The spasmodic torticollis : treatise with special consideration of a new surgical therapy approach

Abstract

Dr. med. Niels Freckmann, Hamburg, 15.12.1987

Abstract of the habilitation thesis

Spasmodic torticollis treatise with special consideration of a new surgical therapy approach

My habilitation thesis deals with the etiologically unexplained “spasmodic torticollis” (ST) with special consideration of pathogenesis and surgical treatment. ST is defined as a movement disorder limited to the neck limited to the neck muscles. The most important hypotheses for the pathogenesis of ST are the psychogenic genesis, the vestibular/labyrinthine hypothesis, the reticular formation hypothesis and the basal ganglia hypothesis, which has generally found the broadest support. There is no known causal treatment for ST. The results of stereotactic surgery are as unsatisfactory as those of rhizotomy of the anterior roots C1 to C3 (50% to 70% improvement), especially as these interventions are destructive in nature.

On the basis of our own clinical, anatomical and electromyographic findings, as well as data from 46 torticollis patients who underwent surgery, the theory of a unilateral disturbance of proprioceptive afferents from the head joints responsible for ST is developed. Accordingly, the surgical treatment of “pure” ST requires a new, peripheral approach. The aim of our “bilateral microsurgical lysis of the spinal accessory roots” (BMLA) is the symmetrization of the afferent stimulation current from the craniocervical region to the reticular formation and thus the suppression of unilateral excessive efferent impulses. Compared to other surgical procedures, BMLA is less destructive and has hardly any side effects. The following results (n=37) were achieved: 7 times there was a complete regression of symptoms, 11 times there were still minor residual symptoms and 13 times there was an improvement observed. In three patients, the condition remained unchanged and we observed a deterioration in two cases. One patient died as a result of a revision. In 82% of ST patients, anastomoses were found between the accessorius root and posterior root C1. This was the case in only 46% of the normal section material. In addition, 2/3 of the ST cases showed compression of the accessory roots with evidence of degenerative changes. An anatomical predisposition is therefore postulated for ST. When the patients with purely horizontal or rotatory ST (n=27) were considered in isolation, it was noticeable that, with one exception, improvements were achieved (96%). In 10 patients with combined torticollis symptoms, we saw only 6 improvements; in 4 patients, the further postoperative course suggested the presence of torticollis dystonicus with a cenral motor cause. This underlines the importance of differential diagnosis for treatment. Stereotactic interventions should be limited to proven central motor movement disorders: Here we were able to achieve an improvement in symptoms in 19 out of 20 patients.