1316 - Worsening Acquired Cervical Dystonia: A Rare Post-Stroke Presentation

Case Diagnosis: Cervical dystonia is a rare disease of abnormal neck movement associated with pain and decreased quality of life. We report a patient with a history of acquired isolated cervical dystonia who presented with four weeks of worsening rotational head tremors preceding the diagnosis of symptomatic central cord stenosis.

Case Description: A 67-year-old female with a history of a cerebrovascular accident resulting in residual left arm weakness and isolated cervical dystonia presented to an acute care hospital with worsening neck pain and left upper extremity weakness. Initial assessment with neck CT revealed an osteophyte complex causing central cord stenosis, later managed non-operatively with an epidural steroid injection. The physical exam revealed a rotational left-to-right beating cervical neck tremor alleviated by a slight chin touch. Hypertonicity and tenderness of the left sternocleidomastoid muscle and action tremor in the left hand were also present.

Discussions: Due to the new left upper extremity action tremor, the patient was treated with a two-week trial of low-dose propanol for possible superimposed essential tremor, as head tremor is a late clinical manifestation of the disease. Within two weeks, the patient showed substantial improvement in her dystonic head tremor. Given the neck pain and left sternocleidomastoid muscle hypertonicity, the patient was also referred for repeat botulinum toxin injections.

Conclusions: In our case report, a patient with worsening cervical dystonia following presentation for symptomatic central cord stenosis was treated with propanol due to suspected overlapping essential tremor. While cervical dystonia can extend to affect the upper extremities in certain patients, the typical pattern involves symptom progression within the first 5 to 10 years, which is earlier than observed in this patient. Additionally, dystonia is estimated to co-exist in 7% of patients with essential tremor. As such, worsening head tremors should prompt a comprehensive workup to rule out the presence of additional movement disorders.