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Lateral axial dystonia (LAD) has been described in patients with Parkinson’s disease (PD) as Pisa syndrome (PS). In patients with PS, the trunk is pulled by the paraspinal muscles to the lateralized side. In these cases, botulinum toxin (BTX) should be injected into the paraspinous muscles of the lateralized side. But, in some cases of LAD, the enlarged paraspinal muscles push contralaterally. When, this happen BTX should be injected into the paraspinous muscles opposite the lateralized side. BTX was injected into the paraspinous muscles of the lateralized side in PS, opposite of the lateralized side in BS and into the sternocleidomastoid muscles or scalene muscles in dropped head syndrome (DHS). We experienced three cases of PS, two cases of BS and four cases of DHS. Seven cases out of eight were improved. Treatment with BTX is useful for PS, BS and DHS in PD. When treating LAD in PD, PS or Bonsai syndrome (BS) should first be identified.

Pisa syndrome, Bonsai syndrome and Dropped Head Syndrome in Parkinson’s disease: Treatment with Botulinum Toxin Injection