Effects of ventro-oral thalamic deep brain stimulation in a patient with musician’s dystonia: illustrative case

Fauve Poncelet Departments of Neurosurgery

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Sara Smeets Departments of Neurosurgery

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Takaomi Taira Department of Neurosurgery, Tokyo Women’s Medical University, Tokyo, Japan

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Veerle Visser-Vandewalle Department of Stereotactic and Functional Neurosurgery, University Hospital Cologne, and Faculty of Medicine, University of Cologne, Cologne, Germany

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Wim Vandenberghe Neurology, UZ Leuven, Leuven, Belgium
Department of Neurosciences, KU Leuven, Leuven, Belgium

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Jana Peeters Department of Neurosciences, Experimental Oto-Rhino-Laryngology, KU Leuven, Leuven, Belgium; and

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Tine Van Bogaert Department of Neurosciences, Experimental Oto-Rhino-Laryngology, KU Leuven, Leuven, Belgium; and

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Bart Nuttin Departments of Neurosurgery

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BACKGROUND

Musician’s dystonia is a task-specific focal hand dystonia characterized by involuntary contraction of muscles while playing a musical instrument. Current treatment options are often insufficient.

OBSERVATIONS

We present the effects of ventro-oral thalamic deep brain stimulation in a patient with musician’s dystonia. The patient was a 67-year-old pianist with musician’s dystonia who underwent deep brain stimulation with the ventralis oralis anterior and posterior nuclei of the thalamus as targets. The Tubiana and Chamagne rating scale was used to evaluate the effects of stimulation. The outcome was evaluated independently by four clinicians in a blinded manner at 3 months postoperatively. There was a distinct reduction of symptoms during stimulation. At 15 months postoperatively, the beneficial effect remained. No lasting side effects were observed.

LESSONS

Further studies are warranted to evaluate the safety and long-term efficacy of this treatment modality.

ABBREVIATIONS

AC-PC = anterior commissure-posterior commissure; DBS = deep brain stimulation; FHD = focal hand dystonia; MCP = midcommissural point; MD = musician’s dystonia; TCS = Tubiana and Chamagne Scale; Voa = ventralis oralis anterior; Voc = ventro-oral complex; Vop = ventralis oralis posterior

BACKGROUND

Musician’s dystonia is a task-specific focal hand dystonia characterized by involuntary contraction of muscles while playing a musical instrument. Current treatment options are often insufficient.

OBSERVATIONS

We present the effects of ventro-oral thalamic deep brain stimulation in a patient with musician’s dystonia. The patient was a 67-year-old pianist with musician’s dystonia who underwent deep brain stimulation with the ventralis oralis anterior and posterior nuclei of the thalamus as targets. The Tubiana and Chamagne rating scale was used to evaluate the effects of stimulation. The outcome was evaluated independently by four clinicians in a blinded manner at 3 months postoperatively. There was a distinct reduction of symptoms during stimulation. At 15 months postoperatively, the beneficial effect remained. No lasting side effects were observed.

LESSONS

Further studies are warranted to evaluate the safety and long-term efficacy of this treatment modality.

ABBREVIATIONS

AC-PC = anterior commissure-posterior commissure; DBS = deep brain stimulation; FHD = focal hand dystonia; MCP = midcommissural point; MD = musician’s dystonia; TCS = Tubiana and Chamagne Scale; Voa = ventralis oralis anterior; Voc = ventro-oral complex; Vop = ventralis oralis posterior

Dystonia has been defined as a movement disorder characterized by sustained or intermittent muscle contractions causing abnormal, often repetitive, movements, postures, or both.1 Focal dystonia is dystonia limited to a single body region. Examples of focal dystonia are writer’s cramp, blepharospasm, cervical dystonia, cranial dystonia, and limb dystonia.1 Musician’s dystonia (MD) is a form of task-specific focal dystonia that occurs only while playing a musical instrument.2 The prevalence of MD is 1% to 8% among professional musicians.3,4 Since this disorder is often misinterpreted as an orthopedic condition, this prevalence may be an underestimate. The dystonia usually occurs in the dominant hand and in the muscles controlling fine movements of the digits. For pianists in particular, it affects the fourth and fifth digit of the right hand in 90% of cases.3 Mean age at onset is generally the mid-30s.5 The etiology of MD is not completely understood but is probably multifactorial. Overuse and compulsive working behavior in combination with predisposing factors such as genetics and biomechanical characteristics are typically associated with the onset of MD.6 The interaction between these predisposing variants is thought to lead to dysfunctional or maladaptive brain plasticity.6

Current treatment options are often insufficient to save a musician’s professional career. First-line treatment modalities include physical therapy and botulinum toxin injections. A more invasive option is stereotactic ventro-oral thalamotomy, with 12 cases first described for writer’s cramp by Taira et al. in 2003 and 15 cases described for MD by Horisawa et al. in 2013.7,8 The ventral lateral nucleus, including the ventro-oral complex (Voc), of the thalamus is known to be an effective target for the treatment of writer’s cramp.7,9 Herein, we study the effects of ventro-oral deep brain stimulation (DBS) on MD in a professional piano player.

Illustrative Case

History

A 67-year-old right-handed professional pianist experienced involuntary movements of his right hand during piano playing. The symptoms had first developed at the age of 62, and his condition slowly deteriorated. It started out as a slight hesitancy of the fourth digit and progressed to a dystonic posture with extension of the second and fifth digit and flexion of the third and fourth digit present only while playing the piano and not while writing. His brother, a professional violinist, had to quit playing violin at the age of 28 because of MD. Our patient was diagnosed with MD 3 years after the onset of symptoms and was unable to continue public performances. He reported that this seriously affected his quality of life. Electromyography-guided botulinum toxin infiltrations at different specialized centers, trihexyphenidyl (2 mg three times a day), physiotherapy, and acupuncture were unsuccessful in treating the dystonia. Because all previous therapies had failed, we proposed thalamotomy 5 years after symptom onset, but the patient requested DBS. The patient was extensively informed about DBS and its investigational nature.

Diagnostic Assessment

Neuropsychological examination showed normal cognitive performances for his age and education level. There were no symptoms of depression, anxiety, or other psychiatric contraindications for DBS. A panel of 68 dystonia and dyskinesia genes (including TOR1A, THAP1, GNAL, ANO3, GCH1, TH, SPR, SGCE, KMT2B, PRKRA, TAF1, ATP1A3 and ADCY5) was negative. Electromyography and brain magnetic resonance imaging (MRI) were normal. The severity of the MD was evaluated using the Tubiana and Chamagne Scale (TCS).10 This rating scale allows for the assessment of musical performance capabilities in patients with MD and consists of six categories varying from unable to play (score 0) to concert performance (score 5; Table 1). The scale is applied by a clinician and is applicable to all musical instruments. In this case, we scored the patient preoperatively as well as at 3 and 6 months postoperatively before and during stimulation (each time after adjustment of the stimulation parameters). A double-blinded evaluation was conducted at 3 months postoperatively. Stimulation was turned on and off, without the patient’s knowledge of the condition. The piano playing was recorded and afterward evaluated independently in a blinded manner by four clinicians with piano experience. At 6 months postoperatively, the scores were assigned by the treating clinicians in a nonblinded manner.

TABLE 1

The TCS: a subjective clinician-based rating scale of musical capabilities

ScoreDescription
0Unable to play
1Plays several notes but stops because of blockage or lack of facility
2Plays short sequences w/o rapidity & w/ unsteady fingering
3Plays easy pieces w/ restrictions; rapid sequences stir up problems
4Nearly normal playing but avoids technically difficult passages for fear of motor problems
5Normal playing; return to concert performance

Based on Taira and Hori, 2003.8

Surgical Technique and Preoperative Findings

The brain electrodes were inserted stereotactically in the left ventralis oralis anterior (Voa) and ventralis oralis posterior (Vop) nuclei, under local anesthesia with intermittent sedation. A Cosman-Roberts-Wells stereotactic frame was fixed to the patient’s skull, and stereotactic brain MRI (3 tesla, 1-mm thick slices) was performed. Based on the experience-based advice on thalamotomy targeting in patients with focal hand dystonia (FHD) of Taira et al.8 and based on the atlas of Schaltenbrand and Wahren, a schematic plan for electrode positioning was established preoperatively (Fig. 1). Taira usually makes one extended lesion, using three trajectories at a distance of 3 mm each to cover both the Voa and Vop nuclei.11 Because it may be difficult to cover this entire area with only one electrode, we decided to implant two electrodes, one in the Voa nucleus and one in the Vop nucleus, spaced approximately 4 mm apart. Given that the STar Drive Manual System (FHC Inc.) of the stereotactic frame provides five trajectories for electrode insertion, each located parallel at 2-mm intervals, we planned one central trajectory at the junction between Voa and Vop nuclei. Electrodes were then implanted 2 mm anterior and posterior to this central trajectory.

FIG. 1
FIG. 1

Schematic overview of electrode positioning in the Voa and Vop nuclei based on Taira’s experience-based advice on thalamotomy targeting. The trajectory is approximately 22° in relation to the midline in the coronal view and 65° in relation to ACPC line in the sagittal view. The dotted line represents the planned trajectory. The dotted line was planned at 13.5 mm lateral from the midline. Two electrodes were implanted, one in the anterior and one in the posterior trajectory of STar Drive Manual System, located 4 mm apart from each other. No other electrode was implanted on the dotted line except for a temporary microelectrode for the microrecording. The laterality of the tip of the Boston Scientific Vercise Cartesia directional lead was 13 mm from the midline for the Voa and 14 mm from the midline for the Vop. MC = midcommissural point; ACPC = distance between anterior and posterior commissure; 25% ACPC behind MC = 25% of ACPC behind MC on the ACPC-line; T = target.

Stereotactic planning of the target and trajectory were accomplished based on the perioperative MRI using Brainlab surgical navigation software. The trajectory was adjusted to the patient’s individual anatomy (especially the location of blood vessels and the caudate nucleus).

Sedation was stopped once the burr hole was made. After incising the dura, three microelectrodes, each 2 mm apart, were placed for registration in the anterior, central, and posterior trajectories. Recordings were made while the patient played a music scale on the keyboard with his right (dystonic) hand versus not playing at all. This was repeated at an interval of 1 mm, starting at −8 mm from target to target along the three trajectories.

Because no clear differences in recording signals were observed at any point, we decided to use only the most anterior trajectory (Voa nucleus) and the most posterior trajectory (Vop nucleus) for further intraoperative stimulation testing. Stimulation with the macroelectrodes (60 µsec, 130 Hz, up to 8mA) was performed. The patient was blinded and did not know whether the stimulation was on or off or which amplitude was used. He was asked to score the dystonia between 1 and 10. Two neurosurgeons with piano experience evaluated the movement of his dystonic hand. Stimulation parameters were set with an external stimulator to a frequency of 130 Hz and pulse width of 60 µsec. Intraoperatively, an immediate positive effect on the dystonia was observed with stimulation of the Voa nucleus as well as the Vop nucleus. However, toward the end of the surgery, this effect could no longer be reliably evaluated because of patient fatigue. At target −8, target −5, target −2 mm and at the target, the therapeutic window was evaluated (Supplemental Table 1). The only adverse effects perceived by the patient at high amplitudes of stimulation were dizziness and lightheadedness. After determining the electrode position with the best clinical effect and the largest therapeutic window, the two final electrodes (Vercise Cartesia directional leads, 8 contacts, Boston Scientific) were implanted at the anterior and posterior trajectory of the STar Drive Manual System, that is, one in the Voa and one in the Vop.

Intraoperative lateral fluoroscopy was used to verify the lead path and location. Thereafter, the neurostimulator (Vercise Genus Rechargeable, Boston Scientific) was implanted prefascially in the left abdomen with the patient under general anesthesia. The postoperative computed tomography scan was fused with the stereotactic MRI plan to verify the correct position of the electrodes. Both electrodes proved to be positioned in the planned targets. Final tip position of the most ventral contact for the Voa was 12.2 mm lateral to the anterior commissure-posterior commissure (AC-PC) line, 2.1 mm superior to the -line, and 0.5 mm anterior to the midcommissural point (MCP). Final tip position of the most ventral contact for the Vop was 12.9 mm lateral to the AC-PC line, 1.7 mm superior to the AC-PC line, and 3.1 mm posterior to the MCP (Fig. 2).

FIG. 2
FIG. 2

Lead reconstruction projected on T1-weighted MRI using Lead-DBS software. A: Sagittal view. B: Axial view with a schematic representation of the thalamic nuclei and location of the bottom lead contacts. STN = subthalamic nucleus; NR = nucleus ruber; S = superior; P = posterior; M = medial.

Follow-Up and Outcome

Follow-up evaluation was performed at different time intervals (Fig. 3). Both electrodes were on at each interval. The dystonia was scored using the TCS preoperatively and at 6 months postoperatively by the treating clinicians. At 3 months postoperatively a double-blinded evaluation was done by a panel of four clinicians with knowledge of playing piano, who scored multiple recordings with DBS on and off. The preoperative TCS score was rated as 1 by the treating clinicians.

FIG. 3
FIG. 3

Overall timeline including postoperative follow-up. The results and stimulation settings at each time interval are represented.

On the first day after the surgery, the Voa electrode was tested and activated. Given the tiredness of the patient, we did not test the Vop electrode. After a monopolar review of both electrodes at day 11, the piano playing improved but still lacked speed. In the first 6 weeks after surgery, the patient’s mood deteriorated, according to the patient because there was only a little improvement in the dystonia at that time. He consulted a psychiatrist once, and his mood improved spontaneously after a few weeks.

At 3 months after surgery, a monopolar review of both electrodes was repeated while the patient played the piano (Video 1, Supplemental Table 2). Median TCS scores from the double-blinded evaluation were 2 when stimulation was off and 4 when stimulation was on, while using the most successful stimulation parameters after the monopolar review (Table 2). When determining the therapeutic window, the patient experienced dizziness and lightheadedness at 8 mA of stimulation. When stimulating at 5 mA, there was sufficient beneficial clinical effect without side effects. In the following weeks, the patient consulted three times for further minor adjustments. Final stimulation settings used contact 6 of the Voa and contacts 7 (40%) and 8 (60%) of the Vop. Parameters consisted of a frequency of 255 Hz, a pulse width of 60 μsec, and an adjustable amplitude between 0 and 10 mA.

VIDEO 1. Clip showing a piano playing with the stimulation turned on and off after the monopolar review at 3 months postoperatively, without the knowledge of the patient. The stimulation settings used contact 6 of the Voa and contact 7 (40%) and 8 (60%) of the Vop. Parameters consisted of a frequency of 255 Hz, a pulse width of 60 μsec, and an amplitude of 5 mA at the moment of the video. Click here to view.

TABLE 2

TCS scoring results of four independent clinicians with piano experience

FragmentClinician 1Clinician 2Clinician 3Clinician 4
1, on4344
2, off3222
3, off2222
4, off2322
5, on4444
6, on4344
7, off3334
8, on3343
9, off2232

off = stimulation turned off; on = stimulation turned on.

The recordings were made 3 months postoperatively, and the clinicians were blinded as to which fragments the DBS was turned on or off. The median score is 2 with the stimulation turned off and 4 with the stimulation turned on. Stimulation parameters as indicated on the overall timeline in Fig. 3.

At 6 months postoperatively, TCS scores were 4, as judged independently by the treating clinicians. The patient was very satisfied, and no additional adjustments to the stimulation settings were required. DBS was turned on continuously, and the patient experienced no negative side effects. He usually reduced the stimulation to 5 mA at night and increased it back to 10 mA in the morning to save battery, but he found that leaving the stimulation on 10 mA at night had no adverse impact on his sleep. When redefining the therapeutic window, dizziness and intermittent contractions of the tongue were perceived by the patient at an amplitude >10 mA at the Vop electrode. These symptoms occurred only transiently and disappeared within a few seconds. At the level of the Voa electrode, no side effects were noted when increasing the stimulation to maximal amplitudes. Stimulation of the Vop electrode had the greatest beneficial effect on the dystonia, in contrast to a minor effect when using only the Voa electrode.

At 11 months postoperatively, an augmentation of the amplitude to 17 mA was necessary to maintain the same effect, but with a reduction of the pulse width to 30µs (only Vop is on, 7- 50%, 8- 50% c+, 30 µsec, 225 Hz, 17 mA [0–17 mA]).

At 15 months postoperatively, the patient was satisfied with the DBS, as he could play concerts again (TCS score 5). He only switches the stimulator on during piano playing, and with this strategy he has a very good effect at 13 or 13.5 mA. However, when he keeps the stimulator on at night, he needs 17 mA the following day to obtain the same effect.

Patient Informed Consent

The necessary patient informed consent was obtained in this study.

Discussion

Functional and structural changes in the brain are observed in healthy musicians.12 However, in patients with MD, this plasticity of the brain when learning new tasks becomes maladaptive. Presumably, this is due to excessive training of repetitive movements in combination with other predisposing factors.9 These maladaptive neuronal structural and functional changes have been observed in the motor and sensorimotor cortices, as well as in the basal ganglia. For example, Kita et al.6 found that MD is associated with disruption of basal ganglia resting-state functional connectivity in the putamen. In turn, this influences the function of connected networks, such as the basal ganglia-thalamo-cortical loops.6 It is believed that interruption of these abnormally functioning loops by stimulation or lesioning of the Voa and Vop nuclei can improve dystonic symptoms.8,13 Therefore, the Voc has been identified as a proper target for thalamotomy as well as DBS in the treatment of different types of dystonia.

Lesional surgery of the Voc for patients with medically refractory FHD was introduced by Siegfried et al.14 in 1969. A recently published retrospective study by Horisawa et al.11 included 171 patients with task-specific FHD who underwent unilateral ventro-oral thalamotomy and provided class IV evidence concerning the feasibility and effectiveness of ventro-oral thalamotomy.15 DBS for FHD is less commonly performed, but several groups have obtained results similar to those with thalamotomy. These studies are case reports or case series with a total of 10 patients suffering from writer’s cramp.14–17 Fukaya et al. compared thalamic Voc DBS to globus pallidus internus DBS by implanting two electrodes in a patient with writer’s cramp.19 Thalamic Voc DBS turned out to be superior in this specific case.

To date, there are no comparative studies between DBS and lesional surgery for the treatment of FHD. In lesional surgery, there are no hardware-associated complications. According to a systematic review including 8983 patients, the overall risk of developing a hardware-associated complication after receiving DBS in general is 11.75%.16 Because the onset of MD is generally at a young age, this means long-term follow-up with adjustment of the stimulation parameters and battery replacement. The psychological and physical burdens of the implantation of a mechanical device should not be underestimated. Conversely, ventro-oral thalamotomy has the potential to cause irreversible side effects. Horisawa et al.7 described one patient with mild hemiparesis postoperatively but with sufficient recovery to resume activities of daily living. Side effects of thalamotomy reported in a study by Tasker et al.17 included worsened hemiparesis, dysarthria, and locomotion in comparison to preoperatively. The target, however, differed from the abovementioned studies in that it included the ventral intermediate nucleus in addition to the Vop. The main advantage of DBS is the reversibility of stimulation and thus a lower incidence of permanent postoperative neurological deficits.18

Observations

The present case suggests that ventro-oral DBS may be an effective treatment option for MD. The most important limitation of this case report is the use of a subjective rating scale (TCS8). Nevertheless, the recordings of the piano playing were blindly and independently evaluated by four different clinicians. Another limitation is that follow-up after surgery lasted only 15 months.

Lessons

Ventro-oral DBS had a beneficial effect on the MD of our patient. Further studies are necessary to determine the safety and long-term efficacy of ventro-oral DBS for MD.

Acknowledgments

We would like to thank the patient for participating in this study. Furthermore, we thank the four independent clinicians (Pauline D’Hoore, Jole Beert, Jonathan Nuyts and Louis Degryse) for evaluating the piano playing.

Author Contributions

Conception and design: Nuttin, Poncelet, Smeets, Visser-Vandewalle, Vandenberghe. Acquisition of data: Nuttin, Poncelet, Smeets, Vandenberghe. Analysis and interpretation of data: Nuttin, Poncelet, Smeets, Vandenberghe, Peeters, Van Bogaert. Drafting the article: Nuttin, Poncelet, Smeets, Visser-Vandewalle. Critically revising the article: Nuttin, Poncelet, Smeets, Taira, Visser-Vandewalle, Vandenberghe, Peeters. Reviewed submitted version of manuscript: Nuttin, Poncelet, Taira, Vandenberghe, Van Bogaert. Approved the final version of the manuscript on behalf of all authors: Nuttin. Administrative/technical/material support: Nuttin, Smeets. Study supervision: Nuttin, Taira.

Supplemental Information

Videos

Video 1. https://vimeo.com/849497246

Online-Only Content

Supplemental material is available with the online version of the article.

Supplemental Tables 1 and 2. https://thejns.org/doi/suppl/10.3171/CASE22569.

Previous Presentations

Poster presentation of the abstract at the annual Belgian Society of Neurosurgery meeting, March 26, 2022, Leuven, Belgium.

References

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    Kita K, Rokicki J, Furuya S, Sakamoto T, Hanakawa T. Resting-state basal ganglia network codes a motor musical skill and its disruption From dystonia. Mov Disord. 2018;33(9):14721480.

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    Ragert P, Schmidt A, Altenmüller E, Dinse HR. Superior tactile performance and learning in professional pianists: evidence for meta-plasticity in musicians. Eur J Neurosci. 2004;19(2):473478.

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Supplementary Materials

  • Collapse
  • Expand
  • FIG. 1

    Schematic overview of electrode positioning in the Voa and Vop nuclei based on Taira’s experience-based advice on thalamotomy targeting. The trajectory is approximately 22° in relation to the midline in the coronal view and 65° in relation to ACPC line in the sagittal view. The dotted line represents the planned trajectory. The dotted line was planned at 13.5 mm lateral from the midline. Two electrodes were implanted, one in the anterior and one in the posterior trajectory of STar Drive Manual System, located 4 mm apart from each other. No other electrode was implanted on the dotted line except for a temporary microelectrode for the microrecording. The laterality of the tip of the Boston Scientific Vercise Cartesia directional lead was 13 mm from the midline for the Voa and 14 mm from the midline for the Vop. MC = midcommissural point; ACPC = distance between anterior and posterior commissure; 25% ACPC behind MC = 25% of ACPC behind MC on the ACPC-line; T = target.

  • FIG. 2

    Lead reconstruction projected on T1-weighted MRI using Lead-DBS software. A: Sagittal view. B: Axial view with a schematic representation of the thalamic nuclei and location of the bottom lead contacts. STN = subthalamic nucleus; NR = nucleus ruber; S = superior; P = posterior; M = medial.

  • FIG. 3

    Overall timeline including postoperative follow-up. The results and stimulation settings at each time interval are represented.

  • 1

    Albanese A, Bhatia K, Bressman SB, et al. Phenomenology and classification of dystonia: a consensus update. Mov Disord. 2013;28(7):863873.

  • 2

    Sussman J. Musician’s dystonia. Pract Neurol. 2015;15(4):317322.

  • 3

    Schuele S, Jabusch HC, Lederman RJ, Altenmüller E. Botulinum toxin injections in the treatment of musician’s dystonia. Neurology. 2005;64(2):341343.

  • 4

    Jankovic J, Ashoori A. Movement disorders in musicians. Mov Disord. 2008;23(14):19571965.

  • 5

    Altenmüller E, Jabusch HC. Focal hand dystonia in musicians: phenomenology, etiology, and psychological trigger factors. J Hand Ther. 2009;22(2):144154, quiz 155.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Kita K, Rokicki J, Furuya S, Sakamoto T, Hanakawa T. Resting-state basal ganglia network codes a motor musical skill and its disruption From dystonia. Mov Disord. 2018;33(9):14721480.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Horisawa S, Taira T, Goto S, Ochiai T, Nakajima T. Long-term improvement of musician’s dystonia after stereotactic ventro-oral thalamotomy. Ann Neurol. 2013;74(5):648654.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Taira T, Hori T. Stereotactic ventrooralis thalamotomy for task-specific focal hand dystonia (writer’s cramp). Stereotact Funct Neurosurg. 2003;80(1–4):8891.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Rosenkranz K, Williamon A, Butler K, Cordivari C, Lees AJ, Rothwell JC. Pathophysiological differences between musician’s dystonia and writer’s cramp. Brain. 2005;128(Pt 4):918931.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Tubiana R, Chamagne P. [Occupational arm ailments in musicians]. Bull Acad Natl Med. 1993;177(2):203216.

  • 11

    Horisawa S, Ochiai T, Goto S, et al. Safety and long-term efficacy of ventro-oral thalamotomy for focal hand dystonia: A retrospective study of 171 patients. Neurology. 2019;92(4):e371e377.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    Ragert P, Schmidt A, Altenmüller E, Dinse HR. Superior tactile performance and learning in professional pianists: evidence for meta-plasticity in musicians. Eur J Neurosci. 2004;19(2):473478.

    • PubMed
    • Search Google Scholar
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