二次改良Foerster-Dandy手术治疗痉挛性斜颈的围手术期神经电生理监测和疗效评价
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摘要
局限性肌张力障碍(focal dystonia, FD)是肌肉异常收缩导致姿势异常。痉挛肌肉的过分活跃被认为是基底节或脑干的神经生理紊乱所导致。痉挛性斜颈(spasmodic torticollis,ST)是局限性肌张力障碍中最常见的一种,已被大多数学者认为是一种锥体外系疾病,以颈部肌肉持续不自主收缩导致的痛性致残性颈部痉挛和头部异常姿势为特征。ST的发病与遗传、.外伤、精神心理、神经递质紊乱、感觉系统功能异常以及某些药物等有关,但到目前为止,尚没有一种学说能从根本上阐释其病因。经常应用于治疗锥体外系疾病的药物用来治疗ST往往疗效较差。肉毒素的应用打破了药物治疗ST的僵局,只要对颈部主要痉挛肌肉作局部注射便能暂时缓解症状,但长期反复应用导致抗体产生,效果差,副作用也较大。
对于保守治疗(至少半年以上)无效的重症ST,则需外科手术干预。由于病因尚不明确,所以目前ST的外科治疗主要为症状性治疗。所采取的术式包括肌切断术、神经切断术、脊神经根切断术、立体定向脑运动核毁损术、副神经根显微血管减压术、脑深部慢性电刺激术、鞘内泵入巴氯芬疗法和Foerster-Dandy手术等。经典Foerster—andy手术即双侧硬脊膜下C1-C4脊神经前根及副神经根切断术。该术式的指导思想是认为参与ST的痉挛肌肉分布广泛,涉及面大,所以不区别临床型别一律作双侧前根切断,不区别痉挛和非痉挛肌肉一律用等量去神经术麻痹颈肌,生理毁损大,牺牲了很多正常肌肉；术后并发症多,且存在去神经不足、痉挛肌肉松弛不够的缺点。我科基于颈段脊神经后根选择性部分切断术治疗脑性瘫痪导致的上肢痉挛状态的原理,对于重型ST患者行相应颈部脊神经后根选择性部分切断也可以部分缓解痉挛,配合前根选择性部分切断,既可保证疗效,又可避免全部前根切断的弊端,使术后并发症大幅减少。并于2001年和2007年先后对该术式进行两次改良,本研究旨在探讨两次改良Foerster-Dandy手术治疗痉挛性斜颈的疗效及并发症。方法回顾分析2001年7月至2009年6月手术治疗的183例痉挛性斜颈患者,其中A组126例采用初次改良Foerster-Dandy手术,即枕后正中入路硬膜下双侧副神经根、C,脊神经根切断、C2-C3脊神经前、后根选择性部分切断术,B组57例采用二次改良的Foerster-Dandy手术,即术中不咬除枕骨鳞部及枕大孔,在硬性神经内镜辅助下行硬膜下双侧副神经根切断术,其余步骤同初次改良Foerster-Dandy手术。
结果全部患者平均随访33.4个月。两组100%病人术后立即感痉挛状态明显缓解,随访期间缓解率分别为92.9%(117/126)、94.7%(54/57),差异无统计学意义(P>0.05)；A组随访期间痉挛状态不同程度复发9例,B组随访期间痉挛状态不同程度复发3例,差异无统计学意义(P>0.05)；术后并发症：两组术后均发生不同程度转颈无力、耸肩无力、双臂外展受限,随访期间有所好转,A组2例发生头颈部支撑困难,因此而影响生活质量,B组无1例发生头颈部支撑困难,差异无统计学意义(P>0.05)；A组36例发生不同程度吞咽困难,随访期间恢复正常18例,明显好转11例,无明显变化而影响生活质量7例,B组8例发生不同程度吞咽困难,随访期间恢复正常5例,明显好转2例,无明显变化而影响生活质量1例(该例仅随访1个月),差异有统计学意义(P<0.05)；A组颅内感染10例(7.9%),B组颅内感染2例(3.5%),出院前均治愈,差异有统计学意义(P<0.05)；B组手术时间(2±0.4h)较A组手术时间(3.3±0.6h)显著减少,差异有统计学意义(P<0.05)；A组术中平均失血量约200m1±15m1(±标准差)。B组术中平均失血量明显减少,约50m1±6m1(±标准差),差异有统计学意义(P<0.05)。
结论二次改良的Foerster-Dandy手术,术中不咬除枕骨鳞部及枕大孔,改在硬性神经内镜辅助下行硬膜下双侧副神经根切断,在不降低疗效及不增加神经系统并发症的前提下,可进一步减少手术创伤,缩短手术时间,减少术中失血量,降低吞咽困难、颅内感染机率,增加寰枕部稳定性,明显降低并发症的发生率。
目的通过围手术期神经电生理监测客观准确的评价二次改良Foerster-Dandy手术治疗痉挛性斜颈的疗效,并进一步提高手术疗效,减少并发症的发生。
方法回顾性分析2011年3月至2013年3月采用二次改良Foerster-Dandy手术治疗的40例重型痉挛性斜颈患者,在围手术期行神经电生理监测：①手术前后行头颈部痉挛主要责任肌肉(胸锁乳突肌、斜方肌、头夹肌)肌电图(electromyogram,EMG)检查,根据其动作电位波幅高低客观判定手术疗效；②术中行脊神经前、后根直接电刺激,观察相应肌肉收缩情况及自由描记EMG动作电位波幅高低,进而行脊神经前、后根选择性部分切断;③术中行体感诱发电位(somatosensory evoked potential,SEP)监测脊髓传导通路功能完整性,及时发现手术可能对颈髓造成的副损伤,并与既往未行神经电生理监测的40例重型痉挛性斜颈患者对比分析。
结果①胸锁乳突肌、斜方肌、头夹肌等痉挛主要责任肌肉手术前后EMG对比研究显示：术后肌肉EMG动作电位波幅均较术前明显降低,差异有统计学意义(P<0.05)：②根据术中脊神经前、后根直接电刺激的结果行脊神经前、后根选择性部分切断,神经切断的比例：双侧副神经100%,颈1前根：80%-90%,颈2前根：60%-75%,颈2后根：10%-15%,颈3前根：45-60%,颈3后根：50%-70%；③所有患者SEP均成功诱发并予以记录,有2例患者术中SEP波幅较预警基准电位下降,经调整手术操作方式或停止操作后恢复,所有患者术后均无脊髓功能损害表现。而未行神经电生理监测的40例患者中4例术后出现上肢麻木,10例术后出现颈肩痛,差异有统计学意义(P<0.05)。
结论①同一痉挛责任肌肉EMG相关参数手术前后差异的显著性为二次改良Foerster-Dandy手术治疗痉挛性斜颈的疗效评估提供了客观指标；②术中通过脊神经根直接电刺激及责任肌肉自由描记EMG进行脊神经根的选择性部分切断,量化了术中神经切断的比例,避免了不必要的神经功能损伤,在提高疗效的同时降低了并发症的发生率；③术中行SEP监测,能有效减少高位颈髓损伤的可能,增加手术的安全性。总之,围手术期神经电生理监测在客观评价二次改良Foerster-Dandy手术治疗痉挛性斜颈的疗效、提高疗效、降低并发症的发生率等方面可发挥重要作用。
Focal dystonias are abnormal contractions of muscles leading to abnormal postures.The overactivity of muscles characteristic of focal dystonia is thought to be mediated by a neurophysiological disturbance in the basal ganglia and/or brainstem. Spasmodic torticollis is the most common form of focal dystonia,which had been thought as a kind of extrapyramidal diseases by most scholars.It is characterized by sustained involuntary contractions of the cervical muscles,often leading to painful and disabling neck spasms and abnormal head positions. The incidence of ST is associated with genetics, trauma, psychological, neurotransmitter disorders, sensory system dysfunction, and certain drugs and so on. But so far, there is no a theory to explain its etiology fundamentally. Drugs often used in the treatment of extrapyramidal disorders bring poor efficacy for the treatment of ST. Botulinum toxin injections for the treatment of ST broke the deadlock.Intramuscular injection with botulinum toxin can temporarily relieve spasm of neck muscles, but long-term repeated applications lead to antibody production, poor effect, and side effects. Once the conservative treatment (at least six months or more) for severe ST is invalid, surgical intervention is required. Since the pathogenesis is not clear, symptomatic treatment become the main surgical method.Different surgical approach has been taken for the treatment of ST,such as muscle resection, nerve transection, spinal nerve rhizotomy, stereotactic nucleus lesioning operation, microvascular decompression for accessory nerve, deep brain stimulation, chronic intrathecal baclofen therapy and Foerster-Dandy operation. The classical Foerster-Dandy operation is intradural section of bilateral roots of spinal accessory nerves and ventral roots of C1-4through occipital midline approach. Considering wide neck muscles are involved in ST,they did bilateral anterior root rhizotomy without distinguishing clinical types and equal denervation without distinguishing spasticity involving neck muscles.This operation sacrifice a lot of normal muscles,and increasing postoperative complications.So it may bring insufficient denervation or muscle relaxation. Basing on principles of selective partial cervical posterior rhizotomy for the treatment of upper limb spasticity in cerebral palsy, we performed selective partial cervical posterior rhizotomy to alleviate spasm for severe ST.Combined with selective partial cervical anterior rhizotomy,we can ensure curative effect, and avoid the disadvantages of all anterior rhizotomy which increase the incidence of postoperative complications.We modified this operation two times in2001and2007respectively. The purpose of this study was to investigate the effectiveness and complications of two modified Foerster Dandy operations in the treatment of ST.
Methods183cases of spasmodic torticollis patients were treated by modified Foerster-Dandy's operation from July2001to June2009,who were classified into group A and group B. Group A(126cases) was treated by firstly modified Foerster-Dandy's operation, which was intradural section of bilateral roots of spinal accessory nerves and C1nerves,partial ventral and dorsal roots of C2,C3through occipital midline approach. Group B (57cases) was treated by secondly modified Foerster-Dandy's operation, without resection of occipital squama and foramen magnum, intradural section of bilateral roots of spinal accessory nerves were achieved under endoscope-assistance,the other surgical steps as firstly modified Foerster-Dandy's operation.
Results All the patients were averagely followed-up for33.4months after surgery. The spasticity was relieved immediately after the operation in all the patients. The relief rate of spasticity was92.9%(117/126) and94.7%(54/57) in A and B groups respectively during the follow-up period. The spasticity recurred in9patients in group A and3patients in group B (P>0.05).Postoperative complications in group A (126patients) included transient weakness of neck, arms and shoulders in124cases, with persistent severe weakness in2cases. But there was no one with persistent severe weakness in group B(P>0.05). In group A,dysphagia of different degrees was observed in36cases, in whom, dysphagia was disappeared in18cases, significantly relieved in11, and unchanged in7during the follow-up period. In group B,dysphagia of different degrees was observed in8cases, in whom, dysphagia was disappeared in5cases, significantly relieved in2, and unchanged in1(follow-up:only one month)(P<0.05). The intracranial infection rates in A and B groups were7.9%and3.5%respectively(P<0.05). The mean operative time was also significantly shorter in group B(2±0.4hours) than that in group A (3.3±0.6hours)(P<0.05). The mean intraoperative blood loss was200ml±15ml (±standard deviation) in group A and50ml±6ml in group B(P<0.05).
Conclusions Cutting off bilateral accessory roots could be performed under endoscope-assisted secondly modified Foerster-Dandy's operation, without resection of occipital squama and foramen magnum. Given keeping the efficacy and non-increasement of nervous complications, further reduction of surgical trauma and intraoperative blood loss,decreasement of intracranial infection rate, increasement of the stability of atlanto-occipital region and significant descreasement of the incidence of other complications could be achieved.
Objective Evaluate the effect of second modified Foerster-Dandy operation for the treatment of spasmodic torticollis objectively and accurately in perioperative period through neurophysiological monitoring,further improve the effect of operation, and reduce the incidence of complications.
Methods40cases of severe spasmodic torticollis were analysed retrospectively, which were treated by second modified Foerster-Dandy's operation from March2011to March2013.First,we underwent preoperative and postoperative electromyography of neck muscles (sternocleidomastoid, splenius capitis,trapezius). We judged the curative effect of this operation according to the amplitude level of action potential involving these muscles. Second,we performed intraoperative immediate stimulation for anterior and posterior roots of spinal nerves,and selectively cut the proportion of associated nerve according to the contraction and amplitude of the action potential involving corresponding muscles. Third, we monitored the functional integrity of spinal cord pathway and discovered spinal accessory injury in time through intraoperative somatosensory evoked potential (SEP).Compared with previous40cases without neurophysiological monitoring,we analysed the difference between them.
Results Postoperative amplitudes of sternocleidomastoid, splenius capitis.trapezius decreased significantly than preoperative amplitudes of these muscles. The difference was statistically significant. According to direct electrical stimulation of anterior and posterior roots of spinal nerves, we selectively cut the proportion. The proportion of nerves in operation was cut as follows:100%in bilateral accessory nerves,80%-90%in anterior roots of C1,60%-75%in anterior roots of C2,10%-15%in posterior roots of C2,45-60%in anterior roots of C3,50%-70%in posterior roots of C3; All patients with SEP were successfully induced and recorded.Compared with the warning reference potential, the amplitudes of SEP in2patients decreased significantly and recovered through adjusting the operation or stopping the manipulation. All operations were performed without injury of spinal cord. Upper extremity numbness occurred in4of previous40patients without electrophysiological monitoring,and10of these40cases occured neck and shoulder pain. The difference was statistically significant.
Conclusions The significant difference between preoperation and postoperation involving the related parameters in the same muscle provides the objective basis for second modified Foerster-Dandy operation in the treatment of spasmodic torticollis. Selective cutting of spinal nerves through intraoperative electrical stimulation and free recording EMG quantify the cutting proportion, avoid unnecessary injury, and reduce the incidence of complications. Intraoperative somatosensory evoked potential monitoring can effectively reduce mechanical injury of cervical cord, protect function of nerves, and improve the safety of such operation. Therefore, perioperative neural electrophysiological monitoring plays an important role in objectively assessing the curative effect of second modified Foerster-Dandy operation in the treatment of spasmodic torticollis, improving efficacy, and reducing the incidence of complications.
对于保守治疗(至少半年以上)无效的重症ST,则需外科手术干预。由于病因尚不明确,所以目前ST的外科治疗主要为症状性治疗。所采取的术式包括肌切断术、神经切断术、脊神经根切断术、立体定向脑运动核毁损术、副神经根显微血管减压术、脑深部慢性电刺激术、鞘内泵入巴氯芬疗法和Foerster-Dandy手术等。经典Foerster—andy手术即双侧硬脊膜下C1-C4脊神经前根及副神经根切断术。该术式的指导思想是认为参与ST的痉挛肌肉分布广泛,涉及面大,所以不区别临床型别一律作双侧前根切断,不区别痉挛和非痉挛肌肉一律用等量去神经术麻痹颈肌,生理毁损大,牺牲了很多正常肌肉；术后并发症多,且存在去神经不足、痉挛肌肉松弛不够的缺点。我科基于颈段脊神经后根选择性部分切断术治疗脑性瘫痪导致的上肢痉挛状态的原理,对于重型ST患者行相应颈部脊神经后根选择性部分切断也可以部分缓解痉挛,配合前根选择性部分切断,既可保证疗效,又可避免全部前根切断的弊端,使术后并发症大幅减少。并于2001年和2007年先后对该术式进行两次改良,本研究旨在探讨两次改良Foerster-Dandy手术治疗痉挛性斜颈的疗效及并发症。方法回顾分析2001年7月至2009年6月手术治疗的183例痉挛性斜颈患者,其中A组126例采用初次改良Foerster-Dandy手术,即枕后正中入路硬膜下双侧副神经根、C,脊神经根切断、C2-C3脊神经前、后根选择性部分切断术,B组57例采用二次改良的Foerster-Dandy手术,即术中不咬除枕骨鳞部及枕大孔,在硬性神经内镜辅助下行硬膜下双侧副神经根切断术,其余步骤同初次改良Foerster-Dandy手术。
结果全部患者平均随访33.4个月。两组100%病人术后立即感痉挛状态明显缓解,随访期间缓解率分别为92.9%(117/126)、94.7%(54/57),差异无统计学意义(P>0.05)；A组随访期间痉挛状态不同程度复发9例,B组随访期间痉挛状态不同程度复发3例,差异无统计学意义(P>0.05)；术后并发症：两组术后均发生不同程度转颈无力、耸肩无力、双臂外展受限,随访期间有所好转,A组2例发生头颈部支撑困难,因此而影响生活质量,B组无1例发生头颈部支撑困难,差异无统计学意义(P>0.05)；A组36例发生不同程度吞咽困难,随访期间恢复正常18例,明显好转11例,无明显变化而影响生活质量7例,B组8例发生不同程度吞咽困难,随访期间恢复正常5例,明显好转2例,无明显变化而影响生活质量1例(该例仅随访1个月),差异有统计学意义(P<0.05)；A组颅内感染10例(7.9%),B组颅内感染2例(3.5%),出院前均治愈,差异有统计学意义(P<0.05)；B组手术时间(2±0.4h)较A组手术时间(3.3±0.6h)显著减少,差异有统计学意义(P<0.05)；A组术中平均失血量约200m1±15m1(±标准差)。B组术中平均失血量明显减少,约50m1±6m1(±标准差),差异有统计学意义(P<0.05)。
结论二次改良的Foerster-Dandy手术,术中不咬除枕骨鳞部及枕大孔,改在硬性神经内镜辅助下行硬膜下双侧副神经根切断,在不降低疗效及不增加神经系统并发症的前提下,可进一步减少手术创伤,缩短手术时间,减少术中失血量,降低吞咽困难、颅内感染机率,增加寰枕部稳定性,明显降低并发症的发生率。
目的通过围手术期神经电生理监测客观准确的评价二次改良Foerster-Dandy手术治疗痉挛性斜颈的疗效,并进一步提高手术疗效,减少并发症的发生。
方法回顾性分析2011年3月至2013年3月采用二次改良Foerster-Dandy手术治疗的40例重型痉挛性斜颈患者,在围手术期行神经电生理监测：①手术前后行头颈部痉挛主要责任肌肉(胸锁乳突肌、斜方肌、头夹肌)肌电图(electromyogram,EMG)检查,根据其动作电位波幅高低客观判定手术疗效；②术中行脊神经前、后根直接电刺激,观察相应肌肉收缩情况及自由描记EMG动作电位波幅高低,进而行脊神经前、后根选择性部分切断;③术中行体感诱发电位(somatosensory evoked potential,SEP)监测脊髓传导通路功能完整性,及时发现手术可能对颈髓造成的副损伤,并与既往未行神经电生理监测的40例重型痉挛性斜颈患者对比分析。
结果①胸锁乳突肌、斜方肌、头夹肌等痉挛主要责任肌肉手术前后EMG对比研究显示：术后肌肉EMG动作电位波幅均较术前明显降低,差异有统计学意义(P<0.05)：②根据术中脊神经前、后根直接电刺激的结果行脊神经前、后根选择性部分切断,神经切断的比例：双侧副神经100%,颈1前根：80%-90%,颈2前根：60%-75%,颈2后根：10%-15%,颈3前根：45-60%,颈3后根：50%-70%；③所有患者SEP均成功诱发并予以记录,有2例患者术中SEP波幅较预警基准电位下降,经调整手术操作方式或停止操作后恢复,所有患者术后均无脊髓功能损害表现。而未行神经电生理监测的40例患者中4例术后出现上肢麻木,10例术后出现颈肩痛,差异有统计学意义(P<0.05)。
结论①同一痉挛责任肌肉EMG相关参数手术前后差异的显著性为二次改良Foerster-Dandy手术治疗痉挛性斜颈的疗效评估提供了客观指标；②术中通过脊神经根直接电刺激及责任肌肉自由描记EMG进行脊神经根的选择性部分切断,量化了术中神经切断的比例,避免了不必要的神经功能损伤,在提高疗效的同时降低了并发症的发生率；③术中行SEP监测,能有效减少高位颈髓损伤的可能,增加手术的安全性。总之,围手术期神经电生理监测在客观评价二次改良Foerster-Dandy手术治疗痉挛性斜颈的疗效、提高疗效、降低并发症的发生率等方面可发挥重要作用。
Focal dystonias are abnormal contractions of muscles leading to abnormal postures.The overactivity of muscles characteristic of focal dystonia is thought to be mediated by a neurophysiological disturbance in the basal ganglia and/or brainstem. Spasmodic torticollis is the most common form of focal dystonia,which had been thought as a kind of extrapyramidal diseases by most scholars.It is characterized by sustained involuntary contractions of the cervical muscles,often leading to painful and disabling neck spasms and abnormal head positions. The incidence of ST is associated with genetics, trauma, psychological, neurotransmitter disorders, sensory system dysfunction, and certain drugs and so on. But so far, there is no a theory to explain its etiology fundamentally. Drugs often used in the treatment of extrapyramidal disorders bring poor efficacy for the treatment of ST. Botulinum toxin injections for the treatment of ST broke the deadlock.Intramuscular injection with botulinum toxin can temporarily relieve spasm of neck muscles, but long-term repeated applications lead to antibody production, poor effect, and side effects. Once the conservative treatment (at least six months or more) for severe ST is invalid, surgical intervention is required. Since the pathogenesis is not clear, symptomatic treatment become the main surgical method.Different surgical approach has been taken for the treatment of ST,such as muscle resection, nerve transection, spinal nerve rhizotomy, stereotactic nucleus lesioning operation, microvascular decompression for accessory nerve, deep brain stimulation, chronic intrathecal baclofen therapy and Foerster-Dandy operation. The classical Foerster-Dandy operation is intradural section of bilateral roots of spinal accessory nerves and ventral roots of C1-4through occipital midline approach. Considering wide neck muscles are involved in ST,they did bilateral anterior root rhizotomy without distinguishing clinical types and equal denervation without distinguishing spasticity involving neck muscles.This operation sacrifice a lot of normal muscles,and increasing postoperative complications.So it may bring insufficient denervation or muscle relaxation. Basing on principles of selective partial cervical posterior rhizotomy for the treatment of upper limb spasticity in cerebral palsy, we performed selective partial cervical posterior rhizotomy to alleviate spasm for severe ST.Combined with selective partial cervical anterior rhizotomy,we can ensure curative effect, and avoid the disadvantages of all anterior rhizotomy which increase the incidence of postoperative complications.We modified this operation two times in2001and2007respectively. The purpose of this study was to investigate the effectiveness and complications of two modified Foerster Dandy operations in the treatment of ST.
Methods183cases of spasmodic torticollis patients were treated by modified Foerster-Dandy's operation from July2001to June2009,who were classified into group A and group B. Group A(126cases) was treated by firstly modified Foerster-Dandy's operation, which was intradural section of bilateral roots of spinal accessory nerves and C1nerves,partial ventral and dorsal roots of C2,C3through occipital midline approach. Group B (57cases) was treated by secondly modified Foerster-Dandy's operation, without resection of occipital squama and foramen magnum, intradural section of bilateral roots of spinal accessory nerves were achieved under endoscope-assistance,the other surgical steps as firstly modified Foerster-Dandy's operation.
Results All the patients were averagely followed-up for33.4months after surgery. The spasticity was relieved immediately after the operation in all the patients. The relief rate of spasticity was92.9%(117/126) and94.7%(54/57) in A and B groups respectively during the follow-up period. The spasticity recurred in9patients in group A and3patients in group B (P>0.05).Postoperative complications in group A (126patients) included transient weakness of neck, arms and shoulders in124cases, with persistent severe weakness in2cases. But there was no one with persistent severe weakness in group B(P>0.05). In group A,dysphagia of different degrees was observed in36cases, in whom, dysphagia was disappeared in18cases, significantly relieved in11, and unchanged in7during the follow-up period. In group B,dysphagia of different degrees was observed in8cases, in whom, dysphagia was disappeared in5cases, significantly relieved in2, and unchanged in1(follow-up:only one month)(P<0.05). The intracranial infection rates in A and B groups were7.9%and3.5%respectively(P<0.05). The mean operative time was also significantly shorter in group B(2±0.4hours) than that in group A (3.3±0.6hours)(P<0.05). The mean intraoperative blood loss was200ml±15ml (±standard deviation) in group A and50ml±6ml in group B(P<0.05).
Conclusions Cutting off bilateral accessory roots could be performed under endoscope-assisted secondly modified Foerster-Dandy's operation, without resection of occipital squama and foramen magnum. Given keeping the efficacy and non-increasement of nervous complications, further reduction of surgical trauma and intraoperative blood loss,decreasement of intracranial infection rate, increasement of the stability of atlanto-occipital region and significant descreasement of the incidence of other complications could be achieved.
Objective Evaluate the effect of second modified Foerster-Dandy operation for the treatment of spasmodic torticollis objectively and accurately in perioperative period through neurophysiological monitoring,further improve the effect of operation, and reduce the incidence of complications.
Methods40cases of severe spasmodic torticollis were analysed retrospectively, which were treated by second modified Foerster-Dandy's operation from March2011to March2013.First,we underwent preoperative and postoperative electromyography of neck muscles (sternocleidomastoid, splenius capitis,trapezius). We judged the curative effect of this operation according to the amplitude level of action potential involving these muscles. Second,we performed intraoperative immediate stimulation for anterior and posterior roots of spinal nerves,and selectively cut the proportion of associated nerve according to the contraction and amplitude of the action potential involving corresponding muscles. Third, we monitored the functional integrity of spinal cord pathway and discovered spinal accessory injury in time through intraoperative somatosensory evoked potential (SEP).Compared with previous40cases without neurophysiological monitoring,we analysed the difference between them.
Results Postoperative amplitudes of sternocleidomastoid, splenius capitis.trapezius decreased significantly than preoperative amplitudes of these muscles. The difference was statistically significant. According to direct electrical stimulation of anterior and posterior roots of spinal nerves, we selectively cut the proportion. The proportion of nerves in operation was cut as follows:100%in bilateral accessory nerves,80%-90%in anterior roots of C1,60%-75%in anterior roots of C2,10%-15%in posterior roots of C2,45-60%in anterior roots of C3,50%-70%in posterior roots of C3; All patients with SEP were successfully induced and recorded.Compared with the warning reference potential, the amplitudes of SEP in2patients decreased significantly and recovered through adjusting the operation or stopping the manipulation. All operations were performed without injury of spinal cord. Upper extremity numbness occurred in4of previous40patients without electrophysiological monitoring,and10of these40cases occured neck and shoulder pain. The difference was statistically significant.
Conclusions The significant difference between preoperation and postoperation involving the related parameters in the same muscle provides the objective basis for second modified Foerster-Dandy operation in the treatment of spasmodic torticollis. Selective cutting of spinal nerves through intraoperative electrical stimulation and free recording EMG quantify the cutting proportion, avoid unnecessary injury, and reduce the incidence of complications. Intraoperative somatosensory evoked potential monitoring can effectively reduce mechanical injury of cervical cord, protect function of nerves, and improve the safety of such operation. Therefore, perioperative neural electrophysiological monitoring plays an important role in objectively assessing the curative effect of second modified Foerster-Dandy operation in the treatment of spasmodic torticollis, improving efficacy, and reducing the incidence of complications.
引文
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[10].Dykstra DD, Mendez A, Chappuis D, et al. Treatment of cervical dystonia and focal hand dystonia by high cervical continuously infused intrathecal baclofen:a report of 2 cases [J]. Arch Phys Med Rehabil,2005,86(4):830-833.
[11].于炎冰,张黎,马延山,等.1244例痉挛状态的显微神经外科手术治疗[J].中华神经外科杂志,2005,21(9)：542-545.
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[13].Munchau A, Bahlke G, Allen PJ, et al. Polymyography combined with time-locked video recording(video EMG)for presurgical assessment of patients with cervical dystonia [J]. Eur Neurol,2001,45:222-228.
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