spastic torticollis
Introduction
Introduction to spastic torticollis Spasmodic torticollis is a localized dystonia involving the neck region, manifested as a paroxysmal involuntary contraction of the neck muscles, causing the head to twist to one side or tilt. It is an extrapyramidal dyskinesia and is an independent organic disease. However, mental factors such as anxiety and reactive depression play a certain role in adjusting the symptoms of the disease. Emotional impulses are even a factor in the accelerated development of the disease. Clinical diagnosis and treatment should be distinguished by careful clinical observation and electromyography. basic knowledge The proportion of illness: 0.003% Susceptible population: more common in adults, the average age of onset is 30-40 years old Mode of infection: non-infectious Complications: dystonia syndrome spastic torticollis depression
Cause
Cause of spastic torticollis
Genetic factors (30%):
Partial adult dystonia localized seizures are genetically determined, and genetic studies of systemic dystonia have made great progress, and genetic research on the effects of lower ventricular dystonia has also progressed bit by bit. In some families, cervical dystonia is seen in about 10% of first- and second-degree relatives, with evidence of autosomal dominant inheritance, with reduced penetrance, and is performed on three families with spastic torticollis The study found that the onset of a family is associated with chromosome 18P, while the lack of DYT1 in the latter two families indicates genetic abnormalities in the pathogenesis of cervical muscle dystonia.
Abnormal vestibular function (12%):
It has been reported that vestibular-ocular reflex reactivity or asymmetry in patients with spastic torticollis cannot be corrected after treatment with botulinum toxin. The vestibular abnormality is not a primary abnormality, and other types of localized dystonia (eg, writing sputum,) can also be associated with spasmodic torticollis, deafness, dizziness and ataxia are not characteristic of spastic torticollis. At the same time, many patients do not have vestibular reflex abnormalities, but have a longer period of spastic torticollis, which may The vestibular abnormality is secondary to the abnormal long-term head posture caused by the spastic torticollis.
Trauma (15%):
Trauma has been considered to be the cause of spastic torticollis. It is reported in the literature that 9%-16% of patients have a history of head or neck trauma, usually occurring weeks to months before onset.
Others: short-term or long-term neck vibration stimulation found that there is a significant difference in the head position of the patient. This is due to changes in the sensory stimulation of the surrounding body, which causes the central control of the head and neck to compensate for the reversal of mediation function, afferent nerve impulses. There is a barrier to central integration.
Pathogenesis
Spasmodic torticollis is a type of dyskinesia, involving only regional muscles, and is a dystonia of adult onset. Pathological changes are still unknown. Only a few spastic torticollis can be found in the basal ganglia. In the epileptic foci, Tarlov reported a case of posterior ascending torticollis with bilateral caudate nucleus and undefined lacunar formation. One patient with spastic torticollis and dance-like acromegaly developed bilateral caudate nucleus and globus pallidus. The ganglion cells in the region are lost, and some scholars have reported no structural changes in the sacral torticollis.
Prevention
Spastic torticollis prevention
Because the cause of the disease is unknown, there is no effective preventive measure. The most important clinical practice is active treatment. Physiotherapy and massage can sometimes temporarily relieve spasms, such as applying a sensible mildness to the ipsilateral mandibular while rotating the head. Stress (sensory biofeedback technique), although the drug is effective in inhibiting dystonia, the effective rate is 25% to 33%, but its effect on pain relief is better, anticholinergic drugs (such as trihexyphenidate, benzylidene) (products) and benzoazepines are effective, muscle relaxants (such as chloramphenic acid) and cyclic antidepressants (such as amitriptyline) are less used, the above drugs should start from a small dose, gradually increase to effective, The level of safety should pay attention to its side effects, especially for the elderly.
Complication
Spastic torticollis complications Complications dystonia syndrome spastic atresia
There are very few complications in this disease, but one third of the patients have dystonia with other parts, such as eyelids, face, jaw or hand. Involuntary movements (such as sputum) can disappear during sleep, and patients can also The combination of pain, which is high in the spastic torticollis, is related to dysfunction, and is related to the degree of sacral rotation and rotation of the head. The dysfunction is often caused by avoiding social interaction due to abnormal head and neck posture. Studies have shown that most patients with this disease also have a combination of depression.
Symptom
Symptoms of spastic torticollis Common symptoms Writing the back of the neck and muscles, the head of the head is biased to one side... Vertebral artery
The incidence of this disease is about 15/300,000, more common in adults, the average age of onset is 30-40 years old, the ratio of male to female is roughly equal, the onset is slow, the condition is gradually aggravated, rarely will resolve or relieve on their own, the head and neck muscles can not Controlled abnormal movements, often affected by bilateral muscle groups, but the degree of involvement is often asymmetrical, causing the head to turn to one side for torsional movement, morning light, exercise, emotional changes or sensory stimulation, aggravation, falling asleep, suffering from muscle hypertrophy Pain, neurological examination is negative, the disease itself will not be fatal.
The clinical manifestations of spastic torticollis are various, most of them are slow onset, a few sudden onset, shallow and deep muscles in the neck can be affected, and each patient has different degrees of muscle involvement and involvement, but The contraction of the sternocleidomastoid, trapezius and head and neck muscles is most easily manifested. According to the extent of the neck muscle involvement and the degree of involvement, the clinical manifestations can be divided into four types:
1. Rotary type:
It is characterized by a squat or clonic rotation of the head around the longitudinal axis of the body.
2. Back type:
Head to the back for squatting or clumping back, squatting, facing the sky, the cervical spine is arched.
3. Front flexion type:
Head to the chest for sputum or clonic flexion.
4. Side type:
The head deviates from the longitudinal axis of the body to the left or right for squatting or clonic lateral flexion. In severe cases, the ear, ankle and shoulder are approaching or close, and often accompanied by the lifting of the shoulders of the same side, shortening the ears and shoulders. distance.
Most patients with spastic torticollis have a muscle contraction frequency greater than 10 times/s, which is characterized by head stiffness in one direction, called sputum; a small number of patients have muscle contraction frequency less than 10 times/s, which is characterized by the head twitching in one direction, For the hustle and bustle.
The spastic torticollis is the same as other extrapyramidal diseases. The clinical manifestations are lighter in the morning when getting up, nervous, impulsive or labor, the symptoms are aggravated when walking or when various body organs are stimulated, the symptoms are relieved when quiet, and the symptoms disappear after falling asleep. When awake, the patient often uses the hand to straighten the head. When the symptoms gradually become obvious, it affects the patient's daily life and mental state. The long-term abnormal movement of the head can show the affected muscles with different degrees of thickening and hypertrophy, and the antagonistic muscles of the contralateral side are in relaxation. The state of disuse, and even varying degrees of muscle atrophy, mild patients can have no muscle pain, severe patients often have severe myalgia, a small number of patients are also accompanied by tremors, occasional patients with pronunciation, swallowing disorders.
Examine
Sexual torticollis examination
Laboratory inspection
General cerebrospinal fluid, blood, urine routine examination are normal.
Film degree exam
1. Electromyography: conventionally traced muscles have bilateral sternocleidomastoid muscles and bilateral cephalic muscles. Unipolar electrodes can be applied. Patients should be recorded at rest (usually sitting position) and the head is in voluntary motion. Under the myoelectric activity, to understand which muscles are active and which muscles are in a state of inhibition, the dominant nerves of the muscles of the latter cannot be cut off.
2. Partial block test: The block should be completed under the monitoring of EMG. The injection point should be selected when the muscle is electrically stimulated, and the maximum contraction occurs. Each muscle should be injected with 10% lidocaine 5~10ml. Even if the block is incomplete, it can help us predict the effect that the muscle may have after its dominant nerve is severed.
3. Spinal X-ray film: visible changes in the shape of the spine, such as side bends, flexion, recoil or torsion, even the subluxation of the facet joints of the cervical spine.
4. CT examination: For complex types of spastic torticollis, CT scan can be performed on the neck. The scan range is from the occipital trochanter to the neck 7 cone plane. The scanning method is continuous thin layer scanning. The CT slices can measure the left and right sides. Compare with the circumference of the muscles, list the names and sideways of the hypertrophic muscles, and help to find the extent of the affected muscles, so that selective muscle resection, brain CT, MRI often have no obvious abnormal changes.
Diagnosis
Diagnostic identification of spastic torticollis
diagnosis
The diagnosis of this disease is relatively easy, it is difficult to determine the muscle involved, according to its specific clinical manifestations, cervical tendon or clonic head tilts the head to one side, nervous system examination (including cone system, extrapyramidal and cerebellar function, feeling Etc.) are in the normal range, due to long-term muscle spasm, the affected muscles are often abnormally solid and hypertrophy, and there are no abnormalities in the CT and EEG of the head. According to the symptoms, the diagnosis of spastic torticollis can be made, combined with palpation and The above electromyography, local block and neck muscle performance, after comprehensive analysis of the patient, make a clinical diagnosis and list of affected muscles, and then develop a treatment plan.
Differential diagnosis
1. Upper cervical disease: such as rib pain, injury, cervical disc herniation, etc., patients often complain of neck discomfort, one side of the neck muscle atrophy, the head can be tilted, but there will be no seizures, at the same time, the above lesions may have The sensory movement and reflex of the upper limbs changed, while the spastic torticollis had no effect on the function of the upper limbs.
2. Cranial-cervical junction lesions: such as severe craniocerebral junction deformities, these patients often have symptoms of craniocerebral junctional nerve compression, such as unstable walking, difficulty swallowing, muscle weakness in the limbs, reflex and muscle tension, also expressed as Thickening of the neck, lower hairline, such as with syringomyelia, may also have upper limb muscle atrophy, segmental pain and tactile separation phenomenon, similarly, the patient may have a torticollis phenomenon, but there will be no seizures.
3. Congenital side sternocleidomastoid muscle atrophy: common in children, more common in birth injury, lesion side muscle atrophy, normal side muscles have compensatory hypertrophy, but there will be no seizures.
4. Children's posterior cranial muscle pain: The patient has a forced head position in order to relieve the pain, causing some muscles in the neck to be stiff. Although there is a head tilting posture, there is no seizure, and the patient has obvious post-cranial symptoms. Such as headache, vomiting, unstable walking, nystagmus, and a short history, children should also be differentiated from the ocular torticollis, due to lesions on one side of the eye, most of the palsy of some eye muscles, causing the sick child to look at the object When the head is in a certain tilting position.
5. Finally, it should be differentiated from the sickle torticollis. The patients have clear mental factors, sudden onset, frequent changes in symptoms, irregularities, and symptoms disappear quickly after emotional stability.
