Peripheral Procedure for Torticollis:
Selective peripheral denervation (Cervical rhizotomy)
Central procedures for Torticollis:
It is indicated in patients with prominent (phasic or myoclonic) dystonic movements or with dystonic head tremor. It is the treatment of choice in a patient of cervical dystonia/torticollis with extracervical symptoms such as blephalospasm, oro-laryngeal dystonia or limb dystonia.
The nucleus ventralis oralis internus i.e. the VOI nucleus of thalamus is the target for lesioning in thalamotomy. Unilateral thalamotomy produces only minor improvements in axial and cervical dystonia. While bilateral thalamotomy is more effective as compared to unilateral thalamotomy, It is associated with a 10–40% risk of serious complications, especially bulbar weakness, resulting in hypophonia or dysphagia, dysarthria, cognitive impairment and ataxia. Generally, immediate results of thalamotomy in cervical dystonia are unimpressive, but progressive benefit occurs over weeks to months. This surgery is not advocated by most functional neurosurgeons.
Posteroventral GPi DBS is the most widely utilized stereotactic target for all types of dystonia. It is particularly effective for the dystonia associated with PD, as well as for generalized dystonia.
Generally the effects of GPi DBS on dystonia are not immediate. The improvement in symptoms follows a sequence, with improvement in pain first, then motor disability and finally severity.
Dystonic movements (including phasic, myoclonic and tremulous features) may improve immediately or may take a few hours or days after surgery. Dystonic postures (i.e., tonic features) generally have a delayed improvement over weeks to months.
The advantage of DBS is that it has additional benefit of titrability. We usually advocate DBS for patients having associated symptoms of dystonia in the upper limb or likely to develop dystonia or other body parts. In all other pure cervical dystonia patients we prefer to perform Cervical Rhizotomy .
For detailed description of the procedure click on – Deep Brain Stimulation.