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a Center for Dystonia, Neurological Institute,
Columbia-Presbyterian Medical Center, b Sergievsky Center, Columbia
University, New York, USA
Correspondence to: Dr Blair Ford, Neurological Institute, Columbia College of Physicians, 710 West 168th Street, New York 10032, USA. Telephone 001 212 305 5548; fax 001 212 305 1304; email Ford{at}movdis.cis.columbia.edu
Received 18
December 1997 and in revised form 11 March 1998;
Accepted 19 March 1998
OBJECTIVE
To investigate the long term outcome of
selective ramisectomy denervation in patients with botulinum toxin
resistant spasmodic torticollis.
BACKGROUNDThe published surgical series of
ramisectomy treatment for torticollis do not provide systematic
information on patients who develop resistance to the current standard
of treatmentbotulium toxin injections. Moreover, there is little
information on surgical outcome using rating scale measurements of
torticollis, or assessments of functional and occupational capacity.
METHODSUsing a structured interview format and
videotape assessments of severity of dystonia in a retrospective
fashion, detailed follow up information was obtained on 16 patients who
underwent open label selective denervation for severe, disabling
torticollis, refractory to injections of botulinum toxin.
RESULTSOf 16 patients with disabling torticollis
followed up postoperatively for a mean of 5 years, six (37.5%) had a
moderate or complete return of normal neck function, as determined
using functional capacity scales, whereas 10 had only minimal relief of
dystonia or gain in function. Six of the 16 patients (37.5%) underwent a second peripheral denervation operation, and one required a third. Of
11 patients working outside the home before surgery, nine were disabled
by dystonia, and only one continued to work after surgery. Dystonia
rating scale scores of videotaped examinations using a modification of
the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS)
improved in 12 of 14 patients (85.7%) who underwent selective
ramisectomy. When patients with primary botulinum toxin resistance were
excluded, the magnitude of benefit for this subgroup was 31.9% of the
baseline dystonia score (p<0.0002), comparable with the degree of
improvement in a group of control patients receiving botulinum toxin
treatment for torticollis.
CONCLUSIONAbout one third of patients with
torticollis resistant to injections of botulinum toxin may derive
modest long term functional improvement from selective denervation,
with a reduction in dystonia by about 30%, but remain unable to work.
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