Fifty-six patients with spasmodic torticollis were treated with local injections of botulinum toxin. The drop out rate was 21%. The remaining 44 patients were followed for a period of 3 to 21 months. Thirty-two patients (76%) had pain relief out of 42 presenting with pain; 37 (66%) improved in the amount of sustained movements of torticollis. The efficacy was reproducible after repeated injections.

A variety of neurotransmitters have been implicated in the pathophysiology of chorea as exemplified by Huntington's chorea. These include dopamine, serotonin, acetylcholine, GABA and a variety of neuropeptides including substance P and somatostatin. Despite biochemical data that suggests that alterations in other neurotransmitters may be of greater significance, pharmacologic data still supports a major role of dopamine in the actual clinical manifestation of chorea.

We studied 112 patients with Tourette's syndrome (TS); the male-to-female ratio was 3.8, the mean age of onset was 7.3 years, and the average duration of symptoms prior to the initial evaluation was 15.2 years. Seventy-nine percent of the patients had at least one family member with motor or vocal tics, and an additional 10 percent had a family member with marked obsessive-compulsive behavior. Simple motor tics occurred as the presenting symptom in about one-third of patients; one-third had multiple motor tics at the onset, and another third started with vocal tics. During the course of the illness all patients developed multifocal motor tics and 86 percent had vocal tics. Verbal and mental coprolalia was present in 44 percent of the patients. Copropraxia was seen in 19 percent of patients, and both coprolalia and copropraxia were more frequent among the males than expected. Attentional deficit disorder was diagnosed in 36 percent of the patients and 32 percent had obsessive-compulsive personality. Sleep disturbances were reported by 62 percent of the patients and polysomnography in 34 patients showed motor and vocal tics during all stages of sleep, sleep apnea, abnormal arousal pattern, and other sleep disturbances. Patients with mild symptoms improved with clonidine or clonazepam, but those with more advanced disorder required fluphenazine, pimozide, haloperidol or tetrabenazine.

Progressive supranuclear palsy (PSP) was first recognized as a distinct morbid entity by Richardson, Steele and Olszewski a quarter century ago. Subsequent experience has confirmed and extended their original observations. PSP has become familiar as a chronic progressive disorder with extrapyramidal rigidity, bradykinesia, gait impairment, bulbar palsy, dementia and a characteristic supranuclear ophthalmoplegia. It is an important cause of parkinsonism. Its etiology remains obscure. Familial concentrations have not been observed.

Some cases exhibit no oculomotor dysfunction. Dementia is usually mild. Recent neuropsychological studies have defined features consistent with frontal lobe cortical dysfunction. Seizures and paroxysmal EEG activity may occur.

CT and MRI scans show midbrain atrophy early and later atrophy of the pontine and midbrain tegmentum and the frontal and temporal lobes. PET scans have shown frontal hypometabolism and loss of striatal D-2 dopamine receptors. Postmortem studies have documented involvment of both dopaminergic and cholinergic systems. Treatment remains palliative and unsatisfactory.