Spasmodic Torticollis: The Role of Surgical Denervation

Abstract

Physicians treating patients with spasmodic torticollis (cervical dystonia) have long faced a difficult dilemma. Medical treatment, relying chiefly on anticholinergics,benzodiazepines, and related drugs, supplemented with physical ther­ apy, biofeedback, bracing, and supportive psy­ chotherapy is satisfactory in only a minority of patients. The pain of the severe muscle spasms may be alleviated, but the involuntary move­ ments and abnormal postures are only modest­ ly decreased. For many years, the alternative has been myotomy or surgical denervation of the affected muscles. This approach has been used not only in torticollis but also in other fo­ cal dystonias-for example, essential blepharo­ spasm, oromandibular dystonia, and spasmod­ ic dysphonia. The procedures have varied with the anatomic region affected, but the principle has remained the same: to damage the neu­ romuscular apparatus. Thus, ophthalmic sur­ geons have avulsed the branches of the facial nerve that innervates the orbicularis oculi to prevent uncontrollable blepharospasm, otorhi­ nolaryngologists have sectioned the recurrent laryngeal nerve to overcome the spasms of the cricoarytenoidmuscles, andneurosurgeonshave developed various procedures for denervating the cervical muscles in an effort to control spas­ modic torticollis. SurgicalApproaches.-Formanyyears, the major surgical approach to spasmodic torticollis was ventral rhizotomy of the upper cervical roots plus section of the spinal accessory nerve on the side of the hypertrophied sternocleido­ mastoid muscle. The fourth cervical root was