Selective Peripheral Denervation

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Carlos A. Arce, M.D.

Neurosurgeon, University of Florida HSC, Jacksonville

Surgical operations for cervical dystonia, also known as spasmodic torticollis, come in two forms: those that are performed on the central nervous system (the brain and the spinal cord) and those that are performed outside the central nervous system. The latter are the safest, as they do not compromise these important structures. Selective Peripheral Denervation is the most successful of these procedures. Since its introduction by Dr. Claude Bertrand in the 1980s, Selective Peripheral Denervation has been performed on over 2000 patients with an excellent rate of success, helping 70 to 80 percent of the patients and allowing them to have a better quality of life. This procedure is safe, with only mild side effects and no significant risk. The principle behind the operation is that only a select number of muscles in the neck are affected in patients with cervical dystonia. These affected muscles determine the direction of the abnormal movement, which varies from patient to patient. By determining which muscles are involved a selective denervation or sectioning of the nerves, going only to the muscles involved, can be performed, thus preserving the muscles that are not involved. This allows the patient to maintain a good range of movement. The division of the nerves is done outside the spine next to the muscles, which makes the surgery safe, and is the main reason there are no significant side effects or complications.

The surgery does not help every patient with spasmodic torticollis. The best candidates for Selective Denervation are patients with rotational torticollis (head turning), lateral torticollis (head tilting), retro-rotational torticollis (head turning with a backward movement) and retrocollis (backward movement). Unfortunately, Selective Denervation does not help patients with anterocollis (in which the head goes down or forward). After the onset of spasmodic torticollis, there is often a progression of the condition. It is, therefore, better to wait at least a year or until the condition has stabilized before seeking treatment with Selective Peripheral Denervation. Patients considering the procedure must be evaluated clinically, have an EMG test to determine the affected muscles, and be videotaped to study their movement. Technical improvements in the surgery have significantly decreased the immediate post-operative pain and patients need only stay in the hospital overnight. Afterwards, it is important that patients do exercises to improve their posture, regain a sense of midline, and improve the range of movement.

Patients who find it difficult to maintain a normal head position and who keep their heads turned or tilted most of the time can eventually develop a fixed, abnormal posture of the spine. It is important for these patients to consider Selective Peripheral Denervation before the spine develops an abnormal posture so they can obtain the most benefit from the surgery. The response to Botulinum toxin should not be considered a determinant factor. Selective Peripheral Denervation can be successful not only in patients who respond to Botulinum toxin, but also in patients who do not respond. Furthermore, having had Selective Peripheral Denervation, patients may continue to receive Botulinum toxin or other treatments. In some cases the combination of Selective Denervation to treat some muscles, and Botulinum toxin to treat others, offers the most success in helping the patient.

Selective Peripheral Denervation is the safest procedure for patients with cervical dystonia and offers them an alternative treatment with an excellent success rate.

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