Motor tics of the head and neck: surgical approaches and their complications.

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 7 1/2% 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 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.