Pathological inclination of the trunk forward

The pathological inclination of the trunk forward (camptocormia in the broad sense) can be permanent, periodic, paroxysmal, rhythmic ("bows"). It can cause pain, postural instability, cause or aggravate dysbasia, lead to falls. The nosological affiliation of this postural syndrome is sometimes difficult to identify, especially when it is the only or major manifestation of the disease. The inclination of the trunk forward is always a symptom, not a disease. Therefore, the identification of other symptoms, against which the torso bent forward appeared, is often the key to diagnosis. Sometimes the situation is complicated by the fact that this phenomenon develops on the background of not one, but two (and more) neurological diseases. For diagnostics it is important to distinguish between permanent (and progressive) inclination of the trunk forward and transient - episodic slopes.

[1], [2]

I. Constant and progressive torso inclination forward

A. Diseases of the spine and large joints.

B. Postural disorders in the late stages of Parkinson's disease and Parkinson's.

C. Progressive weakness of the extensor muscles of the trunk:

1. Myopathy.
2. Amyotrophic lateral sclerosis.
3. Progressive spinal amyotrophy.
4. Dermatomyositis and poliomyositis.
5. Glycogenosis, type 2.
6. Insufficiency of carnitine.

D. Syndrome of the inclined spine in the elderly.

II. Transient episodic and repetitive torso inclinations forward

A. Spasm of muscle-flexors of the trunk:

1. Dystonia is axial.
2. Paroxysmal dystonia.
3. Myoclonus axial muscles of the trunk.
4. Epilepsy.
5. Neuroleptic syndrome.

B. The torso bends forward in the picture of mental (psychogenic and endogenous) diseases:

1. Cytptocormia is psychogenic.
2. Periodic obeisances in the picture of conversion or compulsive disorders.
3. Stereotypy in mental illness.
4. Depression in endogenous mental illness.

C. Torso bends forward as a compensatory (arbitrary) reaction in case of a threat of a fall:

1. Transient weakness in the legs with transient insufficiency of the spinal circulation.
2. Lipotymic conditions in the picture of orthostatic circulatory disorders, including with progressive autonomic failure (walking in the "skater" position).

I. Constant and progressive torso inclination forward

A. Diseases of the spine and large joints

Diseases of the spine and large joints are usually accompanied by pain syndrome and (or) form a mechanical cause of the torso tilt. There is a vertebral syndrome. (Pathological kyphosis and deformations of the skeleton in spondylitis, ankylosing spondylarthritis, traumas, tumors and congenital diseases of the spine, coxarthrosis, rheumatoid arthritis, reflex muscular-tonic syndromes).

The diagnosis is confirmed by neuroorthopedic, X-ray or neuroimaging.

[3], [4], [5], [6], [7]

B. Postural disorders in advanced stages of Parkinson's disease and Parkinson's disease

Standing and walking in the "flexor posture," an accelerated step with the torso tilt forward in the context of other manifestations of parkinsonism (hypokinesia, restless tremor, muscle stiffness, postural disorders). A combination of both of the above causes (joint and parkinsonism) is possible.

[8], [9], [10], [11], [12]

C. Progressive weakness of extensor muscles

Myopathy involving the muscles of the pelvic girdle and paraspinal muscles is referred to here rather arbitrarily, since it tilts forward not only the trunk, but only the pelvis. The pelvis of the patient, due to the weakness of the extensors, tilts forward and the patient compensates to maintain the vertical posture, deflects backward, forming a hyperlordosis. In fact, here the body is constantly deflected backwards (over-extension). In the absence of such compensation, the body would be constantly inclined forward.

Other diseases accompanied by weakness of the extensor muscles of the trunk, for example, amyotrophic lateral sclerosis (proximal forms or a rare debut of the disease with weakness of the extensor muscles of the back); progressive spinal amyotrophy; dermatomyositis; glycogenosis, (type 2, Pompe disease); deficiency of carnitine - for the same reasons are rarely accompanied by a constant torso forward. Patients have difficulty in extending the trunk (for example, after tilting to pick something up) and help themselves with "myopathic techniques."

[13], [14]

D. Syndrome of the inclined spine in the elderly

This syndrome is observed only when standing and walking in persons older than 60 years ("strongent spine syndrome"). The syndrome should be differentiated with vertebral syndrome (kyphosis), but passive extension of the trunk in these patients is normal. Some patients have pain in the lower back, but they are transient and usually go through spontaneously with the course of the disease. CT of paraspinal muscles shows hypodensitivity (decreased density of muscle tissue). Sometimes an easy increase in CK is possible. On EMG nonspecific weakly expressed signs of myopathy (not in all patients). The disease refers to slowly progressing. Its nature and nosological independence are not fully established.

II. Transient episodic and repetitive torso inclinations forward

[15], [16]

A. Spasm of flexor muscles of the trunk

Dystonia (torsion spasm) axial sometimes manifests a persistent postural defect (flexion of the trunk) - dystonic camptocormia. This dystonic syndrome often presents great difficulties for its diagnostic interpretation. It is important to search for the dynamism of the symptoms that is characteristic of dystonia (the dependence of torsion spasm on changes in body position, time of day, rest-activity, alcohol effect, corrective gestures, paradoxical kinesia) and exclusion of other possible causes of postural disorder.

The slopes of the trunk ("bows") in the picture of paroxysmal dystonia. Paroxysmal dystonia (kinesiogenic and non-kinesiogenic) is extremely rarely manifested by such a form of attacks, and if it does, it is always in the context of others, typical enough of its manifestations (short, usually induced by movement, dystonic limbs in the extremities that are not accompanied by impairment of consciousness in normal EEG).

Myoclonus muscle of the flexor of the trunk is syndromically looking in such a way that it is difficult to confuse with any other syndrome. These are short, fast, jerky, flexural movements of the trunk usually of small amplitude, stereotyped. Visually, sometimes short abdominal contractions are seen, synchronous with the flexion movements of the upper half of the trunk. Full-scale bending here does not have time to develop, there is only a hint at it. The source of myoclonus and its nature needs to be specified in each individual case (spinal myoclonus, start-reaction, etc.). It is necessary to exclude the epileptic nature of myoclonus.

Epilepsy (infantile spasms, some seizures in case of complementary epilepsy) is sometimes manifested by rapid flexion movements or slower postural (including flexor) phenomena. It is necessary to search persistently for other clinical and EEG signs of epilepsy (prolonged and profound hyperventilation, deprivation of night sleep, polygraphic registration of night sleep, video registration of the seizure).

"Pseudosalamus convulsions" in the picture of acute dystonic reactions (neuroleptic syndrome) develops sharply in response to the administration of neuroleptic and are usually accompanied by other dystonic phenomena (oculogic crises, blepharospasm, trismus, protrusion of the tongue, dystonic spasms in the extremities, etc., cholinolytics or spontaneously stopping when the neuroleptic is canceled).

[17], [18], [19]

B. The torso bends forward in the picture of mental (psychogenic and endogenous) disorders

The psychogenic psychology is characterized by a typical posture in the form of a torso tilted forward at right angles with freely hanging hands (the "anthropoid posture") and is most often observed in the picture of polysyndrome hysteria (multiple motor disorders, sensory, vegetative and emotional-personality disorders).

Periodic obeisances in the picture of conversion or compulsive disorders are a kind of camptocormia, characterized by paroxysmal manifestations and observed usually in a picture of vivid demonstrative manifestations resembling a pseudoprysis.

Stereotypies in mental illness can acquire a wide variety of forms in the form of elementary senseless movements, including stereotypically repeating torso inclinations. Stereotypies can have a neuroleptic origin ("tardive stereotypes").

Expressed depression in endogenous mental illnesses is characterized by reduced efficiency, hypomia, psychomotor retardation and bent pose in the picture of other emotional, cognitive and behavioral manifestations of mental illness. Here we are not talking about the expressed bending of the trunk, but rather about the bent (stooped) "belittled" posture. There is no such thing as a camptocorm.

[20], [21], [22]

C. Torso bends forward as a compensatory (arbitrary) reaction in case of a threat of falling

The transient weakness in the legs with insufficient spinal circulation can be accompanied by the bending of not only the legs but also the trunk and enters the picture of "myelogenous intermittent claudication" (transient weakness in the legs, often provoked by walking, with a sense of heaviness and numbness in them), usually against a systemic vascular disease. Bending of the trunk here is a reflex or an arbitrary reaction aimed at maintaining the balance and stability of the body, preventing damage from falling.

Lipotymic conditions in the picture of orthostatic circulatory disorders, especially with progressive autonomic failure may be accompanied by persistent arterial hypotension with constant dizziness with a real threat of postural syncope. The presence of pyramidal, extrapyramidal and cerebellar signs (for example, in the picture of Shay-Drageer's syndrome) intensifies postural instability and can lead to characteristic disbasion in the "skater's posture" (inclination of the head and trunk forward, walking wide, directed slightly to the side, steps).

[23]