Multimodal neurosurgical strategies for the management of dystonias.

Dystonia have many subtypes, and is classified as focal, segmental and generalized. As for focal dystonia, spasmodic torticollis (cervical dystonia) and writer's cramp are most common. Cervical dystonia is mainly treated effectively with selective peripheral denervation, and task specific focal dystonia of the hand (writer's cramp) is effectively alleviated by stereotactic ventro-oral thalamotomy. Generalized dystonia is dramatically improved with deep brain stimulation of the globus pallidus interna. Because the majority of dystonia is medically refractory and surgical treatment results in marked improvement, the authors strongly believe that dystonia should be regarded as a definite neurosurgical indication. Based on personal experience of nearly 200 cases of dystonia surgery, the authors describe a multimodal approach to various types of dystonias. Also we discuss possible relation between dystonias and psychiatric conditions, and future new indication of dystonia surgery.