Severe motor tics causing cervical myelopathy in Tourette's syndrome

We describe two patients with Tourette's syndrome in whom severe motor tics involving the neck were complicated by cervical myelopathy. The first patient, a 21-year-old man, had complex tics consisting of violent twisting and extending movements of the neck preceded by an irresistible urge to produce the abnormal postures. Two years after onset of these tics, paraesthesias, sensory deficits up to the level of C4, and a gait disturbance developed. Neuroimaging studies confirmed compressive myelopathy, and the symptoms gradually improved with botulinum toxin injections in the posterior cervical muscles. The second patient, a 42-year-old man, had violent clonic tics consisting of thrusting head jerks. The repetitive flexion-extension neck movements had been present since the age 10 years. At age 23, he developed progressive weakness of all four extremities and bladder and sexual dysfunction. Myelography demonstrated cervical spinal canal stenosis with retrospondylosis from C3 through C5 and a Klippel-Feil malformation. After cervical decompression by C3-C5 laminectomies, his spinal cord symptoms improved temporarily. The tics, however, continued, and the neurologic deficits of cervical myelopathy progressed again after age 34. He did not benefit from a second operation. This report draws attention to the possibility that some tics can produce disabling compressive myelopathy. Early diagnosis and treatment of the movement disorder is essential in such cases.