Introduction: We developed a surgical procedure to expose the XI nerve and a conflicting artery with a unilateral reduced approach. Such approach warrants control over the malfunctioning spinal part of the XIth nerve, which drives the sustained contraction of Sterno Cleido Mastoid Muscle (SCM). The SCM is the principal cause of head deviation in torticollis. The XIth, irritated by a vascular conflict misfires to the SCM muscle fibers. We present our results in in 20 operated patients.

Methods: Twenty patients were evaluated according to the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) parameters before and after surgery. Head deviation was identified as rotocollis, laterocollis and antecollis, or retrocollis according to the standard terminology. Patients selected suffered from a preeminent involvement of one SCM; in our selection we disregarded the complexity and pattern of head deviation. We assumed that the XIth nerve could conflict with vertebral artery or the PICA. In few cases among those presented, we could identify such anomaly on preoperative MRI. In accordance with our purpose, we did a unilateral exposure on the side of involved SCM by performing a unilateral emilaminectomy C0-C2. We combined selective radicellotomy (upon electrophisiologic identification of those directed to the SCM) and microvascular decompression in every case.

Results: Results were considered positive if we obtained an immediate de-contraction of involved SCM and head realignment with preserved range of motion without a need of further medication. It was obtained in 80% of cases. A fair result indicated an imperfect head alignment, obtained in 15% of cases. Patients evaluated with TWSTRS demonstrated an 85% improvement at 6 months since surgery.

Conclusions: The unilateral approach C0-C2 for a microvascular decompression of XIth nerve coupled to selective radicellotomy has been effective in correcting torticollis. The patient’s head realigns immediately after surgery probably because of SCM denervation.

Patient Care: A reduced surgical approach directly aiming at the vascular conflict and allowing immediate denervation of hypertonic SCM warrants shorter recovery time and immediate head alignment.

Learning Objectives: By the conclusion of this session, participants should be able to: 1) Describe the importance of XIth nerve role in torticollis 2) evaluate and discuss a reduced unilateral approach against a bilateral traditional approach. A video clip will illustrate patient changes and surgical technique. 3) Identify an effective surgical treatment for torticollis.

References: MCKENZIE KG The surgical treatment of spasmodic torticollis. Clin Neurosurg. 1954;2:37-43. Jho HD, Jannetta PJ. Microvascular decompression for spasmodic torticollis. Acta Neurochir (Wien). 1995;134(1-2):21-6. Friedman AH, Nashold BS Jr, Sharp R, Caputi F, Arruda J. Treatment of spasmodic torticollis with intradural selective rhizotomies. J Neurosurg. 1993 Jan;78(1):46-53.