Fixed dystonia unresponsive to pallidal stimulation improved by motor cortex stimulation

Abstract

We read with interest the report by Romito et al. about a patient with fixed dystonia who responded to motor cortex stimulation.1 In our view, their conclusions are limited by uncertainties about the diagnosis and shortcomings in the evaluation of the therapeutic response. These aspects are important when an invasive neurosurgical procedure is proposed for consideration in similar cases. The diagnosis of psychogenic dystonia is excluded by the authors with the statement that “nothing indicated somatoform or psychogenic disorder.”1 This diagnosis should be suspected when patients have fixed and painful posturing of the neck or limbs, which renders them unable to carry out basic daily activities.2 Possible, probable, documented, and clinically established categories of certainty can be established by applying Fahn and Williams' criteria.3 Only 10% of the fixed dystonia cohort evaluated prospectively with a standardized neuropsychiatric protocol by Schrag et al. did not meet criteria for psychogenic dystonia.4 Furthermore, the posture exhibited by this patient is similar to …