ABSTRACT
HISTORICAL PERSPECTIVE Spasmodic torticollis or cervical dystonia is a condition that has held the attention of physicians since the 16th century, and the term torticollis has been attributed to the French physician, Francois Rabelais (1494-1553) (1). Physicians have been trying to help patients affl icted with this disabling condition by surgical means since the 17th century. The surgical procedures performed for torticollis can be divided into intracranial procedures and extracranial procedures, with the latter emerging as the preferred method of treatment over several centuries. Finney and Hughson (2) fi rst described bilateral peripheral denervation procedures for torticollis in 1925, and also documented a three-century history of surgical evolution from myotomy to tenotomy, and, fi nally, to nerve sectioning. In the 1600s Isaac Minius reported of open sectioning of the sternocleidomastoid (SCM) and Hendrick van Roonhuyze emphasized myotomies. By 1812, Dupuytren attempted to treat torticollis by performing SCM tenotomy. The era of selective nerve sectioning began in 1866 when Campbell de Morgan (3) was credited with the fi rst peripheral division of the accessory nerve, although Bujalski reported a similar technique in 1834. While Gross re-emphasized multiple myotomies in 1873, nerve sectioning has emerged as the primary focus for extracranial surgical correction of spasmodic torticollis. Collier (4) proposed the quickly abandoned procedure of constricting the accessory nerve in the neck with a silver wire later that century. It was W.W. Keen (5) who fi rst described the division of the posterior divisions of the fi rst three cervical nerves for torticollis in 1891 and, although this procedure became a procedure of choice for American and British surgeons, myotomy continued to be emphasized by German surgeons. In 1924, McKenzie (1) reported a successful intracranial division of the accessory nerve and an intraspinal division of the roots of the fi rst three cervical nerves, performed by Cushing that led to signifi cant improvement in a patient with a rotational-type torticollis. A year later, Finney and Hughson (2) published a more extensive experience with bilateral peripheral denervation procedures of the three fi rst posterior divisions with excellent results (37% cured and 50% improved). However, this procedure never became widely used, probably because of the formidable incision and dissection. In 1930, Dandy (6) fi rst described the bilateral intraspinal divisions of the roots of the fi rst three cervical roots and the intracranial division of the spinal accessory nerve, with excellent results in fi ve out of eight patients. Although initially he divided the anterior and posterior roots, he later modifi ed this to sectioning of only the anterior roots. In 1955, McKenzie (7) advocated the peripheral sectioning of the accessory nerve to the SCM added to the intraspinal procedure and the division of some rootlets of C4. Anterior rhizotomy, or the Dandy-McKenzie procedure, remained the procedure of choice until the late 1970s (8-10). In 1986 Colbassani and Wood (11), in a literature review of anterior
rhizotomy series, warned of the signifi cant risks to this procedure, reporting an incidence of an unstable or weak neck (39%), dysphagia (30%), shoulder weakness (41%), and death (2%). Hemiparesis, subluxation requiring fusion (10), and quadriplegia (12,13) have also been reported with this operation. Because of the complications with anterior rhizotomies, the search for other procedures to treat this condition continued. Stereotactic procedures (14-16) were used in the 1970s, and electrical stimulation (17) and iontophoresis (18) were also tried without success. In 1978 Bertrand (19) reported the use of thalamotomy combined with selective denervation. Because of the signifi cant complications with anterior rhizotomies and bilateral thalamotomies, he felt the combination of thalamotomy and peripheral denervation might lead to a safer and more successful treatment. After his initial experience, he returned to selective denervation without intracranial ablation, a more benign treatment for torticollis. Over the subsequent years he published his results and experience with this procedure (20-22). His descriptions of the use of a midline incision, innovative study of preoperative electromyographic (EMG) analysis, the identifi cation of the muscles to be denervated for the different types of torticollis, as well as his low morbidity have led to the well-accepted surgery for spasmodic torticollis, appropriately termed selective peripheral denervation (The Bertrand procedure).
