痉挛性斜颈的手术治疗(附580例报道)

目的 探讨痉挛性斜颈（ST）的手术方法及其疗效。方法 回顾性分析1995~2015手术治疗的580例痉挛性斜颈的临床资料。借助肌电图、CT或MRI等检查判断参与痉挛的肌群,将痉挛肌肉分为原动肌、协同肌、随动肌,对原动肌做去神经术和肌切断术,协同肌做去神经术,随从肌可不予处理,从而形成三种术式:术式一,面部旋向侧颈后痉挛肌肉选择性切除术;术式二,同侧颈神经 1~6后支选择性切断术;术式三,副神经切断术。旋转型ST和侧屈型ST采用二联术或三联术,后仰型ST采用双侧术式一和术式二组合,前屈型 ST采用双侧术式三组合,混合型ST分期采用颈部神经选择性切断术和肌肉选择性切除术。结果 565例术后随访6个月~15年;术后6个月评估疗效:痊愈429例,显效68例,进步52例,无效16例;优良率为88%。无死亡、无严重并发症。结论 选择性周围神经切断术及肌切断术是治疗痉挛性斜颈安全有效的方法。     

三联手术治疗痉挛性斜颈的手术配合

痉挛性斜颈是指颈肌受到中枢神经异常冲动造成不可控制的痉挛或阵挛，从而使头部向一侧痉挛性倾斜扭动，致使出现多动症状和姿势异常，是一种肌张力障碍性疾病。目前国际上普遍采用的是三联手术，即将副神经、胸锁乳突肌支切断，联合C1～6后支切断术，以此种手术方法缓解痉挛症状，有效率为70％～90％［1］。我院自2008‐02—2014‐03采用三联手术治疗8例痉挛性斜颈患者，均获得良好治疗效果。现将手术配合中应注意的问题及措施总结如下。     

旋转型痉挛性斜颈的手术治疗

目的 研究旋转型痉挛性斜颈（rotational spasmodic torticollis，RoST）的临床分型和手术治疗。方法对RoST按痉挛肌肉范围，姿态，肌肉痉挛的方式，病情程度分型。手术治疗：采用下列术式或二至三种术式组合。术式一：面部旋向侧颈后痉挛肌肉选择性切除术。术式二：同侧颈神经1-6（C1-8）后支选择性切断术。术式三：对侧副神经切断术（或加胸锁乳突肌切除术）。结果术后6个月评定疗效，全组423例，斜颈症状消失292例（69％），显效78例（18．4％），进步42例（10％），无效11例（2．6％）。无死亡，无并发症。结论采用颈部痉挛肌肉和神经选择性切断术治疗RoST创伤小、操作简便，安全无残疾。     

硬膜下超选择神经根切断术治疗痉挛性斜颈(附22例临床分析)

目的探讨经硬膜下超选择神经根切断治疗痉挛性斜颈的手术疗效。方法回顾分析我科自2004年1月~2014年1月收治的22例痉挛性斜颈患者,依据痉挛类型、肌电图结果、神经阻滞试验等明确原动肌及协从肌,行个体化超选择神经根切断术。术中借助电生理监测结果进行副神经根切断或减压、C1~C3脊神经前根高选择性部分切断,切断敏感性较高的神经根同时保留兴奋性较低的神经根。术后疗效评价6个月,随访时间6个月~6年。结果本组患者术后短期即获得不同程度的缓解,本组症状完全消失15例,明显好转3例,进步3例,无效1例,总有效率95.5%。本组无死亡、致残及恶化病例。结论经硬膜下超选择神经根切断治疗痉挛性斜颈安全有效,术前神经阻滞试验对判断参与痉挛发作的肌群及手术的可能疗效有重要意义,个体化的治疗方案有利于提高疗效并降低并发症发生,术中电生理监测是保证手术疗效、减少手术并发症的有效手段。     

丘脑腹外侧核毁损术治疗痉挛性斜颈

丘脑腹外侧核毁损术治疗痉挛性斜颈张伟痉挛性斜颈是一种原因不明的锥体外系疾病，药物治疗效果不佳。目前，此病的手术治疗方法有两种：一是颈部肌肉选择性切断或切断术及颈部肌肉的去神经术；另一类是采用定向手术颅内靶点毁损术。我院干１９９１年和１９９２年采用定向...     

内镜辅助下选择性颈神经根切断术治疗痉挛性斜颈

目的 探讨内镜辅助下选择性颈神经根切断术治疗痉挛性斜颈的疗效.方法 回顾性分析2008年1月至2009年6月显微手术治疗的57例痉挛性斜颈患者的临床资料.该显微手术,术中不咬除枕骨鳞部及枕大孔,在内镜辅助下行硬膜下双侧副神经根及颈1脊神经根切断.结果 全部患者平均随访7个月.100%病人术后立即感痉挛状态明显缓解;随访...     

改良Foerster-Dandy手术治疗痉挛性斜颈

目的 探讨改良Foerster-Dandy手术治疗痉挛性斜颈的疗效。方法 回顾分析2001年7月至2004年6月显微手术治疗的26例痉挛性斜颈病人，全部采用改良Foerster-Dandy手术，即枕后正中入路硬膜下双侧副神经根、C1脊神经根切断、C2～C4脊神经前、后根选择性部分切断术。结果 全部病人平均随访12．8个月。100％病人术后立即感痉挛状态明显缓解，随访期间缓解率为100％。生活质量提高率在随访期间为96％。术后所有病例发生不同程度转颈无力、耸肩无力、双臂外展受限，随访期间均有所好转，1例病人发生头颈部支撑困难，并因此而影响生活质量。随访期间无复发病例。结论 改良Foerster-Dandy手术是治疗痉挛性斜颈安全有效的手术方法。选择合适病例、熟悉局部解剖、掌握显微手术技巧是保证疗效的关键。     

痉挛性斜颈的临床分型和手术治疗

目的 研究痉挛性斜颈(spasmodic torticollis，ST)临床分型和手术治疗关系。方法 对ST按痉挛肌肉范围分型：单纯性ST和症状性ST。按姿态分型：旋转型、侧屈型、后仰型、前屈型和混合型ST。按肌肉痉挛的方式分型：强直型和阵挛型ST。按病情程度分型：轻型和重型。手术治疗：针对ST姿态分型采用不同术式组合。对旋转型ST，采用二联术或三联术，(术式一：面部旋向侧颈后痉挛肌肉选择性切除术或部分切除术。术式二：同侧颈神经1～6(C1～6)后支选择性切断术。术式三：对侧副神经切断术或加胸锁乳突肌切除术。三种术式合用称“三联术”。术式一和三合用称“二联术”)。侧屈型ST采用屈向侧二联术或三联术。后仰型ST采用双侧术式一或术式一和术式二合用。前屈型ST采用双侧术式三。混合型ST采用分期颈部神经选择性切断术和肌肉选择性切除术。结果 术后6个月评定疗效，全组595例，斜颈症状消失404例(68％)，显效107例(18％)，进步67例(11．1％)，无效17例(2．9％)。无死亡和严重并发症。结论 采用颈部痉挛肌肉选择性切除和颈部神经选择性切断术治疗ST，手术安全创伤小、操作简便，无残疾并发症。头部CT和MR检查未发现与痉挛性斜颈有关的颅内病灶。颈部CT显示痉挛肌肉呈肥大性改变。肌电图主要痉挛肌肉显示完全干扰波，次要痉挛肌肉显示不完全干扰波。切除的痉挛肌肉和神经病理切片均有异常表现。     

电生理监测下改良Foerster-Dandy手术治疗痉挛性斜颈初探

目的探讨电生理监测下改良Foerster-Dandy手术治疗痉挛性斜颈的安全性和疗效。方法前瞻性研究2010年11月至2011年7月显微手术治疗的7例痉挛性斜颈病人,全部采用电生理监测下改良Foerster-Dandy手术,手术方法为枕后正中入路硬膜下双侧副神经根、C1脊神经根切断、C2-4脊神经前、后根选择性部分切断术。结果全部病人术后立即感到痉挛状态明显缓解,随访期间缓解率为85.7%(6/7),生活质量提高率在随访期间为85.7%,术后6例发生不同程度转颈无力、耸肩无力,随访期间均有所好转,无吞咽困难和头颈部支撑困难病例,无严重并发症发生。随访期间1例斜颈复发,使用盐酸度洛西汀+苯海索治疗后症状显著改善。结论电生理监测下改良Foerster-Dandy手术治疗痉挛性斜颈安全有效,熟悉局部解剖、掌握显微手术技巧是手术安全的基础;选择合适的病例、合理使用电生理监测技术、个体化制定神经根选择性切断的程度是手术疗效的保证。本研究只是改良Foerster-Dandy手术治疗痉挛性斜颈的初步探索,该术式大宗病例和长期随访资料尚需进一步积累完备。     

A型肉毒毒素治疗痉挛性斜颈及Meige''''s综合征的临床研究

目的　探讨A型肉毒毒素局部注射治疗痉挛性斜颈、Meige s综合征及职业性痉挛的疗效。方法　对 2 3例痉挛性斜颈、10例完全型Meige s综合征及 1例职业性痉挛患者进行A型肉毒毒素局部注射 ,观察其治疗效果以及副作用。结果　 2 3例痉挛性斜颈患者 ,治疗后Tsui量表评分明显下降 ;10例完全型Meige s综合征 ,8例明显好转 ,2例部分缓解 ;1例职业性痉挛患者完全缓解。所有患者均未见过敏反应和严重副反应。结论　A型肉毒毒素局部肌肉注射是治疗痉挛性斜颈等肌张力障碍的有效手段。     

微侵袭手术治疗侧屈型痉挛性斜颈81例

目的研究侧屈型痉挛性斜颈(LFST)微侵袭手术治疗效果。方法将LFST相关的痉挛肌肉分成主要责任肌和次要责任肌,并明确每一肌肉的支配神经。对LFST临床分型,按不同分型制定个体手术方案。采用下列术式组合治疗。术式1:屈向侧颈痉挛肌肉选择性切除术。术式2:屈向侧颈神经1～6后支选择性切断术。术式3:屈向侧副神经切断术(或附加胸锁乳突肌、斜角肌切除术)。三种术式组合称"三联术",术式1和术式3组合称"二联术"。结果术后6～12个月评定疗效,全组81例痊愈69例(85.2%),显效8例(9.9%),进步4例(4.9%),无死亡和严重并发症。35例采用二联术治疗的患者中,痊愈27例,显效5例,进步3例,优良率91.4%(32/35);46例采用三联术治疗患者中,痊愈42例,显效3例,进步1例,优良率97.8%(45/46)。结论采用颈部痉挛肌肉选择性切除和相关神经选择性切断术治疗LFST,手术安全创伤小,效果满意。     

Selective denervation of neck muscles in the treatment of spasmodic torticollis. Preliminary results]

The authors present a review of the methods of surgical treatment of spasmodic torticollis, particularly the selective denervation of cervical muscles. Based on the literature and own experience cases treated by means of this method are described. Using selective ramisectomy it is possible to attain permanent improvement in most patients suffering from spasmodic torticollis, with very low complication rate. Our preliminary cases indicates that this method of treatment allows to acquire improvement of quality of life in patients with this particular type of dystonia.     

Pattern of premature degenerative changes of the cervical spine in patients with spasmodic torticollis and the impact on the outcome of selective peripheral denervation

OBJECTIVES: To characterise the pattern of and risk factors for degenerative changes of the cervical spine in patients with spasmodic torticollis and to assess whether these changes affect outcome after selective peripheral denervation. METHODS: Preoperative CT of the upper cervical spine of 34 patients with spasmodic torticollis referred for surgery were reviewed by two radiologists blinded to the clinical findings. Degenerative changes were assessed for each joint separately and rated as absent, minimal, moderate, or severe. Patients were clinically assessed before surgery and 3 months postoperatively by an independent examiner using standardised clinical rating scales. For comparison of means a t test was carried out. To determine whether an association exists between the side of degenerative changes and type of spasmodic torticollis a chi(2) test was used. Changes in severity, disability, and pain before and after surgery were calculated using a Wilcoxon matched pairs signed ranks test. RESULTS: Fourteen out of 34 patients had moderate or severe degenerative changes. They were predominantly found at the C2/C3 and C3/C4 level and were significantly more likely to occur on the side of the main direction of the spasmodic torticollis (p = 0.015). There was no significant difference in age, sex, duration of torticollis, overall severity, degree of disability, or pain between the group with either no or minimal changes and the group with moderate or severe changes. However, in the second group the duration of inadequate treatment was longer (10.1 v 4.8 years; p=0.009), head mobility was more restricted (p = 0.015), and head tremor was more severe (p = 0.01). At 3 months postoperatively, patients with n or minimal degenerative changes showed a significant improvement in pain and severity whereas no difference was found in those with moderate or severe changes. CONCLUSIONS: Patients with spasmodic torticollis have an increased risk of developing premature degenerative changes of the upper cervical spine that tend to be on the side towards which the head is turned or tilted and compromise outcome after surgery. Effective early treatment of spasmodic torticollis with botulinum toxin seems to have a protective effect. Patients with spasmodic torticollis and restricted head mobility who do not adequately respond to treatment should undergo imaging of the upper cervical spine. Patients with imaging evidence of moderate or severe degenerative changes seem to respond poorly to selective peripheral denervation.     

Reciprocal inhibition of forearm flexor muscles in spasmodic torticollis.

Reciprocal inhibition between forearm extensor and flexor muscles was tested by means of an H-reflex technique in patients with spasmodic torticollis and normal controls. In both, patients and controls three different phases of reciprocal inhibition could be demonstrated with maximal inhibition at conditioning test intervals of 0 ms, 15 ms and 100 ms, respectively. However, the quantitative amount of this inhibition was different for the patients and the controls. Significantly less inhibition was found for the second and the third phase of reciprocal inhibition in the patient group. Discriminant analysis showed a clear separation between normal subjects and patients if the amount of reciprocal inhibition of the second and third phase were taken into account. We were not able to detect any side differences neither for the patients nor for the controls. The findings demonstrate a functional disturbance of motor control mechanisms of a clinically unaffected extremity in spasmodic torticollis. This is believed to reflect a bilateral disturbance most likely within the basal ganglia or their outflow. Therefore, our data support the idea, that spasmodic torticollis is associated with or even due to a generalized rather than a focal disturbance of motor control mechanisms.     

Treatment of idiopathic spasmodic torticollis with botulinum toxin A: a double-blind study on twenty-three patients

In a double-blind, placebo-controlled study, 23 patients suffering from intractable spasmodic torticollis (ST) were given successively either botulinum toxin A (BTA) or normal saline by intramuscular injections in the affected muscles. Evaluation was carried out by three blinded observers, using a clinical and video assessment of the severity of torticollis, employing a scoring system described by Tsui (1). Patients were also asked to subjectively comment on changes in the amount of pain and on changes in the activities of daily living (ADL). BTA was proven to be superior on all forms of assessment to placebo, and these results were statistically significant. Side effects mainly consisted of pain at the injection site. Tiredness occurred at equal frequency with BTA and placebo. No serious or systemic side effects were noted. Botulinum toxin is a safe, effective and relatively simple treatment for spasmodic torticollis.     

三联术治疗痉挛性斜颈

采用三联手术方法治疗旋转型（ｎ２６）、侧屈型（ｎ６）痉挛性斜颈共３２例，其中男性１８例，女性１４例，平均年龄３６．５岁。适应证：１．药物治疗一年无效的旋转型、侧屈型患者。２．颈肌严重痉挛的扭转痉挛患者。结果，旋转型２６例，优１８例（６９．２％）；良７例（２７．０％）；进步１例（４％）。侧屈型６例，优４例（６６％）；良２例（３３％）。本研究结果证实三联手术的疗效较二联手术优越。     

An exteroceptive reflex in the sternocleidomastoid muscle produced by electrical stimulation of the supraorbital nerve in normal subjects and patients with spasmodic torticollis

We examined suppression of EMG activity in the contracting sternocleidomastoid muscles, produced by electrical stimulation of the supraorbital nerve in 10 normal subjects and 9 patients with spasmodic torticollis. This exteroceptive reflex in the sternocleidomastoid muscle consisted of 2 or 3 phases: (1) an early, small, and unstable phase of facilitation, followed by (2) a period of suppression beginning 35 msec after the stimulus, lasting for 35 msec with a reduction in EMG activity to approximately 40% of the prestimulus level, and (3) a further phase of facilitation at a latency of 70 msec, with duration 35 msec and an increase in EMG activity to approximately 35% above prestimulus levels. The latency and duration of the suppressive phase of this reflex were similar to the exteroceptive suppression of EMG activity in the masseter muscle after supraorbital nerve stimulation (masseter silent period). In patients with spasmodic torticollis, the depth of this exteroceptive suppression in the sternocleidomastoid muscles was less than that observed in an age-matched cohort of normal subjects, although the latency and duration were normal. In contrast, exteroceptive suppression in the masseter muscle was normal. These findings suggest abnormal function of inhibitory interneuronal networks between the 5th cranial nerve and the motor neurons of the spinal accessory and upper cervical nerves which mediate exteroceptive suppression in the sternocleidomastoid muscle in patients with spasmodic torticollis.     

Effect of prolonged neck muscle vibration on lateral head tilt in severe spasmodic torticollis

Short term vibration of the dorsal neck muscles (10-35 s) is known to induce involuntary movements of the head in patients with spasmodic torticollis. To investigate whether neck muscle vibration might serve as a therapeutic tool when applied for a longer time interval, we compared a vibration interval of 5 seconds with a 15 minute interval in a patient with spasmodic torticollis with an extreme head tilt to the right shoulder. Head position was recorded with a two camera optoelectronic motion analyzer in six different test conditions. Vibration regularly induced a rapid change of head position that was markedly closer to a normal, upright posture. After 5 seconds of vibration, head position very quickly returned to the initial position within seconds. During the 15 minute interval, head position remained elevated. After terminating vibration in this condition, the corrected head position remained stable at first and then decreased slowly within minutes to the initial tilted position. CONCLUSIONS: (1) In this patient, muscle vibration was the specific sensory input that induced lengthening of the dystonic neck muscles. Neither haptic stimulation nor transcutaneous electrical stimulation had more than a marginal effect. (2) The marked difference in the change of head position after short and prolonged stimulation supports the hypothesis that spasmodic torticollis might result from a disturbance of the central processing of the afferent input conveying head position information-at least in those patients who are sensitive to sensory stimulation in the neck region. (3) Long term neck muscle vibration may provide a convenient non-invasive method for treating spasmodic torticollis at the central level by influencing the neural control of head on trunk position.