A Ten Year Experience

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SELECTIVE PERIPHERAL DENERVATION FOR SPASMODIC TORTICOLLIS

A TEN YEAR EXPERIENCE

CARLOS A. ARCE, M.D.

DEPARTMENT OF NEUROSURGERY

UNIVERSITY OF FLORIDA, HSC, JACKSONVILLE

Selective Denervation is a procedure that was introduced by Dr. Claude Bertrand in the 1980’s. He based his operation on the fact that in torticollis only a selected group of muscles are involved and these muscles are going to determine the direction of the head and neck movement. By finding which muscles are involved, a selective denervation, or nerve sectioning, can be performed on only the muscles involved. The division of these nerves is done outside the spine minimizing the risks and side effects. The operation has helped a significant number of patients and has allowed them to improve their quality of life. More than a thousand patients have been successfully treated and this is a tribute to Dr. Bertrand and his efforts to help patients with torticollis.

This operation is most successful in treating patients with the following types of torticollis: rotational – in which the head turns; laterocollis – in which the head tilts toward the shoulder; retrorotational – in which the head turns and tilts backwards, and retrocollis – in which the head only tilts backwards. It has not been successful in helping patients with anterocollis – in which the head tilts downward. In patients with segmental dystonia – that is, patients who have torticollis and also involvement of the trunk and/or arms, and in patients with mixed movements – alternating movements in different directions, only a partial improvement will be obtained.

There are several factors that can affect the success of the operation, and one of the most important is the development of an abnormal posture of the spine, because of the time the patient spends with his/her head in an abnormal position. Once an abnormal posture has developed, this will prevent the patient from achieving a straight posture and regaining a normal range of movement, regardless of the treatment. Ideally, if surgery is to be considered, it should be performed before the abnormal posture develops. Many patients consider surgery as the last resort, and by the time they consider it, they have developed an abnormal posture of the spine, lost significant range of movement, and are affected by worsening pain. By then selective denervation may not be performed, or, if it is, the success will be limited. Patients need to have this in mind and not wait too long before considering surgery. The best results are obtained in patients with normal posture and range of movement.

The other aspect that is paid little attention is the time or number of years the patient has his/her torticollis. In my experience, patients who have the operation early, within two or three years of the onset, do the best. It is possible that doing the operation early may effectively arrest the condition. This is important as more and more of the patients that I am seeing now are patients who have had the condition for many years, and have tried multiple treatments, and by the time that they decide to consider surgical treatment they have developed fixed abnormal postures and complex movements. Although surgery may help them somewhat, a better result could have been obtained had we operated earlier. The other advantage of doing the operation early, especially before developing resistance to Botulinum toxin, is that; if needed, surgery can be complemented with Botulinum toxin (for example shoulder muscles such as the trapezius can be treated with Botulinum toxin), enhancing the overall results. Furthermore, the amount of Botulinum toxin used will be less as the number of muscles that will need treatment is smaller.

In the last ten years, I have had the opportunity to treat over 400 patients. Excellent results (more than 70% improvement) have been obtained in over 80% of the patients with the types of torticollis described above. The results of the operation are lasting – having followed up on patients now for ten years with persistent good results.

The evaluation of the patient consists of a clinical examination and an EMG evaluation. The surgery takes six to eight hours to perform. Most of the patients are discharged after one or two days in the hospital. In some cases, the operation may need to be done in stages six months apart. There has been no mortality and there have been no cases of paralysis or major side effects. One common fear in patients considering this surgery is that their head is going to drop forward. This has never happened with selective denervation. In the last year I have used a lateral incision instead of the usual midline incision, which has decreased the immediate post-operative pain significantly.

After surgery, it is important to do exercises to regain a midline posture and to increase the range of movement; however, it is important not to overdo it. There is no need for strong manipulations, intensive exercise that brings on pain or shoulder muscle exercises. Patients with torticollis need to learn to relax their shoulder muscles.

Selective denervation is a safe surgery that offers patients with torticollis an alternative treatment with excellent success, especially if performed before developing an abnormal posture of the spine or loss of range of movement.

My mom and I wanted to thank you for hosting such a great symposium this year. This was our third year and we are looking forward to next years. E. Mathews