Pattern of premature degenerative changes of the cervical spinein patients with spasmodic torticollis and the impact on the outcome ofselective peripheral denervation

摘要

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 χ² 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 outof 34 patients had moderate or severe degenerative changes. They werepredominantly found at the C2/C3 and C3/C4 level and were significantlymore likely to occur on the side of the main direction of the spasmodictorticollis (p=0.015). There was no significant difference in age, sex,duration of torticollis, overall severity, degree of disability, orpain between the group with either no or minimal changes and the groupwith moderate or severe changes. However, in the second group theduration 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 no or minimaldegenerative changes showed a significant improvement in pain andseverity whereas no difference was found in those with moderate orsevere changes.
CONCLUSIONS—Patientswith spasmodic torticollis have an increased risk of developingpremature degenerative changes of the upper cervical spine that tend tobe on the side towards which the head is turned or tilted andcompromise outcome after surgery. Effective early treatment ofspasmodic torticollis with botulinum toxin seems to have a protectiveeffect. Patients with spasmodic torticollis and restricted headmobility who do not adequately respond to treatment should undergoimaging of the upper cervical spine. Patients with imaging evidence ofmoderate or severe degenerative changes seem to respond poorly toselective peripheral denervation.