选择性周围神经切断和肌切断治疗痉挛性斜颈400例结果

目的 分析400例选择性周围神经切断和肌切断术治疗痉挛性斜颈的方法和效果。方法 借助肌电图(EMG)，CT或MRI等检查揭示参加痉挛的肌群。作者将痉挛肌分为三类，原动肌作去神经术和肌切断术，协同肌作去神经术，随从肌可不予处理。文中介绍三种临床型别的手术入路。结果 手术共400例，其中272例经2～31年长期随访，总优良率为86．4％，无死亡，无重大并发症，颈向各方向运动有力，疗效最长的患者至今已31年。结论 本手术方法适用于姑息治疗无效的痉挛性斜颈病例。     

Selective peripheral denervation for spasmodic torticollis: is the outcome predictable?

If botulinum toxin fails in the treatment of cervical dystonia, selective peripheral denervation is now accepted as the best surgical option. Despite the very promising results, however, there is still a substantial group of patients who do not benefit from this procedure. Positive response to prior botulinum toxin therapy seems to be a very good predictor of outcome after selective pepripheral denervation (P <0.01). The meaning of the histological findings of the resecte nerves is uncertain. Patients with histologically proven pathological nerves do not seem to benefit more than patients with histological normal ones (P <0.30).     

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...     

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.     

Botulinum toxin treatment in spasmodic torticollis.

Botulinum toxin A was administered to 19 patients in a double-blind placebo controlled trial. Toxin was more effective than placebo for improving both head position and pain which was measured by an objective rating scale and videofilm assessments. Following the controlled trial, treatment with botulinum toxin was continued in an open fashion. A total of 60 patients with torticollis received toxin in a total of 117 treatment periods. The mean follow up period was 8.4 months. In 39 patients with pain there was benefit in 77% of treatment periods. Some improvement in neck posture occurred in 83% of the treatment periods with a mean duration of 12 weeks. Side effects were frequent with dysphagia being the most common (28% of treatment periods). Botulinum toxin is an effective treatment for toticollis but treatment should be initiated with doses at the lower end of the range used in this study (400-600 mouse units).     

Therapeutic outcome of spasmodic torticollis]

We investigated 117 patients with spasmodic torticollis who had visited us to seek for appropriate treatment in these 14 years. They were 71 men and 46 women, aged 44 +/- 14 (mean +/- SD) years, and suffered from this disorder during 4 +/- 5 years, maximum 26 years. Involuntary abnormal head positions, not only torticollis but also laterocollis and antero- or retrocollis, were contained in this study. Most of them were torticollis due to idiopathic focal dystonia. One or more courses of alcoholization therapy was accomplished in 82 patients who wished to be done. This therapy course consisted of about ten times totally of 99% ethanol injection to the motor point of two most hypertonic neck muscles, either side of the sternocleidomastoideus and the opposite side of the splenius in most cases, repeated every 2 or 3 weeks. One patient received as many as 98 times of this injection and resolved completely. Training to reinforce antagonistic muscles was also instructed. Twenty-one patients (26%) were resolved completely after this treatment. Fifty-four patients (66%) were ameliorated and satisfied partially, but 18 of them relapsed in 1 to 4 years after the treatment and were obliged to repeat one more course of this treatment. On the other hand, in five patients their torticollis improved under certain drug therapy alone. Sixteen patients (14%) gave up to continue the treatment within two months, and 14 patients (12%) dropped out before starting the therapy. This alcoholization therapy resulted in amelioration of torticollis in about 90% of the patients with a long effective period. Nevertheless, this alcohol injection is painful, and requires 5 to 6 months to be completed. In 2 patients who had already received many times of this injection, sudden hoarseness occurred one day immediately after the alcohol injection to the sternocleidomastoideus. This complication was presumably brought about by the unexpected infiltration of alcohol to the laryngeal area, located posterior to that muscle. They recovered in two months, but careful attention should be paid to the adverse effects. If botulinum toxin be available also in our country, we will be able to have another choice of therapy and the treatment of this disorder will become easier.     

Comparative radiological study between spasmodic torticollis and Parkinson's disease. Notes on the etiology of spasmodic torticollis]

The comparative clinic-radiological study between 45 patients with spasmodic torticollis and the same amount of patients with either essential Parkinsonism or tremor is reported. The study was based mainly on the alterations verified by plain roentgenograms and pneumoencephalography. The comparison between the findings obtained on both groups led the authors to conclude that neuroradiological aspects have statiscally no value in clarifying the etiology of the spasmodic torticollis.     

Remission in spasmodic torticollis.

In 26 patients with spasmodic torticollis followed up for a median period of 12 years, the frequency of sustained remission was 23%, the median duration of remission was 8 years and duration of torticollis before remission 3 years. These results are more favourable than stated in the literature and should be taken into consideration before recommending surgical treatment.     

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。     

Local alcoholisation treatment of spasmodic torticollis

Idiopathic spasmodic torticollis is a type of focal dystonia. Major muscles which rotate the neck are M. sternocleidomastoideus (SCM) and M. splenius capitis (Spl) on both sides. In torticollis patients, its clinical characteristics could be understood as a vectorial summing up of tonus in bilateral SCM and Spl at rest. There is not any curative treatment for dystonia yet. A variety of medications and many types of surgical interventions have been tried without consistent or satisfactory results. In recent days local injection of botulinum-A toxin has shown to be effective in weakening focal dystonias. We used pure ethanol for local injection. Fourteen patients aged between 20-77 years (mean 48.9) were treated by alcoholisation. Disease duration ranged from 5 months to 12 years (mean 4.9 years). All had torticollis alone or had segmental dystonia containing spasmodic torticollis. Patients were recorded electromyographically using surface electrodes to make sure which neck muscles were hypertonic, and were rated before and after treatment according to the stages (0; normal-5; most severe). On the bases of these recordings the two most active muscles were selected for injection. Into the motor point of these muscles 1 ml of 1% lidocaine, and then the same dose of 99% ethanol were injected. This procedure was repeated on the mean ten times (6-14 times) every other week. The number of times of injection was decided in each case. Using the paired Student t test, there was a significant (p less than 0.01) improvement of the stage for the patients after injection, with a mean of 3.7 before treatment and 2.3 after treatment.(ABSTRACT TRUNCATED AT 250 WORDS)     

Vestibular involvement in spasmodic torticollis.

Vestibular findings in a group of 35 patients with spasmodic torticollis without other otological or neurological symptoms were reviewed. The most consistent abnormality, present in more than 70% of cases, was a directional preponderance of vestibular nystagmus in the dark in a direction opposite to the head (chin) deviation. Rigidly clamping the head to a rotating chair did not abolish the directional preponderance. In the presence of optic fixation the directional preponderance was less frequent and its severity tended to diminish as a function of the duration of the disease. Smooth pursuit and optokinetic nystagmus were only occasionally affected. The results are indicative of primary involvement of the vestibular system in spasmodic torticollis and are discussed in terms of a break-down of the central mechanisms conveying sensory information responsible for head and eye orientation.     

Botulinum toxin in spasmodic torticollis.

Ten patients with spasmodic torticollis were treated by injection of a total dose of 30 ng of botulinum toxin type A into the affected sternomastoid and posterior cervical muscles. Nine patients reported improvement in head position and control, which was confirmed in seven cases by clinical assessment and "blind" videotape ratings before and 6 weeks after injection. Five patients who had pain reported relief. Seven patients had mild transient dysphagia after injection; two who were given a more concentrated solution of the toxin developed more severe dysphagia, but this also recovered. Other minor transient side effects included weakness of the voice and local pain. The beneficial effects of botulinum toxin injections lasted some 2 to 3 months. A slight reduction in the total dose of toxin injected avoided the main side effects, and this method of treatment appears to offer successful control of head position and pain in the majority of patients with torticollis.     

Saccadic function in spasmodic torticollis.

Twelve patients with idiopathic spasmodic torticollis were compared with 19 normal controls on tests of saccadic eye movements thought to depend upon normal basal ganglia function. The patients were able to make random, predictive, remembered, and self-paced saccades equally as well as control subjects. This suggests that those parts of the basal ganglia which may be damaged in spasmodic torticollis, are separate from pathways responsible for the normal initiation and execution of saccades.     

Short latency trigemino-sternocleidomastoid response in muscles in patients with spasmodic torticollis and blepharospasm.

OBJECTIVES: To further elucidate the pathogenesis of focal dystonias. METHODS: Short latency responses can be recorded in tonically active sternocleidomastoid muscles after stimulation of the infraorbital branch of the trigeminal nerve. Such trigemino-sternocleidomastoid response consists of a bilateral positive/negative wave in the average of unrectified surface EMG, corresponding to a short period of inhibition of motor unit firing. This brain stem reflex was investigated in 10 normal subjects, in 16 patients affected by spasmodic torticollis (ST) and in 10 patients with blepharospasm (BSP). RESULTS: All ST patients presented abnormalities of SCM responses after infraorbital nerve stimulation. The abnormalities were bilateral in all but one of the patients and were independent from previous treatment with botulinum toxin. No BSP patients showed alterations of this reflex. CONCLUSIONS: Abnormalities of brain stem interneurons which are responsible for oligosynaptic exteroceptive suppression reflexes occur specifically in ST. These findings further support the relevance of sensory inputs in the determinism of focal dystonias.     

Bromocriptine treatment of spasmodic torticollis. A double-blind crossover study.

A double-blind crossover study (12 weeks and 12 weeks) was performed to evaluate the effects of bromocriptine on the symptoms and serum prolactin levels of 14 women with spasmodic torticollis. While the serum prolactin level decreased in response to bromocriptine, no difference was found between the effects of placebo and bromocriptine on the symptoms of spasmodic torticollis. Our findings suggest that dopaminergic neurotransmission is not involved in the pathogenesis of this syndrome.     

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。