대한정위기능신경외과학회 Year-end Conference

Presentation on theme: "대한정위기능신경외과학회 Year-end Conference"— Presentation transcript:

1 대한정위기능신경외과학회 Year-end Conference
인천성모병원 R3. 박 재 현

2 SCM denervation plus GPi DBS for Laterocollis

3 Case-1 Case 45/F 천 O 미 Underlying ds (-) 2010년 4월, Cervical dystonia 증상 발생 (Rt. Laterocollis) 증상 점차 악화되어, 서울삼천포병원에서 SCM m.의 peripheral denervation 수술 시행 받음. 이 후, 증상 호전되지 않아 2012년 4월, 본원 내원함. Trigger factor : walking

4 Pre Op

5 Post Op

6 20 6 24 14 4.5 58 16.5 Post Op PreOp Post Op Torticollis Severity
Disability 24 Pain 14 4.5 Total TWSTRS Score 58 16.5

7 Post Op

8 Case-2 Case 51/F 이 O 자 Underlying ds (-) 2009년, 걸을 때 발생하는 Cervical dystonia (Rt. Laterocollis) 주소로 2010년 3월, 서울 삼성병원 내원하여 Botox 치료 3회 시행 받은 후 증상 일시적으로 호전되었다가 다시 악화됨. 2011년 3월, 부산 메리놀 병원에서 Bilat. Gpi DBS 시행 받음. 증상 조절 잘 되지 않아 2012년 6월, 본원 외래로 내원함. Trigger factor : walking

9 Pre Op

10 23 15 20 5 13.5 2 56.5 22 Pre Op PreOp Post Op Torticollis Severity
Disability 20 5 Pain 13.5 2 Total TWSTRS Score 56.5 22

11 Post Op

12 Deep brain stimulation for patients who underwent peripheral surgery previously the Outcome ?

13 The 1st treatment of Option for patients with Cervical dystonia (CD)
Brief review The 1st treatment of Option for patients with Cervical dystonia (CD) Injection of Botulinum toxin into the dystonic muscles Majority of patients have satisfactory benefit If this treatment fails, consider for functional surgery Selective peripheral denervation Bertrand’s technique with modification Combined with Myotomy/Myectomy Deep brain stimulation Posteroventral lateral Globus pallidus internus (Gpi) Recurrence of Dystonia Reinnervation of the denervated muscle Disease progression with muscles in the neck being affected (other m.) Initial study protocol of DBS for CD excluded patients with previous surgery Selective peripheral denervation vs DBS

14 Brief review 7 patients CD patients who underwent bilat. Pallidal DBS
Who had previous peripheral denervation 4 patients from Mannheim/Hannover, Germany University Hospital Mannheim & Medical School Hannover 3 patients from Umea, Sweden Umen University 4 men / 3 women Mean age : 64세 (39-76) / Mean age of onset : 49세 7명 모두 Bertrand Op. 를 받고 최소 50% 이상 주관적으로 증상이 좋아졌다가 다시 재발. 약물 치료는 Trihexyphenidyl, Benzodiazepine, Baclofen이 포함되어 있었다. Peripheral denervation을 받고 DBS를 받기까지의 시간으로 보면 독일에서는 10.3년, 스웨덴에서는 9.7년이 평균적으로 걸림.

15 Brief review Cervical dystonia의 severity는 독일 Mannheim과 Hannover에서는
Burke-Fahn-Marsden (BFM) scale 과 Toronto western spasmodic torticollis scale (TWSTRS) scale을 사용하였고, Sweden Umen에서는 Tsui Scale을 사용하여 서로 다른 scale을 사용해서 비교 분석하였다.

16 Brief review BFM scale & TWSTRS in Mannheim/Hannover
Tsui scale in Umen Short-term f/u : 3~9 months after surgery Long-term f/u : 24~72 months after surgery Target of DBS : 20-22mm lateral & 4mm below the intercommissural line 2-3mm anterior to the midcommissural point No surgical complications Umen : Tsui score 수술 전 평균 7점에서 수술 후 평균 14개월 f/u에서 평균 3점으로 62.5% 감소 표에서 보이듯이 DBS 이전에 Peripheral denervation을 받은 경우와 아닌 경우에서 TWSTRS 또는 BFM scale 모두 short-term하게든 long-term하게든 통계적으로 유의한 차이를 보이지 않았음. Matched controls

17 Discussion Conclusion Brief review
Patients with CD who have had previous peripheral denervation surgery may achieve sustained improvement after pallidal DBS that is comparable with that of patients who did not have previous surgery CD patients who had previous peripheral denervation surgery can be counseled to expect valuable benefit after pallidal DBS if dystonia has recurred after initial improvement. Limitation Use of different assessment scales Small data span Conclusion Patients who have had prior peripheral surgery for CD experience improvement from subsequent pallidal DBS that is comparable to that of de novo patients

18 Deep brain stimulation vs Peripheral denervation ?

19 Brief review Oct, 2000 ~ Feb, 2009 24 patients with CD underwent operation Selective peripheral denervation (SPD) : 16 Deep brain stimulation (DBS) : 8 Type of SD : Tonic, Phasic, Tremulous SPD 16명, DBS 7명 – 한 명은 둘 다 시행 Follow-up은 평균 46.6개월 (27 ~ 65개월) Subjective score와 TWSTRS로 objective score를 평가함. (치료의 효과를 4가지 class로 구분하였고, 모두에게서 정도의 차이가 있을 뿐 수술전보다 호전된 결과를 보임) Pain에 대해서도 평가함

20 Brief review Results Recurrence rate 12.5% (2/16) in SPD group None in DBS group Complications of SPD Wound infection (2) Occipital neuralgia (3) Delirium (1) Venous air embolism (1) No statistically significant difference between the SPD & DBS groups in terms of surgical outcome. Only a trend toward greater pain reduction in the DBS group Might be related to reinnervation of the neck muscles In terms of recurrence & complications, DBS was likely to be more safe & effective 20

21 Combined treatment for Laterocollis ?

22 Torticollis + Retrocollis
Type Operative Procedures Torticollis contralateral SCM denervation & myomotomy ipsilateral post. neck muscle selective rhizotomy (C1,2)& post. ramisectomy(C3-6) Retrocollis bilateral post. neck muscle selective rhizotomy (C1,2)& post. ramisectomy (C3-6) Laterocollis ipsilateral SCM denervation & myomotomy Torticollis + Retrocollis contralateral SCM denervation selective rhizotomy (C1,2 and C3) & ipsialteral post. Ramisectomy (C4-6) Torticollis + Laterocollis bilateral SCM denervation & myomotomy Laterocollis ipsilateral SCM denervation & myomotomy ipsilateral post. neck muscle selective rhizotomy (C1,2)& post. ramisectomy(C3-6)

23 Movement of Torticollis
Simple movement : rotation, lateral tilting, extension, flexion Rotation – Rotatory torticollis Main : SCM opposite to the rotation + post. muscles on the same of the rotation Lateral tilting – Laterocollis Main : the levator scapulae m. Synergists : the posterior m. on the same side Extension – Superior retrocollis Main : the recti and obliqui m. Synergists : splenius and semispinalis m. Flexion – Anterocollis Main : both SCM m. Synergists : the longus capitis and longus colli m. Inclination Ventral ramus of C3-4

24 SPD + GPi DBS 25 15 5 20 4 17 13 63 43 9 PreOp After SPD After DBS
Torticollis Severity 25 15 5 Disability 20 4 Pain 17 13 Total TWSTRS Score 63 43 9 The patient on whom we performed SD followed by DBS one year after SD was done, shows significant improvement in all categories. Before the SD was performed, the patient could not perform day to day normal life functions. However, after SD, he improved dramatically so that he could perform normal day to day functions but still he was not able to work at a job nor maintain social life. After DBS was done about a year later, he improved even more so that he could now carry on a normal life.

25 14 7 5 8 4 17 39 25 12 PreOp After SPD After DBS Torticollis Severity
Disability 8 4 Pain 17 Total TWSTRS Score 39 25 12

26 Selective peripheral denervation with GPi DBS combined treatment may have Synergistic effect for Cervical dystonia (esp. Laterocollis)