May 30, 2024

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

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  

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

  1. Unipolar release
    1. Mild deformity
    1. distally
  2. Bipolar release
    1. Moderate to severe deformity
    1. Proximally and distally
  3. Endoscopic release
  4. Myotomy
  5. Selective denervation
  6. Distal cord stimulation

Surgical steps of Bipolar Release

The transverse proximal incision behind the ear

Skin incision for bipolar release

Divide SCM insertion just distal to the tip of mastoid process (avoid Spinal Accessory Nerve)

Sternocleidomastoid muscle dissection

Make distal incision 4-5 cm in the line with cervical skin crease

Finger breathe proximal to the medial end of clavicle and sternal notch

Divide platysma + sub-cutaneous tissue

Expose clavicular + sternal attachment

(avoid jugular veins and carotid artery)

Cut clavicular portion transversely

Sternal attachment with Z-plasty

Alternately, release the clavicular head directly from the clavicle

Transecting sternal head proximal to its insertion by 1-2 cm

Suture 2 ends together/ side to side or end to end

Obtained designed degree of correction by manipulating Head and Neck during the release

Release additional contracted bands of fascia or muscle occasionally before closure

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.