Torticollis is defined as a twisting of the neck that causes the head to rotate and tilt as well as restriction of lateral movement of the neck
The Head is rotated and tilted towards one side with some lateral flexion called the ‘cock-robin’ position
The sternocleidomastoid muscle is shortened, tight and hard in torticollis.
Classification of torticollis
- Congenital
- Acquired
- Tumor
- Eosinophilic granuloma
- Infections
- Discitis
- Lymphadenitis
- URI
- Cervicothoracic scoliosis
- Inflammatory disease
- Neurological cause (Painless)
- Idiopathic
- Tumor
In 25 % of cases, underlying causes are not seen
Infantile (Congenital) Torticollis
It accounts for 1 % of cases
This condition is a common disorder in neonates
One SCM is fibrous and fails to elongate as the child grows
Etiology
Unknown etiology malposition of fetus inutero
History of difficult labor and breech presentation
Clinically
- Palpable cord-like Sternocleidomastoid muscle
- Clinically lump is visible in 1st few weeks after birth which disappears within a few months
- No deformity or obvious limitation of movements till 1-2 years
Later, the deformity is seen
- Head tilted towards affected side and
- Face rotated towards contralateral shoulder so that ear approaches the shoulder
Asymmetrical face
| Associated anomalies with torticollis |
- Hemihypoplasia
- Plagiocephaly (flattening of one side of the skull)
- DDH
- Metatarsal adductor
Investigation for torticollis
Especially done to rule out other causes for torticollis
(Xray, MRI)
Treatment options for congenital torticollis
Most have complete/ spontaneous resolution with time
Physiotherapy (Stretching of neck muscle by parents)
Benign SCM lump will disappear with time
But, if the condition persists beyond 1 year
Operative correction is required to avoid progressive face deformity
Indications for Surgical management
- The age of the child is more than 1 year
- Severe contracture of SCM
- ROM <30 °, limitation of passive rotation
- Facial asymmetry
Surgical Options for Congenital torticollis
- Unipolar release
- Mild deformity
- distally
- Bipolar release
- Moderate to severe deformity
- Proximally and distally
- Endoscopic release
- Myotomy
- Selective denervation
- Distal cord stimulation
Surgical steps of Bipolar Release
The transverse proximal incision behind the ear
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Divide SCM insertion just distal to the tip of mastoid process (avoid Spinal Accessory Nerve)
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Make distal incision 4-5 cm in the line with cervical skin crease
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Finger breathe proximal to the medial end of clavicle and sternal notch
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Divide platysma + sub-cutaneous tissue
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Expose clavicular + sternal attachment
(avoid jugular veins and carotid artery)
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Cut clavicular portion transversely
Sternal attachment with Z-plasty
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Alternately, release the clavicular head directly from the clavicle
Transecting sternal head proximal to its insertion by 1-2 cm
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Suture 2 ends together/ side to side or end to end
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Obtained designed degree of correction by manipulating Head and Neck during the release
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Release additional contracted bands of fascia or muscle occasionally before closure
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Closure of both wounds with sub-cuticular sutures
Post Operatively
Physiotherapy is advised
- Stretching
- Muscle strengthening
- Active ROM exercises
Head-Halter traction / Cervical brace is used for 1st 6-12 weeks following surgery then,
Manual stretching is done 3- 5 times daily for 3-6 months
Complications of Surgery
- Injury to Spinal Accessory Nerve
- Injury to jugular veins and carotid artery
- Neck muscle atrophy
- Loss of muscle control
- Instability
- Viable numbness or sensory loss; pain
- Neck deformity
Features of a child presenting late with congenital torticollis
- Present with fixed anatomical changes
- Facial asymmetrical
- Elevation of ipsilateral shoulder
- Front-occipital diameter of the skull ( may become less than normal)
Precaution before surgery in the late presentation:
- Fixed anatomical structures will/ may not reverse in spite of corrective surgery and surgery only cosmetically correct deformity
- Should not be aggressive d/t chance of injury to neurovascular structures
Atlantoaxial rotatory subluxation (AARS)
Atlantoaxial rotatory subluxation is a cause of torticollis where the lateral mass of the first cervical mass subluxed relatively to the second.
- Osseous causes
- Painless torticollis
- But no band
Atlantoaxial pathological displacement of the atlas on axis in a position that is normally accomplished during head rotation
They are associated with minor trauma ( So-called traumatic torticollis) or with recent nasopharyngeal infection
- Tonsillectomy
- A retropharyngeal abscess ( Grisel’s syndrome)
Onset: acute/after a period of a week
Early diagnosis and therapy are crucial to preventing neurological complications. Because it causes compression of the medulla oblongata by dislocation of the odontoid.
Plain X-Ray
- Open-mouth view
- CT is helpful
Treatment Options for AARS
Conservative treatment is recommended for mild cases.
Soft collars along with analgesics are used
If no resolution after weeks then Halter traction and Bed Rest with analgesics are used
Physiotherapy is contraindicated
An attempt at manual reposition with/out GA is not tolerated
In more resistant cases, halo traction is used
If articular remains unstable, subluxation persists, and recurs early or neurological compromise then C1-C2 fusion is recommended.
