies have reported that BTAinjection therapy was beneficial for some patients with focal posttraumatic shoulderdystonia.7,8 A poor response to BTA injection therapy may be due to the fixednature of the dystonia. It is known that patients with psychogenic movementdisorders, however, have poor outcomes, and therapeutic interventions,including BTA injection therapy, have not been well studied.3 In this case, thedramatic effects of EMGguided BTA injection may be explained by the following considerations.First, although the movement was a continuous type of dystonia, it did not leadto sustaine instead, it showed sequential or chainedcontractions within one muscle or among several muscles of the shoulder girdle.The other consideration may involve the relatively rarly intervention by BTAinjection, which was administered at 5 wks after onset of symptoms. Thus, EMG-guidedBTA injection may be considered as a first-line treatment option for patientswith involuntary posttraumatic focal or segmental dystonia in the acute orsubacute period.CLINICAL PEARLInvoluntary dystonic movements occurring aftera traumatic event can be due to an atypical posttraumatic dystonia, arelatively uncommon diagnosis. This may be managed effectively with BTAinjections.
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动态跟踪版骨干站友
Am J Phys Med Rehabil. ):246-9. doi: 10.1097/PHM.0245.Atypical posttraumatic dystonia treatedsuccessfully by botulinum toxin injection.肉毒素注射治疗显著改善外伤后非典型肌张力障碍Lee SY1, Lim JY.Author information
1From the Department of Physical Medicine and Rehabilitation,Soonchunhyang University, Bucheon Hospital, Gyeonggi, Korea (SYL); andDepartment of Rehabilitation Medicine, Seoul National University College of Medicine,Seoul National University Bundang Hospital, Gyeonggi, Korea (J-YL).Abstract摘要This study presents the case of a 39-yr-oldwoman who had atypical involuntary dystonic movements of the shoulder and back.Ten months earlier, she was involved in a motor vehicle collision. Involuntarymovements developed abruptly 3 wks before her first visit to the clinic. Herinvoluntary movements had some atypical features, such as continuous, bizarre,and rhythmic or semirhythmic characteristics, and showed mixed symmetric andasymmetric patterns. She was treated successfully with electromyography-guidedbotulinum toxin type A injection. Involuntary dystonic movements may be due toposttraumatic dystonia, a relatively uncommon diagnosis. Atypical posttraumaticdystonia may be managed effectively with botulinum toxin type A injections.本研究中所记载的病例是一名39岁的非典型性肌张力障碍造成肩背不自主活动的女性患者。10个月前，她遭遇了一场车祸。不自主运动是在她第一次来医院前3周逐渐出现的症状。她的不自主运动有些非典型的特征，如：持续性、奇异的、节律性或者半节律性，并表现出对称性和非对称性模式的特征。在肌电图引导下的A型肉毒毒素注射治疗后，其症状得到了显著改善。不自主肌张力障碍的运动可能的原因是外伤后肌张力障碍，这是一个不常见的诊断。非典型性外伤后肌张力障碍可通过A型肉毒毒素注射治疗有效改善症状。PMID: Dystonia is a neurologic movement disorderin which sustained muscle contractions cause twisting and repetitive movementsor abnormal postures.1 Posttraumatic dystonia is an uncommon nonprimarydystonia, and its pathophysiology is not well understood. Patients withposttraumatic dystonia have poor responses to conventional medications orbotulinum toxin compared with other focal dystonia.2肌张力障碍是一个神经运动障碍，表现为持续肌肉收缩，导致扭曲重复的动作或异常的姿势。外伤后肌张力障碍是一种不常见的非原发性肌张力障碍，其病理生理学机制仍不是十分清楚。与其他局灶性肌张力障碍相比，外伤后肌张力障碍对常规药物治疗或肉毒素治疗的反应更差。The authors report the case of a woman whoexperienced abnormal involuntary movements that developed after an accident andwere treated successfully with botulinum toxin injection. She had unusualmovement patterns of the shoulder girdle muscles, which were bizarre,continuous, and rhythmic or semirhythmic. These involuntary movements are rareand atypical in posttraumatic dystonia. The details of the atypical patternsand treatment experience in the case may help physicians pay more attention todiverse features and outcomes in posttraumatic dystonia.在本研究中，来自于韩国首尔国立大学的李医生等报道到了一例在车祸后出现异常不自主活动的女性患者，经肉毒素注射治疗后症状得到明显改善。该患者存在异常的肩带肌运动模式（奇异的，持续的，节律性或半节律性）。这些不自主运动在外伤后肌张力障碍中是非常罕见及不典型的。本例患者所出现的非典型模式，以及该患者的治疗细节或能帮助医生在今后的临床工作中注意到外伤后肌张力障碍不同特征和预后。CASE REPORT病例报道A 39-yr-old female patient visited theclinic for evaluation of continuous, involuntary dystonic movements of hershoulder and back, which developed 3 wks earlier. Approximately 10 mos beforethis visit, she had been involved in a motor vehicle collision. She underwentcervical spine magnetic resonance imaging for evaluation of posterior neck painwith radiating pain to both upper extremities that developed after theaccident. The magnetic resonance imaging showed right central C4/5 diskextrusion with inferior migration. No spinal cord compression or abnormal cordsignals were found.一名39岁的女性患者因持续性肩背部不自主肌张力障碍（持续3周）来院就诊。10个月前，她遭遇了一场车祸，在车祸后患者逐渐出现颈痛及双上肢放射痛，为此做了颈椎核磁共振（MRI）进行评估，结果提示C4/5椎间盘突出，未发现脊髓压迫或脊髓异常信号。She was treated with physical therapy andmedications, including nonsteroidal anti-inflammatory drugs and gabapentin.However, her symptoms did not resolve. Subsequently, a cervical epiduralsteroid injection helped her pain somewhat but not substantially. A deep achingpain with tingling and a cold sensation remained in both upper extremities. Involuntarymovements of her shoulder and upper back developed suddenly 3 wks before her firstvisit to the clinic and were especially aggravated at night. However, sleep disturbancewas not severe. She had no psychiatric history before the accident. No possiblework or personal stressors related to her dystonic movements were detected.之后她接受了物理治疗和药物治疗，包括：非甾体类消炎药物及加巴喷丁，但是她的症状并没有缓解。随后，该患者接受了颈部硬膜外封闭注射，该治疗能缓解部分疼痛，但是双上肢仍有严重的酸麻刺痛及怕冷的症状。在来医院就诊的3周前，该患者突然出现了肩背部不自主运动，晨轻暮重，但并未严重到影响睡眠。在车祸发生前，该患者无精神科疾病史。医生也未发现可能与她肌张力障碍相关的工作及个人压力。Evaluation revealed consistent involuntarydystonic movements of the upper and middle trapezius muscles bilaterally at amean frequency of approximately 0.5 Hz. During more severe episodes, the abnormalmovements continued for 10 mins without a break. Overall, the bilateralscapular movements showed mixed symmetric and asymmetric patterns. When theseinvoluntary dystonic movements were symmetric, they presented as simultaneous bilateralscapular retraction, with the medial scapular border on both sides moving closeto the thoracic spinous process line and at a frequency of up to 1 Hz. Theasymmetric movement patterns occurred randomly and were characterized byinitial movement on either side, followed by movement on the opposite side andat a rate slower than that of the symmetric movement pattern. The scapula wasfirst elevated, mildly upwardly rotated, and then depressed and retractedexcessively, in sequence (video 1 [/PHM/A87]; Fig. 1). The strengthof the shoulder girdle muscle, by a manual muscle test, was normal, and therange of motion of the shoulder joints was also normal in all directions. Focaltenderness was present at the bilateral upper trapezius muscles. No definitehypertrophy of the shoulder girdle muscles was found.评估显示该患者存在持续的双上肢及斜方肌中间束的不自主活动，平均频率约为0.5Hz。严重发作时，这种不自主运动会持续10分钟而没有间歇。总的来说，双侧肩胛骨活动为混合对称和不对称模式。当不自主运动是对称时，表现为双侧肩胛骨内收，两侧斜方肌中间束同时向胸椎收缩，其频率约1Hz。而不对称的不自主运动则随机出现，初始表现为单侧的不自主运动，紧接着对侧也出现不自主运动，频率较对称模式为慢。不自主运动的顺序如下：肩胛骨首先上抬，轻度上旋，然后较明显的下降回缩（图1）。手法肌力评估提示肩带肌肌力正常，肩关节各个轴向的活动度均正常。双侧斜方肌上部存在局灶性压痛，未发现明显的肩带肌肥厚。Although no definite abnormality in theperipheral nervous system such as radiculopathy was found in the electrodiagnosticstudy, the authors observed semirhythmic continuous abnormal motor activity inthe shoulder girdle muscles regardless of the patient’s efforts. Thisinvoluntary motor activity was examined by needle electromyography (EMG) analysis,and abnormal activity was much more distinct in the upper and middle trapeziusmuscles than in the other shoulder girdle muscles. Together, these findings weresuggestive of focal dystonia.电生理检查未发现周围神经系统（如神经根病）异常，但是作者观察到肩带肌部分节律性的持续性异常活动（患者主观无法控制）。针极肌电图提示斜方肌上、中束异常活动更为明显（与其他肩带肌相比），这些症像都提示局灶性肌张力障碍的存在。After obtaining consent for botulinum toxintype A (BTA) (BOTOX; Allergan, Inc) as a treatment, EMG-guided BTA injectionswere performed. Because abnormal EMG activities of both sides were similar, 25units of BTA was injected at two different points in each muscle (i.e., 50units of BTA per muscle). In total, 200 units of BTA was injected in the upperand middle trapezius muscles bilaterally. At 2 wks after the BTA injections,although the pain had not improved significantly, the frequency of dystonicmovements was reduced to approximately 20% of the initial frequency. At1 mo after treatment, the abnormal dystonicmovements had almost completely disappeared (video 3,/PHM/A89). Follow-up needle EMG showed that the abnormalmotor activity previously present in the shoulder girdle muscles wassignificantly reduced and similar to the other muscles.在患者同意接受A型肉毒素（保妥适，艾尔建）治疗后，研究者在肌电图引导下进行了肉毒素靶肌肉注射。因为双侧的异常EMG活动是相似的，因此每块肌肉上都有两个注射位点，每个点的剂量为25u（每块肌肉的注射剂量为50u）。双侧斜方肌上束和中束的注射剂量为200u。在肉毒素治疗后两周，尽管疼痛没有得到显著缓解，但不自主运动的频率减少到了最初的20%。在治疗后一个月，异常的不自主运动几乎完全消失。随访肌电图提示肩带肌的异常电活动较前显著减少，其他肌肉也存在相应改善。After this treatment, only mild neck painremained. Another 4 mos later, similar involuntarydystonic movements occurred again in thesame region, but compared with the first outpatient visit, the frequency ofmovements was approximately 20%Y30% lower. The longest duration was less than 10secs. A second BTA injection was administered as before. Two months after thesecond injection, the involuntary dystonic movements had resolved. No seriouscomplication was observed after BTA injection.治疗后，患者残存轻度的颈部疼痛。此后的4个月，相似的不自主活动再次发生在相同区域，但是与首次门诊就诊时相比，不自主活动频率下降大约20%-30%，最长的持续时间低于10秒。患者进行了第二次肉毒素注射，治疗方案同前。第二次肉毒素治疗两月后，不自主运动明显缓解。肉毒素注射后也没有观察到明显的并发症。DISCUSSIONPosttraumatic dystonia is a rare and poorlyunderstood condition. Diagnostic criteria include (1) onset within at least 1yr of injury, (2) anatomic correlation between the site of injury and dystonic symptoms,and (3) symptoms persisting for more than 2 wks.2 The present case may havebeen a type of posttraumatic dystonia, as distinguished from primary dystonia.Abnormal features previously reported in posttraumatic dystonia, however, suchas hypertrophy, limited range of motion, and the presence of complex regional painsyndrome,2 were not found. The patient had distinguishing features that are notcommon in posttraumatic dystonia,
bizarre, continuous,rhythmic, or semirhythmic involuntary movements of the bilateral sh and the inability to sustain any posture even for a short time.Regarding these specific features, the patient may have had an atypical type ofposttraumatic focal or segmental dystonia with continuous involuntary movementsin the bilateral shoulder girdle muscles.讨论：外伤后肌张力障碍极为罕见，目前对其产生机制也知之甚少。其诊断标准包括1）伤后1年内起病；2）损伤部位和肌张力障碍发生部位之间存在解剖学联系；3）症状持续2周以上。本例患者或是外伤后肌张力障碍的一种类型，与原发性肌张力障碍存在显著差异。外既往所报道过的伤后肌张力障碍的特征如增生、关节活动受限和复杂性区域性疼痛综合症都没有在本例患者中出现。但是本例患者中存在一些外伤后肌张力障碍的少见症状如双侧肩带肌突然发生的奇异的、持续的、节律性或部分节律性的不自主运动，并且无法短时间保持任何的姿势。结合上述特征，该患者存在以双侧肩带肌肉持续不自主运动为表现的非典型外伤后局部或部分肌张力障碍。Various types of movement disorderrepresenting dystonia as well as myoclonus, tremor, and others can be mimickedby psychogenic movement disorder. 3 Differentiating between psychogenic and organicnature of movement disorders is quite complicated. 4 Abrupt onset,inconsistency over time, and multiple somatizations are features frequentlydocumented in patients with psychogenic movement disorders.5 They more oftenhave fixed dystonia and coexisting tremor.6 Conversion or somatization disorderis a common psychiatric diagnosis in these cases, sometimes accompanied by apsychiatric illness such as depression, anxiety, or personality disorder.3 Generally,patients with psychogenic movement disorder have tendencies toward chronicprogressive conditions and poor prognoses.4肌张力障碍的表现形式包括肌痉挛、震颤以及一些其他的运动障碍，需要注意的是精神性运动障碍也有相似的表现。辨别精神性运动障碍和器质性运动障碍是一个复杂的过程。突然发生、时间持续较短以及躯体化症状多样化是精神性运动障碍的主要特征，通常表现为混合性肌张力障碍，同时伴有震颤。在此类患者中，常见的精神科诊断为转化障碍或躯体化障碍，有时可伴有抑郁症、焦虑或人格障碍。总的来说，存在精神性运动障碍的患者病程趋向慢性进行性，预后较差。This patient had several suspiciousfeatures suggesting a psychogenic movement disorder (abrupt onset, presence ofa precipitating event, unusual movement patterns). However, she also hadextremely mobile dystonia and consistent movement patterns. She did not havetremor, symptoms, or a history of psychiatric illness. Her symptoms were notaffected by others’ attention. Moreover, her condition was alleviated withbotulinum toxin injections. Although underlying psychogenic movement disorderscould not be completely excluded, atypical posttraumatic dystonia seems more likely,supported in this patient by the lack of features suggesting psychogenicmovement disorders, symptom consistency, and clinical outcome after BTAinjections.本例患者中存在的一些症状，如突然发生、存在突发事件、不同寻常的运动模式，这些特征提示精神性运动功能障碍可能。但是，该患者同样存在移动性肌张力障碍和持续运动的模式。她不存在震颤，或精神类疾病的病史。她的症状与并不受其他人注意的影响。此外，她的情况在接受肉毒素注射后能缓解。虽然不能完全除外精神性运动功能障碍的可能，非典型外伤后肌张力障碍的可能性更大，因为该患者缺乏精神性运动功能障碍的特征，症状的一致性以及经过肉毒素注射后的临床反应。BTA injection has been widely used for the treatmentof focal or segmental dystonia. Previous studies have reported that BTAinjection therapy was beneficial for some patients with focal posttraumatic shoulderdystonia.7,8 It is known that patients with psychogenic movement disorders,however, have poor outcomes, and therapeutic interventions, including BTAinjection therapy, have not been well studied.3 In this case, the dramaticeffects of EMG guided BTA injection may be explained by the following considerations.First, although the movement was a continuous type of dystonia, it did not leadto sustaine instead, it showed sequential or chainedcontractions within one muscle or among several muscles of the shoulder girdle.The other consideration may involve the relatively rarly intervention by BTAinjection, which was administered at 5 wks after onset of symptoms. Thus, EMG-guidedBTA injection may be considered as a first-line treatment option for patientswith involuntary posttraumatic focal or segmental dystonia in the acute orsubacute period.肉毒素注射广泛用于局灶性或节段性肌张力障碍的治疗。既往研究报道过肉毒素注射治疗有利于一些外伤后肩关节肌张力异常的患者。然而，精神性运动功能障碍的患者预后更差，包括肉毒素治疗在内的多种治疗干预手段的疗效较差，究其原因却不明确。在本例患者中，肌电图引导下肉毒素注射所产生的显著疗效的解释如下。其一，虽然肌张力障碍是持续的，但并不会导致肌肉持续收缩，而是在一块肌肉或是数块肩带肌中有序的收缩。另一种观点可能与症状发生后5周才进行肉毒素注射干预相关。因此，在外伤后局灶性或节段性肌张力障碍的患者中（急性期或亚急性期），肌电图引导下肉毒素注射可做为一线治疗。CLINICAL PEARLInvoluntary dystonic movements occurring aftera traumatic event can be due to an atypical posttraumatic dystonia, arelatively uncommon diagnosis. This may be managed effectively with BTAinjections.临床意义在外伤后发生的不自主运动障碍可视为外伤后肌张力障碍，可采用肉毒素有效治疗。编译后（2411）病例讨论：肉毒素有效治疗外伤后肌张力障碍一例肌张力障碍是一种神经运动障碍，表现为持续肌肉收缩，导致扭曲重复的动作或异常的姿势。外伤后肌张力障碍是一种不常见的非原发性肌张力障碍，其病理生理学机制仍不是十分清楚。与其他局灶性肌张力障碍相比，外伤后肌张力障碍对常规药物治疗或肉毒素治疗的反应更差。在本研究中，来自于韩国首尔国立大学的李医生等报道到了一例在车祸后出现异常不自主活动的女性患者，经肉毒素注射治疗后症状得到明显改善。该患者存在异常的肩带肌运动模式（奇异的，持续的，节律性或半节律性）。这些不自主运动在外伤后肌张力障碍中是非常罕见及不典型的。本例患者所出现的非典型模式，以及该患者的治疗细节或能帮助医生在今后的临床工作中注意到外伤后肌张力障碍不同特征和预后。病例报道一名39岁的女性患者因持续性肩背部不自主肌张力障碍（持续3周）来院就诊。10个月前，她遭遇了一场车祸，在车祸后患者逐渐出现颈痛及双上肢放射痛，为此做了颈椎核磁共振（MRI）进行评估，结果提示C4/5椎间盘突出，未发现脊髓压迫或脊髓异常信号。之后她接受了物理治疗和药物治疗，包括：非甾体类消炎药物及加巴喷丁，但她的症状并没有缓解。随后，该患者接受了颈部硬膜外封闭注射，该治疗能缓解部分疼痛，但是双上肢仍有严重的酸麻刺痛及怕冷的症状。在来医院就诊的3周前，该患者突然出现了肩背部不自主运动，晨轻暮重，但并未严重到影响睡眠。在车祸发生前，该患者无精神科疾病史。医生也未发现可能与她肌张力障碍相关的工作及个人压力。评估显示该患者存在持续的双上肢及斜方肌中间束的不自主活动，平均频率约为0.5Hz。严重发作时，这种不自主运动会持续10分钟而没有间歇。总的来说，双侧肩胛骨活动为混合对称和不对称模式。当不自主运动是对称时，表现为双侧肩胛骨内收，两侧斜方肌中间束同时向胸椎收缩，其频率约1Hz。而不对称的不自主运动则随机出现，初始表现为单侧的不自主运动，紧接着对侧也出现不自主运动，频率较对称模式为慢。不自主运动的顺序如下：肩胛骨首先上抬，轻度上旋，然后较明显的下降回缩（图1）。手法肌力评估提示肩带肌肌力正常，肩关节各个轴向的活动度均正常。双侧斜方肌上部存在局灶性压痛，未发现明显的肩带肌肥厚。电生理检查未发现周围神经系统（如神经根病）异常，但是作者观察到肩带肌部分节律性的持续性异常活动（患者主观无法控制）。针极肌电图提示斜方肌上、中束异常活动更为明显（与其他肩带肌相比），这些症像都提示局灶性肌张力障碍的存在。在患者同意接受A型肉毒素（保妥适，艾尔建）治疗后，研究者在肌电图引导下进行了肉毒素靶肌肉注射。因为双侧的异常EMG活动是相似的，因此每块肌肉上都有两个注射位点，每个点的剂量为25u（每块肌肉的注射剂量为50u）。双侧斜方肌上束和中束的注射剂量为200u。在肉毒素治疗后两周，尽管疼痛没有得到显著缓解，但不自主运动的频率减少到了最初的20%。在治疗后一个月，异常的不自主运动几乎完全消失。随访肌电图提示肩带肌的异常电活动较前显著减少，其他肌肉也存在相应改善。治疗后，患者残存轻度的颈部疼痛。此后的4个月，相似的不自主活动再次发生在相同区域，但是与首次门诊就诊时相比，不自主活动频率下降大约20%-30%，最长的持续时间低于10秒。患者进行了第二次肉毒素注射，治疗方案同前。第二次肉毒素治疗两月后，不自主运动明显缓解。肉毒素注射后也没有观察到明显的并发症。讨论：外伤后肌张力障碍极为罕见，目前对其产生机制也知之甚少。其诊断标准包括1）伤后1年内起病；2）损伤部位和肌张力障碍发生部位之间存在解剖学联系；3）症状持续2周以上。本例患者或是外伤后肌张力障碍的一种类型，与原发性肌张力障碍存在显著差异。既往所报道过的伤后肌张力障碍的特征如增生、关节活动受限和复杂性区域性疼痛综合症都没有在本例患者中出现。但是本例患者中存在一些外伤后肌张力障碍的少见症状如双侧肩带肌突然发生的奇异的、持续的、节律性或部分节律性的不自主运动，并且无法短时间保持任何的姿势。结合上述特征，该患者存在以双侧肩带肌肉持续不自主运动为表现的非典型外伤后局部或部分肌张力障碍。肌张力障碍的表现形式包括肌痉挛、震颤以及一些其他的运动障碍，需要注意的是精神性运动障碍也有相似的表现。辨别精神性运动障碍和器质性运动障碍是一个复杂的过程。突然发生、时间持续较短以及躯体化症状多样化是精神性运动障碍的主要特征，通常表现为混合性肌张力障碍，同时伴有震颤。在此类患者中，常见的精神科诊断为转化障碍或躯体化障碍，有时可伴有抑郁症、焦虑或人格障碍。总的来说，存在精神性运动障碍的患者病程趋向慢性进行性，预后较差。本例患者中存在的一些症状，如突然发生、存在突发事件、不同寻常的运动模式，这些特征提示精神性运动功能障碍可能。但是，该患者同样存在移动性肌张力障碍和持续运动的模式。她不存在震颤，或精神类疾病的病史。她的症状与并不受其他人注意的影响。此外，她的情况在接受肉毒素注射后能缓解。虽然不能完全除外精神性运动功能障碍的可能，非典型外伤后肌张力障碍的可能性更大，因为该患者缺乏精神性运动功能障碍的特征，症状的一致性以及经过肉毒素注射后的临床反应。肉毒素注射广泛用于局灶性或节段性肌张力障碍的治疗。既往研究报道过肉毒素注射治疗有利于一些外伤后肩关节肌张力异常的患者。然而，精神性运动功能障碍的患者预后更差，包括肉毒素治疗在内的多种治疗干预手段的疗效较差，究其原因却不明确。在本例患者中，肌电图引导下肉毒素注射所产生的显著疗效的解释如下。其一，虽然肌张力障碍是持续的，但并不会导致肌肉持续收缩，而是在一块肌肉或是数块肩带肌中有序的收缩。另一种观点可能与症状发生后5周才进行肉毒素注射干预相关。因此，在外伤后局灶性或节段性肌张力障碍的患者中（急性期或亚急性期），肌电图引导下肉毒素注射可做为一线治疗。临床意义在外伤后发生的不自主运动障碍可视为外伤后肌张力障碍，可采用肉毒素有效治疗。
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