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Pattern of Premature Degenerative Changes of the Cervical Spine in Patients with Spasmodic Torticollis and the Impact on The

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Pattern of Premature Degenerative Changes of the Cervical Spine in Patients with Spasmodic Torticollis and the Impact on The J Neurol Neurosurg Psychiatry 2000;68:465–471 465 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.68.4.465 on 1 April 2000. Downloaded from Pattern of premature degenerative changes of the cervical spine in patients with spasmodic torticollis and the impact on the outcome of selective peripheral denervation S J Chawda, A Münchau, D Johnson, K Bhatia, N P Quinn, J Stevens, A J Lees, J D Palmer Abstract modic torticollis with botulinum toxin Objectives—To characterise the pattern of seems to have a protective eVect. Patients and risk factors for degenerative changes with spasmodic torticollis and restricted of the cervical spine in patients with spas- head mobility who do not adequately modic torticollis and to assess whether respond to treatment should undergo these changes aVect outcome after selec- imaging of the upper cervical spine. tive peripheral denervation. Patients with imaging evidence of moder- Methods—Preoperative CT of the upper ate or severe degenerative changes seem cervical spine of 34 patients with spas- to respond poorly to selective peripheral modic torticollis referred for surgery were denervation. reviewed by two radiologists blinded to the (J Neurol Neurosurg Psychiatry 2000;68:465–471) clinical findings. Degenerative changes were assessed for each joint separately Keywords: osteoarthritis; spasmodic torticollis; com- and rated as absent, minimal, moderate, puted tomography; selective peripheral denervation or severe. Patients were clinically assessed before surgery and 3 months postopera- Idiopathic spasmodic torticollis is the most tively by an independent examiner using common form of adult onset focal dystonia.1 It standardised clinical rating scales. For comparison of means a t test was carried is characterised by repetitive or sustained con- tractions of neck muscles that lead to an out. To determine whether an association 2–4 exists between the side of degenerative abnormal posture of the head and neck. changes and type of spasmodic torticollis Depending on the pattern of muscular activity a ÷2 test was used. Changes in severity, dis- the head is rotated, tilted, flexed, or extended but often there is a combination of these ability, and pain before and after surgery 5 were calculated using a Wilcoxon matched movements. Spasmodic torticollis often causes pain, interferes with daily activities, and pairs signed ranks test. 6–8 Results—Fourteen out of 34 patients had can be very socially disabling. Secondary 9 http://jnnp.bmj.com/ moderate or severe degenerative changes. problems include dysphagia and impairment 10 They were predominantly found at the of balance. C2/C3 and C3/C4 level and were signifi- Non-physiological repetitive head and neck cantly more likely to occur on the side of movements can stress the joints in the cervical the main direction of the spasmodic torti- spine. Cervical spondylosis with resulting collis (p=0.015). There was no significant radiculopathy or myelopathy has been reported 11–26 diVerence in age, sex, duration of torticol- in patients with generalised dystonia and, National Hospital for rarely, in patients with spasmodic lis, overall severity, degree of disability, or on October 2, 2021 by guest. Protected copyright. Neurology and torticollis.11 26–28 It has also been noted that Neurosurgery, Queen pain between the group with either no or minimal changes and the group with degenerative changes in patients with general- Square, London, UK 11–26 S J Chawda moderate or severe changes. However, in ised dystonia tend to occur prematurely. So A Münchau the second group the duration of inad- far no systematic study considering this D Johnson equate treatment was longer (10.1 v 4.8 problem using modern imaging methods has K Bhatia years; p=0.009), head mobility was more been carried out. N P Quinn We investigated 34 patients with spasmodic J Stevens restricted (p=0.015), and head tremor was more severe (p=0.01). At 3 months postop- torticollis who were referred for surgery (selec- A J Lees 29–31 J D Palmer eratively, patients with no or minimal tive peripheral denervation (SPD)) because degenerative changes showed a significant of primary resistance to or secondary failure of Correspondence to: improvement in pain and severity whereas botulinum toxin (BT) treatment. In all patients Dr Sanjiv Chawda, Department of Radiology, no diVerence was found in those with CT of the cervical spine from the occipitocer- Oldchurch Hospital, moderate or severe changes. vical junction down to the mid/upper cervical Waterloo Road, Conclusions—Patients with spasmodic spine was carried out mainly to look for Romford,Essex RM7 0BE, craniovertebral abnormalities that may not UK torticollis have an increased risk of devel- [email protected] oping premature degenerative changes of have been apparent on plain radiographs such the upper cervical spine that tend to be on as os odontoideum and rotatory atlantoaxial Received 14 June 1999 and the side towards which the head is turned dislocation.32 Plain radiographs of the cervical in revised form 15 October 1999 or tilted and compromise outcome after spine were not always available to us; therefore Accepted 25 November 1999 surgery. EVective early treatment of spas- degenerative changes were only assessed on 466 Chawda, Münchau, Johnson, et al J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.68.4.465 on 1 April 2000. Downloaded from 440/15; FOV 24 cm; NEX=4; ma- trix=256×192) and T2 sagittal fast spin echo (TR/TE, 5000/130; FOV 24 cm; NEX=4; matrix=160×256) and relevant axial T2 gradient echo images (flip angle 20 degrees; TR/TE, 560/25; FOV 16 cm; NEX=5; ma- trix=160×224) were obtained. The sagittal sequences were 4 mm thick witha1mm interslice gap. PATIENTS A total of 34 patients with spasmodic torticol- Patient with left tremulous torticollis with left grade 3 and lis, all of whom had received BT injections in right grade 0 changes at the C2/3 facet joints. the past, were referred for consideration of SPD surgery over the period 1997–8. The CT. In some patients MRI of the cervical spine interval between the last botulinum toxin (BT) was also performed. All patients were assessed injection and the investigation before surgery clinically before surgery and 3 months postop- was at least 4 months in all patients and often eratively by an independent examiner using more than 6 months. Patients were referred for standardised rating scales. surgery because of either primary or secondary failure of BT treatment. Patient characteristics Methods are given in tables 1 and 4. Of the 34 patients IMAGING STUDIES referred 22 underwent surgery. They were all Craniocervical CT was carried out in all 34 examined again 3 months after surgery. patients on a Siemens Somaton plus 4 (VB3 In addition to a detailed history from each version OB). A single spiral scan (kVp 120, 200 patient, medical notes were studied to deter- mA) continuing in a caudal direction was mine the documented response to BT injec- obtained (2 mm collimation, with a table feed tions over the years. Patients were classified as of 5 mm/s) and the data reconstructed as 1 mm having predominantly torticollis (head rotation thick slices. Axial sections were obtained from in the horizontal plane), laterocollis (head tilt the clivus to the midcervical spine with coronal in the coronal plane), or anterocollis or and sagittal reformats. All images were retro- retrocollis (head flexion or extension). This spectively reviewed by two radiologists (SJC was done taking into account the primary dys- and DJ) and any diVerences in interpretation tonic position and the degree of restriction of were resolved by consensus. The radiologists head movements. For instance, a patient with a were blind to the clinical findings in these combination of head rotation to the right and patients. tilt to the left was labelled primarily right torti- The joints considered were: occipital collis when left rotation was more restricted condyle-C1 lateral mass articulation (O-C1), than right tilt and vice versa. Severity at the C1-C2 lateral mass articulations, C1 anterior time of the investigation was determined using arch-C2 odontoid peg articulation, C2/3 facet the Toronto western spasmodic torticollis and uncovertebral joint articulations, and also rating (TWSTR) severity scale.33 This scale http://jnnp.bmj.com/ lower levels if they were scanned. The degree of takes into account the dystonic position of the spondylotic change was assessed from a head, the eVectiveness of any sensory trick, and combination of loss of joint space, subchondral how long the patient can keep the head in a sclerosis or cysts, and osteophytes. Degenera- straight position and estimates the degree of tive changes were recorded on a scale of 0–3 head mobility and position of the shoulder. (0=normal, 1=minimal, 2=moderate, and The maximum severity on this scale is 35. 3=severe). Apart from the C1 arch-C2 peg To further characterise restriction of head on October 2, 2021 by guest. Protected copyright. articulation, the left and right joints were and neck movements we used a geniometer to scored individually. Figure 1 shows an example measure the degree of head mobility opposite of grade 3 degenerative change. to the direction of the dystonic head position— Eighteen patients also had MRI of the cervi- for example, contralateral tilt in a patient with cal spine and these were reviewed with particu- laterocollis. Firstly, patients were asked to lar emphasis on the cervical spinal cord. All actively tilt their head in the direction opposite MRI images were performed on a GE Vectra to the main dystonic position; secondly, the 0.5 T scanner. A quadrature anterior neck coil head was moved passively. If the patient was was used. T1 sagittal spin echo (TR/TE, able to actively or passively tilt the head less than 5 degrees past the midline a score of 6 was Table 1 Spasmodic torticollis patient characteristics given.
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