Comparison of 2 Operative Methods for Treating Laterocollis and Torticollis Subtypes of Spasmodic Torticollis: Follow-Up of 121 Cases

Selective Peripheral Denervation and Selective Nerve Injury for the Treatment of Cervical Dystonia Through a Periauricular Incision

Traditional selective peripheral denervation methods for treating cervical dystonia (CD) involve complete transection of the nerves to muscles through a posterior incision proximally after they exit the spinal cord. This report presents a case where anterior muscles involved in CD cannot be easily addressed through the traditional posterior approach. Furthermore, complete denervation of certain muscles, such as the trapezius, can lead to functional limitations. The objective of this report is to describe an anterior surgical treatment approach for focal CD. Specifically, we describe the use of a periauricular incision to perform selective peripheral denervation of anterior and posterior neck muscles at a more peripheral location near their target muscle entry point. Complete denervation was performed for expendable muscles while Sunderland third-degree nerve injury was performed to weaken nonexpendable muscles. This approach facilitates clearer identification of nerves as they enter the pathologic target muscle. Additionally, the therapeutic use of Sunderland third-degree nerve injury in the treatment of CD is a useful adjunct to muscles that are nonexpendable as it allows for only partial denervation as opposed to complete denervation with traditional methods.

[Historical view on the pathogenesis and surgical treatment of cervical dystonia]

In the past few decades, approaches to surgical treatment of dystonia passed through paradigmatic shift. Intradural upper cervical anterior rhizotomy was replaced by selective peripheral denervation with lesser spectrum of side-effects. Such techniques as microvascular decompression of accessory nerve or spinal cord stimulation for cervical dystonia were abandoned due to lack of proven efficacy. Introducing globus pallidus interna (GPi) DBS in 1990's to treat all types of dystonia, including cervical dystonia, was a fundamental factor. With the growing body of knowledge on the pathophysiology of dystonia, GPi DBS appears to be the most expedient, effective and safe method with limited indications to peripheral destructive procedures.

Cervical Dystonia Caused by Chronic Nonunion C2 Fracture: A Case Report

Chronic nonunion cervical fracture leading to cervical dystonia (CD) is very rare. This study reports a 72-year-old man who presented with 9-month history of progressively worsening neck tilting, neck tightness, neck pain, headache, and difficulty with swallowing. The patient was referred to speech therapy and confirmed to have dysphagia on modified barium swallow study. A cervical spine radiograph showed a chronic C2 nonunion fracture. Subsequent cervical spine magnetic resonance imaging confirmed chronic C2 nonunion fracture with kyphotic deformity of the cervical canal with associated cord compression at C1-C2 and severe central canal stenosis. Needle electromyography revealed dystonic or spasmodic neck muscles, consistent with diagnosis of CD. Botulinum toxin injection resulted in marked clinical improvement. The patient finally underwent occipital to C4 posterior segmental fusion. No recurrence of CD had occurred 12 months after botulinum toxin injection and surgery, which supports the conclusion that chronic C2 nonunion fracture is most likely responsible for CD in this case. The authors suggest that all patients with CD receive dysphagia evaluation and more importantly cervical spine imaging to rule out chronic C2 nonunion fracture.

Improvement of quality of life and mental health in patients with spasmodic torticollis after microvascular decompression

OBJECTIVE

Although not life threatening, spasmodic torticollis (ST) impairs patients' daily activity, socialization and work. The aim of this study was to evaluate the quality of life (QOL) and mental health in patients with ST after microvascular decompression (MVD).

PATIENTS AND METHODS

From June 2014 to June 2017, patients with ST who underwent MVD in our department were included in this study. Toronto Western Sparse Torticollis Rating Scale (TWSTRS) were used to evaluate the ST symptoms. Quality of life was assessed by the craniocervical dystonia questionnaire (CDQ-24). Beck Depression Inventory (BDI-II) and Beck Anxiety Inventory (BAI) were used to evaluate the mental health. Intraoperative findings and follow-up results were analyzed.

RESULTS

A total of 104 consecutive patients were enrolled in this study. At the 12 months follow-up, the total effective rate was 81.73%. After MVD surgery, 88(84.62%) ST patients experienced QOL improvement. The severity of ST symptoms was positively correlated with the CDQ-24 score(r = 0.31, P = 0.02). Forty-eight patients (46.16%) with ST have moderate to severe depression and nine (8.65%) have depression preoperatively. Pain and disability domains of TWSTRS were found have high relation with BDI-II score(r = 0.27, P = 0.02; r = 0.33, P = 0.03). There was a positive correlation of educational levels with the BDI-II scores(r = 0.45, P = 0.02).

CONCLUSION

ST affects patients' QOL both physically and mentally. MVD for ST not only provides high spasm-relief rate but also leads to significantly higher QOL after surgery. Not only ST symptoms, but also psychiatric status of patients should be routinely followed. Psychological care and psychopharmaceuticals should also be considered for these patients.