ACTA NEUROCHIRURGICA Acta Neurochirurgica 48, 47--66 (1979) 9 by Springer-Verlag 1979 Motor Tics of the Head and Neck: Surgical Approaches and Their Complications* By W. B. Scoville** and D. B. Bettis*** With 4 Figures Summary Motor tics of the head and neck, especially hemifacial spasm and spastic torticollis, are the substance of this paper. Forty-six cases are presented, and surgical techniques are described. In hemifacial spasm the intracranial neurovascular lysis of Jannetta is a valid operation with the best results to date but has a 789 risk of unilateral deafness. The extracranial submastoid partial section of Scoville is completely safe and gives excellent results, but there is a probability of mild to moderate return of the spasm in one to two year's time. In spastic torticollis the accepted radical operation consists of bilateral anterior rhizotomy of the upper three motor roots plus bilateral spinal accessory nerve section in the neck. A tragic complication of this operation has recently been observed by ourselves, Sweet, and Hamlin. This complication is bilateral infarction of the medulla (bilateral Wallenberg's syndrome). This has also been reported as occurring following chiropractic manipulations. For this reason the writer does limited unilateral sectioning of the spinal accessory nerve in the neck and resection of the upper third of the sternomastoid muscle, as a first stage procedure, in those cases in which rotation of the neck is the principal symptom, before doing the radical operation. Safeguards to prevent this complication include preoperative vertebral arteriography and preservation of both motor and sensory radicular arteries under magnification and maintenance of adequate neck support during the early postoperative days. Keywords:Hemifacial spasm; spastic torticollis; deafness; medullary infarction. * Presented at a joint meeting of the American Academy of Neurological Surgery and The Society of British Neurological Surgeons, Bermuda, November, 1974. ** Clinical Professor of Neurosurgery, Yale University Medical School and the University of Connecticut Medical School. Director Emeritus, Department of Neurosurgery Hartford Hospital, Hartford, CT 06106, U.S.A. *** University of Colorado School of Medicine, Denver, Colorado, U.S.A. 0 0 0 1 - 6 2 6 8 / 7 9 / 0 0 4 8 / 0 0 4 7 / $ 04.00 48 W.B. Scoville and D. B. Bettis: Various motor tics of the head and neck including spastic torticollis and hemifacial spasm, operated on in the past 35 years, are the substance of this paper. Twenty-three cases of spastic torticollis, 20 cases of hemifacial spasm, 2 cases of bilateral blepharospasm, and one case of platysma spasm underwent operation. All were motor tics, although Jannetta has proved that sensory tics of the fifth nerve, the glossopharyngeal nerve, and possibly the eighth nerve have been equally helped 8. :~. These motor tics, frequently beginning as habit forming spasms, can become totally disabling and, regardless of aetiology, psychiatric and drug therapy are of no avail. Presentation is made of the above motor tics, especially hemifacial spasm and spastic torticollis, with observations on the two serious complications which may result from surgical intervention. 1. Hemifacial S p a s m Hemifacial spasm is not uncommon. Females fall victim to it four times more frequently than males. The average age of onset is 52 although age is not significant. Hypertension is present in one half of the cases. Surgery is necessary because of its social implications, suffering, and the rarity of spontaneous subsidence. Choice of operation lies between the writer's extracranial proximal submastoid partial sectioning of the seventh nerve and intracranial neurovascular lysis popularized and perfected by Jannetta 1~, 7. Heifetz is trying radiofrequency percutaneous coagulation, which is certainly simple, may be repeated, and is more accurate than alcohol injection 6. I plan to try it. The extracranial operation is completely safe giving excellent results after a three month period of weakness (Fig. 1) 18. A technical point is the rapid identification of the seventh nerve as described by Tabb et al, 2.2. It consists of identifying the tympanomastoid fissure and the facial nerve 8 mm deep to it. This is identified by electrical stimulation (Fig. 2). However, there is a probability of mild to moderate return of the spasm in one to two years' time with eventual fading of the spasm. The alternative is intracranial operative decompression of the seventh nerve at its outlet from the pons, freeing it from contact with a pulsating branch of the AICA or PICA, or less commonly the basilar or vertebral artery or crossing vein, by interposing a bit of silicone sponge or gelfoam, or more recently muscle, between the nerve and artery (Fig. 3) v. It is imperative to make the separation directly at the point of emergence of the nerve from the pons. The results of Jannetta's modification, when done by expert hands, is M o t o r Tics of the H e a d a n d Neck 49 excellent. Yet there remains a risk of 5 to 10~ of unilateral deafness even in expert hands, as well as occasional temporary partial paralysis of the seventh nerve. Although Jannetta claims Fig. 1. Scoville's extracranial partial section of facial nerve. We n o w use the Castroviega keratome as used in eye operations 40/0 total or partial unilateral deafness, it has occurred in a much higher percentage when done by others, especially in the more lateral operations of Gardner 2, 16. This is probably because the auditory or 4 Acta Neurochirurgica, Vol. 48~ Fasc. 1--'2 Fig. 2, Operatio~J for blepharospasn~ with illustration of the tympanol~aastoid fissure ~a .,g Motor Tics of the Head and N e & 51 cochlear artery accompanies the nerve more distally and is an end artery reversing itself by sharp angulation within the internal acoustic meatus, making it more vulnerable to infarction if stroked in those cases already exhibiting hemifacial spasm 18 In a review of the late results of 20 cases of hemifacial spasm (Tables 1 and 2), eleven had extracranial submastoid partial sections and nine had cerebellar angle explorations. Of particular interest is Fig. 3. Illustration of vascular compression of cranial nerves V, VII, and I X at their exit from the pons by various cranial nerves as demonstrated by Jannetta. A Flocculus, B choroid plexus, C choroid plexus, D PICA, E vertebral artery, F superior cerebellar artery, G fifth nerve, H VIII nerve component, I VII nerve component, J AICA, K basilar artery, L spinal accessory nerve, M vagal nerve, N hypoglossal nerve one having a dermoid tumor: a young nun was referred to the writer from St. Louis with no signs of an angle tumour on meatal X-ray or audiographic laboratory work-up. She had had two previous extracranial selective sections done elsewhere. Dr. Jannetta, by invitation, explored the angle, intending to demonstrate his lysis operation, but instead found and removed a dermoid turnout, with a complete and immediate cure. Of the other intracranial operations for facial spasm, four were made unilaterally deaf. Two had distal operations 4* severe with selective distal to blepharoparotid, 1946; spasm, 1 year SSSS *, 1948 severe moderate SSSS *, 1949, intermittent, deeper, one half 4 years cut moderate, 9 years moderate, 5 years 6 years NK M 30 PL F 49 JZL F 49 FC F 58 FG M 59 ML F 68 age ? reports "perfect at 5 years" SSSS *, 1957 total for 6 months; recovered fair to good, second SSSS % 1953, repeat sectioning 4 days tol~e 200/0 at 1 year; intermittent thereafter yes, 180/90 5 years; 500/0 intermittent no thereafter 25~ at 2years; none yes, 220/120 at 20 years ? eye lid only and when excited 900/0 for 3 months; good facial eye blinking, very nervous tuck taken in eye lid because of slight droop, now has slightly diminished lid slit drug sensitivity requiring general anesthesia; hence 2nd operation traumatic peroneal palsy hypertensive symyes, severe pathectomy in 1947 3 months spasm slowly faded ComplicaGons 75~ at 11 years; only 25~ at 16 years Hypertension yes Recurrence 22 months slight droop of mouth 3 months Temporary paralysis excellent excellent good to excellent Result SSSS *, 1952 SSSS % 1949 Severity and Operation duration and date sex~ Name, Table 1 100~/0 at 5 years; "a couple of twitches thereafter" 5 years; 50~ intermittent recurrence 21 years; excellent; 950/0 recovery 1 year; eye lid only, when excited; 660/0 recovery by telephone, 750/0 improved over 16 years excellent at 18 years; death Follow-up ~Ta t~ 8- o .< moderate, 6 years moderate, 6 years HS F 72 LY F 50 SSSS " 1975, '' under innovar gen. anesth, SSSS *, 1975, with difficulty SSSS *, 1974 SSSS ::" 1972 SSSS ", 1962 excellent excellent excellent good reports "poor" '" Scoville's Submastoid Selective Sectioning. moderate, 7 years moderate, 10 years moderate, 10 years JS M 72 F 63 HJ ZG F 56 750/0 return of function at 3 months slow recovery over 7 months slight, recovered in 2 weeks 50%, recovery in 2 months 3 months 9 months; 500/0 intermittent nolle none 250/0 at 1 year, eye lid 500/0 (eye only) at I ~ years moderate yes no yes 15 years; does not wish intracranial operation loss preoperatively "comes and goes" slight cochlear hearing mittent2 years;; 500/0 inter- difficult operation ; no primary branching of VII nerve; slight 2 years; clinical cure cochlear hearing loss preoperatively 3 years; clinical cure does not wish 5 years; intracranial operation 90~ improvement neurotic; wished she had not had the operation :Z e~ ~a ~Z ~" o o 8 moderate, 5 years not severe enough to warrant op. moderate, 5 years moderate, 3 years most severe permanent, 5 years KS F 62 HS M 56 LAS F 70 CA F 30 CP F 32 excellent Result none 2 months; none 2 Gardner ops. by Don Wilson (sect. VIII and nervus intermedius) 1969; poor, SSSS with difficulty by temp., clin. cure WBS, 1970; Jannetta's op. by Jannetta, 1971 3 months none 3 months good good no no Temporary paralysis alcohol inj. in Peru, 1960; poor SSSS with difficulty; both primary branches selectively cut, WBS, 1969; good repeat alcohol inj. 1973 excellent select, section, distal to parotid, German, 1965; repeat op., Poppen, 1967 2 facial plastic operations, 1960; negative exploration no Change angle, WBS, 1962 cerebellar lysis of cochlear artery distal, WBS, 1961 Severity and Operation and date duration age sex) Name, severe no ? Hypertension 2 months no noo-benefit; recurred 3 years no mira twitching eyelid 1 year; slight 1 year no no Recurrence Table 2. Other Procedures 16 years; clinical cure Follow-up 4 years; good cosmetic (rain. eyelid), 800/0 recover), unilat, deafness after Gardner op. early recurrences 6 years; after WBS Ache clinical curt' face and head after Jannetta's op. required 2 alcohol injections plus one SSSS unilat, deafness followed sliding dis3 years; sued sector between art. and nerve death senile dementia 10 years; no spasm unilateral deafness Complications e~ c~ L5 2. o .~ moderate, 5 years moderate, 5 years moderate, 9 years severe, 13 years CA F 5O AP F 75 HL F 38 F 34 MJ clinical cure Jannetta operation by WBS, 1976 immediate cure Jannetta operation by Jannetta 1973, reoperation no benefit, by Jannetta 1974 clin. cure Jannetta operation by Jannetta 1973 2 German ops. 1970 and 1971, Jannetta exploration no benefit, in 1973, dermoid tumor clin. cure removed no 110 4 months no no no benefit; clinical cure no early after 1st two operations no 11o no no p~ z g2. o minimal decay hearing audiolab; 1 year; does not bother her clinical cure 9 o unilat, deafness permanent; replace3 years; ment of sponge, clinical cure deeper level temporary paralysis 4 years; clinical cure dermoid tumor 4 years; found and removed clinical cure by Jannetta 56 W.B. Scoville and D. B. Bettis: by the w r i t e r in the early days % one was d e l i b e r a t e l y m a d e deaf b y a n o t h e r surgeon w h o used G a r d n e r ' s a p p r o a c h ; a n d one of J a n n e t t a ' s cases required r e - o p e r a t i o n due to m i s p l a c e m e n t of the I v a l o n sponge too far distally (his second o p e r a t i o n cured the h e m i facial spasm b u t n o t the deafness). Thus, the need of an experienced m i c r o s u r g e o n a n d the possibility of u n i l a t e r a l deafness are evident. 2. Blepharospasm This disease f r e q u e n t l y starts as a h a b i t spasm but occasionally becomes so disabling that the p a t i e n t is u n a b l e to leave his home u n a t t e n d e d or to d r i v e a car. Case 1. M. P. A 66-year-old plumber was admitted to the Hartford Hospital on 26 September 1972, tense and anxious, having had several abdominal aortic aneurysm operations, and ultimately requiring leg amputation. His spasms were so frequent as to cause his eyes to remain closed 50% of the time. He had received almost every drug in the pharmacopeia and 25 subinsulin shock treatments, and was unable to drive his car or to go out without holding his wife's arm for guidance. In his case we made the same extracranial submastoid exposure of the proximal main trunk of the facial nerve as performed for hemifaciaI spasm (Fig. 2). The upper primary "Y" branch proximal to the parotid gland was identified, stimulated in order to demonstrate orbicularis movement, and then cut and avulsed for a length of 2 to 3 cm. We did this bilaterally in one sitting under light Innovar anaesthesia. Avulsion of the entire primary branch will still leave some orbicularis function because of its multiple branching with anastomoses with the oral main branches as demonstrated by McCormack et al. 11 l'-,. This technique is offered as a rapid, simplified method in preference to selective avulsion of minute multiple orbicular branches distal to the parotid gland as reported by Greenwood, Reynolds, and others a iv Case 2. D.W. A 68-year-old woman presented with bilateral facial spasm, more especially blepharospasm, caused by progressive basilar impression secondary to advancing Paget's disease of the base of the skull. In 1964 and 1965 we carried out bilateral partial sections of the seventh nerve twice, with recurrence in a matter of months, and finally in desperation in 1967 followed Norman Dott's suggestion of total bilateral sections of the seventh nerve. The patient was most grateful and was able to swallow, eat, and sufficiently close her eyes by gravity to function well, although she could not smile. All spasm cleared, but in a ten year follow up she ultimately had a partial return of function of one seventh nerve in spite of the total sections indicating this nerve's remarkable regenerative ability. She also developed vagal nerve paralysis from her preoperative Paget's disease and required a permanent gastrostomy to prevent aspiration pneumonitis. The results in both of the above cases were cosmetically better t h a n a n t i c i p a t e d . Both could close their eyes b y g r a v i t y , a n d the d a n g e r of corneal u l c e r a t i o n is slight in c o n t r a d i s t i n c t i o n to the d r y corneas f o l l o w i n g t e m p o r a l f i f t h n e r v e root operations. Motor Tics of the Head and Nedi 57 3. P l a t y s m a Tics L.M. A 38-year-old, admittedly neurotic, divorced woman was first seen in December 1971 for increasing platysma myoclonic spasm accompanied by laryngeal spasm over a three year period in spite of tranquillizers, psychotherapy, and six electric shock treatments. She was followed conservatively with every conceivable drug for another one and a half years by a neurologist, and admitted to the Hartford Hospital on 31 May 1973. Bilateral avulsion of the submental branch of the facial nerve was performed in one stage by exposing the submastoid main trunk of the facial nerve and following its primary inferior branch to its second submandibular branch (which reproduced her spasm upon stimulation). This branch was clipped, cut, and distally avulsed for a distance of 3 cm. She had an excellent early result, but a four year follow up indicated other multiple complaints of neck and laryngeal spasm. 4. Spastic Torticollis Just as in facial tics, m o t o r tics of the neck (spastic torticollis) can become a devastating disease. We have been surgically interested in this lesion for 35 years and present the late results on 23 cases (14 females and 9 males) who underwent either complete bilateral high anterior cervical rhizotomies plus complete cervical extraspinal sectioning of the spinal accessory nerves (Table 3) or a limited operation of unilateral avulsion of the spinal accessory nerve in the neck together with resection of the upper one third of the sternomastoid muscle (Table 4). This latter procedure is done in those cases in which rotation of the head constitutes the chief disability. I prefer to cut and avulse the entire spinal accessory nerve including its trapezius branch and to resect the u p p e r two inches of the sternomastoid muscle to prevent the nerve f r o m regenerating. For the complete operation we had followed in the footsteps of Foerster, D a n d y , Kenneth McKenzie, and H a m b y , all of w h o m described high intraspinal cervical anterior r h i z o t o m y with separate extraspinal accessory nerve sections in the early course of the disease rather than limiting the operation to the spinal accessory alone. They believed that the disease was always widespread and would eventually involve all nerves to the cervical muscles. I was of the same opinion until experiencing recently a tragic complication of medullary vascular infarction (bilateral Wallenberg's syndrome) following such anterior cervical rhizotomy. Case report. E.L. A 49-year-old male country club manager had developed a rapid onset of involuntary rotary motions of the head to the right. Within two months the head had permanently turned to the extreme right. This caused considerable mental anguish and refusal to leave the bedroom because of sociaI embarrassment. He was referred to us five months after the onset, and admitted to the Hartford Hospital on 6 January 1974 with a negative brain isotope scan. On 8 January 1974 he underwent sectioning of the anterior motor roots of the EH 64 F 6 months; mild rotation to left; platybasia temporary difficulty swallowing bilat. C 1-2-3 and right C 4; bilat, sp. access, in neck; suboccip, decompression 25.2. 1959 bilat. C 1-2-3 sp. access, in he& 12.6. 1957; C 4 sens. root bilat, 2nd stage 2 weeks later rhiz. C 2 for occipital pain 18.1. 1954; right C I-2-3 23.9. 1957 good 1st op.; excellent 2nd op. " f i n e - - n o complaints"; saved his life grateful good little trouble elevating arms above head good 22 years; glad she had op.; ult. 100% relief 18 years; state senator winning campaign 2 years (no further record; glad she had op. 20 years; 750/0 improved; has not missed 1 day from work 12 years; fair to good; grateful 26 years; 100~ improvement; very grateful Follow-up slight difficulty swaUowing good 1 year; many complaints head tilted; tremors good for torticollis; 16 years; tleck satisfactory; poor writing jaw and hand cure spasm and and eating rotation head remained tilted limitation turning head to left hilat, sp. access, in neck 2 years severe drug later C i-2-3 rhizotomy 6.6. 1955 addiction bilat. C 1-2-3 and C 4 left; 1 year; spastic torticollis later sp. access, in neck; reop. (uncut with Parkinson's arm and fascicle right C 2) 3. 10. 1957, face; Sp. arachnoiditis 8.10. 1957, 8.12. 1958 several years; neurotic torticollis; mild platybasia IW 34 F neg. myelo, and T.P.; after 1 year C 1-2-3 bilat, and sp. access, in neck 17. 2. 1954 DH 44 M many years; pain left lie&; right rotation; neurotic overlay AM 43 F Evaluation postop, spasm post. cervical muscles, good left Complications bilat. C 1-2-3 and C 4 sells.; bilat. sp. access, in neck 1 week later none 19.2. 1953 bilat. C 1-2-3 and sens. of C 4; bilat, spinal access, in neck 6. 1. 1950 3 years; moderately severe; head rotated to left 9 years; moderately severe; rotated to left AJ 57 F weeks; fulminating progressive spastic torticollis; Organic basal ganglia syndrome 2 months severe; Jerking of head; mild over years MB 51 M Operation EP 41 M ES 35 F Symptoms Pt. Table 3. Intraspinal Rhizotomy and Spinal Accessory Section (13 Cases) ~'.. ~" .~ o~ 2 years; mild; rotary; anxiety state 2 months; extremely severe; rotatory to left with hyperextension 5 months; severe rotary and tilt to left see case report jv 41 F j p -':- AG 43 M EL 49 M 42 M several months; severe rotation to left; spasm sternomastoid and pIatysma JB 47 M bilat. C 1-2-3 and right C 4; resect, upper 1/a sternomastoid and sp. access, branch, 30.3. 1973 bilat. C 1-2-3; sp. access, in neck 5.11. 1957; repeat C 1-2 right; repeat access, left, 3.8. 1965 bilat. C 1-2-3, 23.11. 1966; spinal access, and upper sternomastoid muscle resection 1.12. 1966 bilat. C 1-2-3 and right C 4 and sp. access branches 10. 11. 1960; reop. resect, upper sternomastoid unsatisfactory neurotic elevate arms 1 day postop.; sat up and had ischemic attack of medulla with cerebellar signs, right pyramidal leg, diffic, swallowing; gasping asymptornatic paralysis right dia- good; glad she phragm.; temp. had op. holding chin temp. difficulty swallowing and recurrence fair; posterior cervical spasm beginning to die down 4*/,,, years; 500/0 improved; no return of spasm 17 years; not glad she had op. although 7 5 % improved 8 years; symptom cleared; excellent result; glad he had operation 6 months z o g- o avulsion spinal access, and total resection sternomastoid muscle, right, 29.5. 1968 3 years intermittent; tilt and rotation only when walking 3 to 4 years; moderately severe 6 months rotation to right; moderately severe DS 43 M FR 59 F MM 55 F unable to laterally elevate arm above head none none selective spinal access, in neck weakness on plus 2 inches of muscle (sup.), elevation of arm 13.2. 1974 above head resection left sternomastoid muscle, 2.2. 1974 8 months severe rotation to selective section spinal accesright plus rhythmic motion; torsion dystonia; hypertrophy sory branch and resection of entire muscle: 2I. 11. 1967 left sternomastoid LW 36 F return of spasm 6 months; pleased with result; head faces straight ahead 2 months; 50% improved in both rotation and spasm 15 years; 80% recovery; very pleased; tiny tremor in head only 31 years; says she should not have had operation Follow-up good; head held straight 8 months; 75~ improved 2 years; better than before op. hut turns uncontrolfair; hypothyroidism and depression lably to right 60% improved; to try bio feed back satisfactory good no good result; head tremor unchanged congenital head tremor, 10 years; moderate torticollis section left spinal access. 1953; section right spinal access, elsewhere, with regeneration: 1957; avulsion right spinal access. 7. 8. 1958 CF 22 F severe anxiety state excellent result; no torticollis 6 months rotation to right; marked anxiety; ? habit spasm selective section spinal access. 15. 1. 1942; bilat, total section spinal access, and right sternomastoid sectioned: 4. 12. 1945 Evaluation Complications Operation AD 43 F Symptoms Table 4. Selective Section (10 Cases) g ~a spinal accessory section plus resection upper third of sternomastoid, 23.3. 1977 1 89 years; severe rotation to left; when concentrating is OK; atrophy right sternomastoid; psychiatric inadequacy none none RG 47 M none total upper one third muscle spinal accessory nerve resection 9. 7. 1974 resection sp. access, branch to and upper 1/a sternomastoid, 7. 1. 1975 slight weakness on elevating arms above horizontal resection upper left spinal access, nerve and upper 1/,~ sternomastoid muscle: 27. 6. 1974 9 years; severe rotatory to left; hypertrophy right sternomastoid 6 months; torsion turning of head to right; tremor voice and right hand; ataxic speech; inco-ord, of breathing with speech 1 month extreme rotation head to left; rhythmic motions against resistance; ? encephalitic WM 34 M JA 24 F JB 62 F fair 2 years; selective op. and bio feed back has resulted in voluntary control of rotation poor early; fair late; does not need "big" op. 8 months; 400/0 improved; can voluntarily hold head straight ahead. Refuses further op. 2 years; glad she had operation; 100~ relieved 2 years; glad she had the operation excellent; clinical cure; spasm gone excellent; cure of rotation and rhythmic motion head and neck Z r eL. r o o o 62 W.B. Scoville and D. B. Bettis: first, second, and third cervical nerves with the lower roots of the spinal accessory nerves intraspinally in a prone position under light halothane and nitrous anesthesia without apparent mishap. The operation was done under magnification. He woke up immediately postoperatively and appeared normal with cure of his rotary spasm but eight hours later when asleep there developed sudden sIeep apnoea with respiratory and speech arrest immediately recognized in the Intensive Care Unit and treated with intubation. He was unable to handle his secretions or to swallow or be elevated, and had temporary phrenic paralysis requiring a full time respirator for one month, tube feedings by left pharyngostomy tube for three months and an indwelling bladder catheter for four months. He showed frequent attacks of pnenmonitis from aspiration of his saliva. He had a total orthostatic loss of blood pressure and sympathetic control for three weeks, and a diminishing quadriparesis without sensory involvement. There was slow continued improvement in all of these symptoms over the ensuing three months with first return of speech, then of feeding, then slow ability to assume an erect posture, and finally ambulation after five months. He was transferred to a Veterans Administration Hospital on the road to recovery but continued to have occasional aspiration pneumonitis, and suddenly died from such aspiration eight months postoperatively. Antemortem he had been believed to have a vertebral basilar artery infarction but incomplete autopsy showed no such infarction. The brain and spinal cord were unfortunately removed separately with severance of the cord at approximately the level of the rhizotomy. The basilar artery and distal vertebral arteries were normal without plaques or hypoplasia. The spinal cord well above and below the site of severance was also normal except for minute microscopic pinpoint dots of infarction well away from the site of rhizotomy, attributed to his hypoxic episode. The medulla showed gross infarction corresponding well with the clinically observed bilateral Wallenberg syndrome (Fig. 4). Microscopic examination: Three sections of pons show no abnormality. The basilar artery is normal and free of atherosclerosis. The next lower section of medulla, # 10, taken at the site of the grossly observed, wedge-shaped cavity, demonstrates this cavity in the lateral medulla involving masses of lipid-laden phagocytes. The appearance is typical of old infarction. On the opposite side there is a similarly situated but smaller ischaemic lesion lying anterior to the olive and extending almost to the midline. This lesion is filled with lipid-laden macrophages, but is not grossly cavitated, and is not distinctly visible grossly... (By Dean F. Uphoff, neuropathologist, Hartford Hospital.) Results in Torticollis In the vast majority of cases, the results of both the selective operation or the more complete intraspinal rhizotomy are eminently satisfactory. Following the latter operation, some patients have difficulty in swallowing when the neck is flexed, this improves, but the neck posture may give a cosmetically unpleasant retraction of the chin from weakness of the strap muscles. It is the author's own belief that spastic torticollis runs a subacute course for a period of years during which the patient exhibits rhythmic jerking of the neck muscles, as in encephalitis. This ultimately is replaced by fixation and fibrosis of these muscles. Surgery is indicated to prevent the hyper- Motor Tics of the Head and Neck 63 Fig. 4. Bilateral infarction of the medulla--from E. L. case report trophy and fixation during this irritative encephalitic period. With this concept in mind, some form of surgical nerve interruption to the involved neck muscles would seem to be indicated. 64 W.B. Scoville and D. B. Bettis: Discussion Discussion of the Consequences of the Reported Case Since this catastrophe I have been obviously reluctant to subject the usual run of the mill torticollis cases to the complete operation without first trying selective sections in the neck, more especially because my apprehensions have been confirmed by simultaneous reports of similar Wallenberg syndrome with equally devastating results following: 1. chiropractic manipulation of three people, reported at length by Mehalic and Farhat and by Lyness and Wagman 15. i0; 2. Sorensen had a similar bow hunter's paralysis 2; and 3. exactly similar results in two separate cases of Hamlin and Sweet '~. They all showed lower brain stem infarctions attributed to chiropractic manipulation, or pressure on the neck, or vascular infarction during this same fateful period in the spring of 1974. Since then the senior author has reviewed in detail his past cases and has elicited one more case of a much milder mishap originally attributed to stroke but probably due to lower brain stem minor infarction with complete recovery (Table 3--J. P. "). Extreme care must be exercised in carrying out the complete and more radical intraspinal nerve resections, although I believe they are justified because such severe complications are rare and the results have been termed satisfactory over many years time by such eminent surgeons as D a n d y and McKenzie. H a m b y and Schiffer, and Sorensen and H a m b y reported 80 cases of spasmodic torticollis treated by rhizotomy without such complications but one surgical death--alI without magnification ~, 21 In the past I have made every effort to preserve the radicular arteries of the sensory root, which are large, but have made little effort to preserve those of the motor roots, which are nearly invisible without magnification. Such complications may have been due to nonsurgical factors such as congenital hypoplasia of a vertebral artery, or a compression factor occurring from trauma 10, ~5, 2% or the extreme rotation syndrome of torticollis, particularly since the author's case and that of Hamlin exhibited such rotation. It also may be that torticollis, as motor tics of the face, is due to vascular pre-existing abnormalities. The author's own future plan of attack it to use unilateral avulsion ': Since writing this, John Potter of Oxford, England, described a delayed complication exactly similar to mine. All of these cases unfortunately resulted in suits. Potter queried whether modern drugs and new anaesthetics could have caused a lowering of blood pressure because none of us had such complications "in the old days". Motor Tics of the Head and Neck 65 of the spinal accessory nerve in the neck w i t h a t w o inch resection of the overlying u p p e r sternomastoid muscle in cases of p r i m a r y rotation. I f this fails to give sufficient relief, the patient will u n d e r g o bilateral vertebral a n g i o g r a p h y and, o n l y if it is normal, will he receive the intraspinal u p p e r cervical anterior r h i z o t o m y . C o n c o m i tantly, e v e r y effort will be m a d e to: 1. preserve b o t h m o t o r and sensory radicular arteries u n d e r m a g n i f i c a t i o n of 6 to 10 p o w e r ; 2. m a i n t a i n n o r m a l blood pressure during and after the procedure, w i t h the patient kept flat until there is p r o o f of stability; and 3. m a i n t a i n adequate neck s u p p o r t using a cervical Philadelphia collar for one m o n t h to p r e v e n t extreme rotation, w h i c h is possible postoperatively. References 1. Dandy, W. E., An operation for the treatment of spasmodic torticollis. Arch. Surg. 20 (1930), 1021--1032. 2. Gardner, W. J., Sara, G. A., Hemifacial spasm; a reversible pathophysiologic state. J. Neurosurg. 19 (1962), 240--247. 3. Greenwood, J., The surgical treatment of hemifacial spasm. J. Neurosurg. 3 (1946), 506--510. 4. Hamby, W. B., Schiffer, S., Spasmodic torticollis: results after cervical rhizotomy in 80 cases. Clin. Neurosurg. 17 (1970), 28--37. 5. Hamlin, H., Sweet, W. H., Cervical myelo-vascularity: a neurosurgical hazard. Presented at the meeting of the New England Neurosurgical Society, Mystic, Connecticut, October 11, 1974. 6. Heifetz, M., Personal communication--September 1977. 7. Jannetta, P. J., Abbasy, M., Maroon, J. C. et al., Etiology and definitive microsurgical treatment of hemifacial spasm. Operative techniques and results in 47 patients. J. Neurosurg. 47 (1977), 321--328. 8. Jannetta, P. J., Observations on the etiology of trigeminal neuralgia, hemifacial spasm, acoustic nerve dysfunction and glossopharyngeal neuralgia; definitive microsurgical treatment and results in 117 patients. Neurochirurgia (in press). 9. Jannetta, P. J., Trigeminal neuralgia and hemifacial spasm; etiology and definitive treatment. Trans. Amer. Neurol. Assn. 100 (1975), 53--55. 10. Lyness, S. S., Wagman, A. D., Neurological deficit following cervical manipulation. Surg. Neurol. 2 (1974), 121--124. 11. McCormack, L. J., Cauldwell, E. W., Anson, B. J., The surgical anatomy of the facial nerve with special reference to the parotid gland. SG and O 80 (1945), 620--630. 12. McCoy, E. G., Boyle, W. F., Reinnervation of the facial muscles following extratemporal facial nerve resection. Laryngoscope 81 (1971), 1--7. 13. McKenzie, K. G., Intrameningeal division of the spinal accessory and roots of the upper cervical nerves for the treatment of spasmodic torticollis. SG and O 39 (1924), 5--10. 14. McKenzie, K. G., Surgical treatment of spasmodic torticollis in Clin. Neurosurg. (Proc. of the Congress of Neurological Surgeons, 1954) edited by Thompson, R. K., and Jackson, I. J., Vol. 2, Chapter 3, pp. 37--43. Baltimore: The Williams and Wilkins Co. 5 ActaNeurochlrurgica,Vol. 48, Fasc. 1--_9 66 W.B. Scoville et al.: Motor Tics of the Head and Ne& 15. Mehalic, T., Farhat, S. M., Vertebral artery injury from chronic manipulation of the neck. Surg. Neurol. 2 (1974), 121--124. 16. Neagoy, D. R., Dohn, D. F., Hemifacial spasm secondary to vascular com~ pression of the facial nerve. Cleveland Clinic Quarterly 41 (1974), 205--214. 17. Reynolds, D. H., Smith, J. W., Walsh, T. J., Differential section of the facial nerve for blepharospasm. Trans. Amer. Acad. Ophthal. Otolaryng. 71 (1967), 656--664. 18. Scoville, W. B., Partial extracranial section of the seventh nerve for hemifacial spasm. J. Neurosurg. 31 (1969), 106--108. 19. Scoville, W. B., Hearing loss following exploration of cerebellopontine angle in hemifacial spasm. J. Neurosurg. 31 (1969), 47--49. 20. Sorensen, B. F., Bow hunter's stroke. Submitted for publication to Neurosurgery 1977. 21. Sorensen, B. F., Hamby, W. 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