Effects of Deep Brain Stimulation and Botulinum Toxin to Manage Pisa Syndrome in Parkinson's Disease

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BACKGROUND: Pisa Syndrome (PS) is an abnormal postural deformity characterized by lateral trunk flexion leading to significant disability in patients with Parkinson's disease (PD). Botulinum toxin (BTX) and deep brain stimulation (DBS) have emerged as potential interventions. OBJECTIVES: To systematically review the available evidence on the efficacy and safety of BTX and DBS in managing PS in patients with idiopathic PD. METHODS: A systematic review was conducted following PRISMA guidelines. PubMed and Embase were searched for studies reporting BTX or DBS interventions for PS in PD patients. Outcomes included lateral trunk flexion (LTF) angle, pain scores, and clinical scales assessing posture. Risk of bias was assessed using RoB-2, ROBINS-I, and JBI tools. Meta-analyses were performed using random-effects models for BTX-related outcomes. RESULTS: Sixteen studies comprising 113 patients with PD and PS were included. Of these, 96 patients received BTX injections and 17 underwent DBS. Pooled analysis of four BTX studies (n = 45) showed a significant reduction in LTF angle (MD: 5.94°; 95% CI: 1.05 to 10.84) and VAS pain score (MD: 3.36; 95% CI: 1.73 to 4.99). Among the 17 patients treated with DBS, 14 received subthalamic nucleus (STN) stimulation, and the remainder underwent PPN or GPi targeting. Improvement in trunk posture was observed in 13 (76%) DBS cases. CONCLUSIONS: This review finds that BTX injections are safe and effective for managing PS in PD, showing consistent, although modest, benefits in reducing posture abnormalities and pain. DBS shows promise, particularly with STN targeting, but stronger evidence is needed to confirm its efficacy.

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