Pharmacological and surgical options for the treatment of cervical dystonia.

Cervical dystonia (CD) is a condition in which patients experience involuntary and abnormal head movements, such as tilting, twisting, or extension, often accompanied by pain. Although the exact pathologic mechanisms underlying idiopathic CD have not yet been identified, a number of therapeutic strategies have been developed to alleviate the symptoms of this disorder. Oral medications include anticholinergic agents, dopamine receptor antagonists, and GABAmimetic agents. These drugs are employed in a trial-and-error manner and have a low rate of efficacy. Localized therapy using botulinum toxin injections has revolutionized the treatment of CD, providing a high rate of response with a low incidence of side effects. However, as with oral medications, neurotoxin therapy is palliative, not curative, and repeated injections are required. In patients who develop resistance to botulinum toxin therapy and who do not achieve an adequate response to, or are intolerant of, oral medications, surgical approaches are appropriate. Among the options for peripheral surgery, the greatest experience and most consistent results have been achieved with selective dorsal ramisectomy. Recent developments in stereotactic surgery suggest that, for more complex forms of CD or when more widespread dystonia is present, bilateral pallidotomy or globus pallidus deep brain stimulation may be the treatment of choice.