The treatment of spasmodic torticollis needs drug treatment first. When the symptoms develop to a certain extent, or the effect of conservative treatment is getting worse, you can choose surgical treatment. Surgical treatment is still in the development stage, and there is no standard surgical method. The key to surgical treatment is the understanding of spastic muscle groups. At present, among the popular surgical treatments in the world, selective peripheral neurotomy is the most popular, and bilateral cervical radiculotomy and accessory nerve microvascular decompression are still selected by some doctors. The triple operation and selective neck extensor amputation advocated by Professor Chen Xinkang in China have also achieved good results and are widely used in China.

1, drug therapy

Botulinum toxin injection therapy is a major breakthrough in the treatment of spastic torticollis. Most patients can get obvious relief after intramuscular injection of botulinum toxin for 3 ~ 4 months, and some patients produce anti-botulinum toxin antibodies, which gradually become ineffective for this treatment. There are also some patients who do not respond to botulinum toxin treatment. In addition, some patients find it difficult to maintain this treatment.

Other drugs and physical therapy, the initial drug therapy includes anticholinergic drugs such as diphenhydramine and antipsychotic drugs such as diazepam. When these drugs are used in large doses, spasmodic torticollis can be relieved to some extent, and the side effects are also obvious. In addition, long-term physical therapy and biofeedback therapy may also improve the symptoms of mild spastic torticollis.

2. Surgical therapy

(1) indications and contraindications:

① Drug therapy, mainly botulinum toxin injection therapy, no longer has satisfactory effect, or has serious side effects. Surgery can only be considered after the failure of botulinum toxin treatment for 4 months.

② The course of disease 1 year or more, preferably 3 years or more, and the clinical symptoms do not progress.

③ The symptoms of dystonia are confined to the neck, at least mainly neck symptoms.

④ The best surgical indications are rotation, lateral contracture and bilateral head tilt. The first two are suitable for triple operation, and the latter is suitable for selective suboccipital muscle amputation. Selective peripheral neurotomy has the most satisfactory effect on patients with rotation or mild flexion or retroflexion.

⑤ Bilateral accessory nerve amputation or bilateral sternocleidomastoid muscle amputation can be considered if the symptoms can be improved after blocking bilateral sternocleidomastoid muscles with 1% lidocaine. However, flexion torticollis mostly involves the deep muscles in front of the neck, and the surgical effect is not good. Have a history of surgery, fibrosis or arthropathy, and the surgical effect is poor.

(2) Bilateral cervical rhizotomy: This operation was first designed by Cushing and Mckenzie as a unilateral method to denervate the muscles at the back of the neck. This operation severed the anterior roots of neck 1, neck 2, neck 3 and part of neck 4. Later, at Dandy's initiative, in order to get better results through thorough treatment, bilateral surgery was changed. However, the side effects of cutting off the anterior branch too much are also obvious, such as neck weakness and dysphagia. This operation has been widely used in clinic as the main surgical method of spastic torticollis before 1970s. It is difficult to imagine the significance of cutting the anterior roots of neck 1 and neck 2 in the treatment of spasmodic torticollis, because the anterior roots of neck 1 and neck 2 dominate the muscles that manage swallowing in the throat, and have nothing to do with the posterior cervical muscles. In addition, the amputation of the main branches of the posterior branches of neck 4 and neck 5 is very important for denervation of the posterior cervical muscle, and it is also very useful for preserving the function of the antagonistic muscle and restoring normal movement after operation, so this operation has been rarely used.

(3) Accessory nerve microvascular decompression: This operation was first reported by Freckman( 198 1). Freckman and others believe that the symptoms of patients with spastic torticollis are related to the compression of accessory nerve roots, and its pathogenesis may be the same as hemifacial spasm and trigeminal neuralgia. The abnormal impulse of blood vessels may be transmitted to the roots of cervical meridians through the communicating branches of accessory nerve roots, which makes the neck muscles extremely excited. Only a few authors have reported that this operation can relieve spasmodic torticollis.

(4) Selective peripheral neurotomy: It started at 1978 and has become a successful surgical method for the treatment of spastic torticollis. After years of improvement, this surgical method has strong pertinence, good effect and few complications, and has become the only surgical method for treating spastic torticollis in most neurosurgical centers in the world. The reason for its success is that it only resects those innervating nerves that produce abnormal head muscles, so it is very important to identify the muscles involved in abnormal head movements before operation. Therefore, we must determine the types of abnormal exercise and the muscle groups related to it. Through rigorous clinical examination before operation, combined with electromyography, local block, thin-layer CT scan of cervical spine and the history of botulinum toxin treatment, the muscles involved in abnormal movement can be roughly determined, and the identification of the involved muscles and their innervated spinal nerves during operation is the key to successful operation.