Orthopaedic Surgery - Torticollis

Basics

Torticollis is a condition in which the:

Head and neck are held in an abnormal tilted and rotated position.

The deformity may result from:

Muscular

Skeletal

Neurologic

or other systemic abnormalities.

Typical Posture

The characteristic posture consists of:

Lateral flexion of the head toward one side

with rotation of the:

Chin toward the opposite side.

Classification

Torticollis can broadly be divided into:

Congenital

and

Acquired forms.

Congenital Torticollis

Congenital causes include:

Congenital muscular torticollis

and

Congenital cervical skeletal abnormalities.

Acquired Torticollis

Acquired torticollis may result from:

Trauma

Inflammation

Atlantoaxial rotatory subluxation

Neurologic disease

Ocular disorders

or other:

Systemic conditions.

Synonyms

Historical terms include:

Wry neck

Congenital wry neck

Skeletal wry neck

and

Cock-robin deformity.

Sandifer Syndrome

Sandifer syndrome refers to episodic torticollis or abnormal head positioning associated with:

Gastroesophageal reflux

and sometimes:

Hiatal hernia.

Prevention

Prompt recognition and treatment of the underlying cause may prevent:

Fixed deformity

and reduce the need for:

Surgery.

Epidemiology

Torticollis can occur at:

Any age

depending on the underlying cause.

Congenital Muscular Torticollis

Congenital muscular torticollis usually becomes apparent during the first:

6–8 weeks of life.

Atlantoaxial Rotatory Subluxation

In children, one important acquired cause is:

Atlantoaxial rotatory subluxation.

This may follow:

Upper respiratory infection

Pharyngitis

or

Trauma.

Sex

Males and females are affected approximately:

Equally.

Incidence

Because torticollis has many causes, the exact incidence is difficult to define.

Historical estimates range from approximately:

1 in 100

to

1 in 1,000 individuals.

Risk Factors

Risk factors depend on the specific:

Etiology.

Congenital Muscular Torticollis Risk Factors

Potential associations include:

Difficult delivery

Birth trauma

and localized injury or ischemia involving the:

Sternocleidomastoid muscle.

Atlantoaxial Rotatory Subluxation Risk Factors

Potential triggers include:

Upper respiratory infection

Pharyngitis

and

Neck trauma.

Genetics

Several congenital disorders associated with torticollis have:

Genetic components.

Down Syndrome

Down syndrome is an important genetic condition associated with:

Cervical instability

including abnormalities involving the:

Atlantoaxial joint.

Etiology

The cause depends on whether the disorder is:

Muscular

Skeletal

Neurologic

Inflammatory

or

Traumatic.

Congenital Muscular Torticollis

Congenital muscular torticollis results from shortening and fibrosis of the:

Sternocleidomastoid muscle.

Sternocleidomastoid Effect

Contracture of one sternocleidomastoid causes the head to:

Tilt toward the affected side

while the chin rotates:

Away from the affected side.

Congenital Bony Torticollis

Congenital skeletal causes include abnormalities of the:

Occipitocervical junction

and

Cervical vertebrae.

Bony Abnormalities

Examples include:

Cervical hemivertebrae

Congenital vertebral fusion

and

Asymmetry of the occipital condyles.

Atlantoaxial Rotatory Subluxation

This condition involves abnormal rotation of:

C1 relative to C2.

It may occur after:

Trauma

Inflammation

or occasionally as part of a:

Congenital abnormality.

Diagnosis

Diagnosis begins with careful assessment of:

Head position

Neck motion

Neurologic status

and possible:

Underlying systemic disease.

Signs and Symptoms

The hallmark feature is:

Head tilt with restricted cervical range of motion.

Direction of Motion

The patient may be able to rotate the head farther:

Away from the neutral position

but may have difficulty rotating toward:

Correction.

Neck Mass

Infants with congenital muscular torticollis may have a palpable:

Sternocleidomastoid mass.

This represents localized:

Fibrosis or thickening.

Pain

Pain is less prominent in infants but is more common in:

Older children and adults.

Occipital Symptoms

Some patients report:

Occipital pain

Vertigo

or

Dizziness

that worsens with certain:

Head movements.

Plagiocephaly

Persistent torticollis in infancy may cause secondary:

Plagiocephaly

or facial:

Asymmetry.

Physical Examination

Observe the patient’s:

Head

Face

Neck

and

Shoulder alignment.

Characteristic Position

The ear is typically tilted toward the:

Affected side

while the chin points toward the:

Opposite side.

Range of Motion

Assess:

Active

and

Passive cervical rotation

and

Lateral flexion.

Sternocleidomastoid Examination

Palpate the sternocleidomastoid for:

Tightness

Fibrosis

or a localized:

Mass.

Craniofacial Asymmetry

Longstanding torticollis may produce:

Flattening of the skull

Facial asymmetry

or altered:

Ear position.

Cervical Skeletal Abnormality

A patient with congenital cervical fusion may have a:

Short neck

Low posterior hairline

and reduced:

Cervical motion.

These findings may suggest:

Klippel-Feil syndrome.

Neurologic Examination

A complete neurologic examination should assess:

Strength

Sensation

Reflexes

and

Coordination.

Laboratory Tests

There are no laboratory tests specific for:

Torticollis.

Inflammatory or Neoplastic Evaluation

If infection, inflammatory disease, or malignancy is suspected, laboratory studies may include:

CBC

ESR

and

C-reactive protein.

Additional Specialist Evaluation

When no obvious musculoskeletal cause is present, additional assessment may be needed by:

Ophthalmology

Audiology

or

Gastroenterology.

Imaging

Plain Radiographs

AP and lateral cervical spine radiographs may be used to identify:

Congenital bony abnormalities

Fracture

Dislocation

or abnormal:

Alignment.

CT

CT is particularly useful for evaluating:

Atlantoaxial rotatory subluxation

Occipitocervical injury

Fracture

or

Dislocation.

Rotatory Subluxation

CT may demonstrate persistent abnormal rotational alignment between:

C1

and

C2.

MRI

MRI is indicated when there is concern for:

Spinal cord

Brainstem

Soft-tissue

or other:

Neurologic lesions.

Pathological Findings

In congenital muscular torticollis, the:

Sternocleidomastoid muscle

typically demonstrates:

Fibrosis

and

Shortening.

Differential Diagnosis

The differential diagnosis is broad.

Neurogenic Causes

Potential neurologic causes include:

Brainstem tumor

Cervical spinal cord tumor

Cerebellar tumor

and

Syringomyelia.

Ocular Causes

An ocular disorder may cause compensatory:

Head tilt

to optimize:

Vision.

Traumatic Causes

Traumatic causes include:

Atlantoaxial subluxation

Cervical fracture

and

Occipitocervical dislocation.

Inflammatory Causes

Potential causes include:

Cervical lymphadenitis

and

Rheumatoid arthritis.

Congenital Skeletal Causes

Examples include:

Hemivertebra

Congenital fusion

and

Occipital condyle asymmetry.

Gastrointestinal Cause

In infants, episodic abnormal head positioning may result from:

Sandifer syndrome

associated with:

Gastroesophageal reflux.

Treatment

Treatment depends on the:

Underlying cause

and duration of the:

Deformity.

Congenital Muscular Torticollis

Early treatment consists primarily of:

Stretching exercises.

Early Prognosis

When treatment begins before approximately:

1 year of age

stretching is successful in the vast majority of:

Infants.

Positioning

Parents can position:

Toys

Lights

or other points of interest so the child is encouraged to rotate the head toward the:

Restricted side.

Home Program

A structured home stretching program should focus on:

Gentle cervical rotation

and

Lateral flexion.

Atlantoaxial Rotatory Subluxation

Recent-onset atlantoaxial rotatory subluxation may respond to:

Rest

Analgesics

Physical therapy

and a:

Soft cervical collar.

Early Treatment

Patients treated within approximately the:

First week

often recover without:

Surgery.

Muscle Relaxants

Selected patients may require:

Muscle relaxants

when painful spasm prevents:

Reduction.

Rigid Immobilization

Persistent symptoms may require a:

Hard collar

or another form of:

Cervical bracing.

Traction

If treatment is delayed or the deformity becomes fixed, reduction may require:

Cervical traction.

Activity

Contact sports and strenuous activity should be restricted until the:

Cause is identified

and cervical stability is:

Confirmed.

Physical Therapy

Physical therapy can be curative for many cases of:

Congenital muscular torticollis

and

Recent-onset atlantoaxial rotatory subluxation.

Stretch Direction

The therapist should receive clear instructions regarding:

Direction of stretching

and whether:

Traction

is appropriate.

Medication

Pain may be treated with:

Acetaminophen

or

Ibuprofen

when medically appropriate.

Surgery

Surgery is reserved for selected cases that fail appropriate:

Nonoperative treatment.

Muscular Torticollis Surgery

Persistent congenital muscular torticollis may require:

Sternocleidomastoid release

or

Lengthening.

Timing

Surgery is generally considered when:

Persistent contracture

Restricted motion

or progressive:

Craniofacial asymmetry

remains despite adequate:

Stretching.

Atlantoaxial Rotatory Subluxation Surgery

Severe or chronic atlantoaxial rotatory subluxation that cannot be reduced with:

Traction

may require:

Reduction and C1–C2 fusion.

Congenital Bony Abnormality

Selected congenital cervical abnormalities causing severe persistent deformity or instability may also require:

Spinal fusion.

Follow-Up

Follow-up should assess:

Head position

Range of motion

Neurologic findings

and development of:

Craniofacial asymmetry.

Prognosis

Most cases of torticollis improve:

Spontaneously

or with appropriate:

Treatment.

Early Muscular Torticollis

Congenital muscular torticollis treated early generally has an:

Excellent prognosis.

Delayed Treatment

Delayed treatment increases the risk of:

Persistent contracture

and

Plagiocephaly.

Complications

Potential complications include:

Fixed atlantoaxial subluxation

Persistent neck deformity

and

Plagiocephaly.

Fixed Subluxation

Untreated atlantoaxial rotatory subluxation may become:

Fixed

and increasingly difficult to:

Reduce.

Plagiocephaly

Persistent head positioning in infancy may cause permanent:

Cranial or facial asymmetry

if treatment is delayed beyond the period of active:

Remodeling.

Patient Monitoring

Neurologic status should be followed:

Closely.

Imaging Follow-Up

Bony abnormalities such as persistent:

Atlantoaxial rotatory subluxation

may require repeat:

Imaging.

CT use should be balanced against cumulative:

Radiation exposure, particularly in children.

Clinical Summary

Typical presentation: Head tilted toward one side with the chin rotated to the opposite side and restricted neck motion.

Most common infant cause: Congenital muscular torticollis from sternocleidomastoid fibrosis or contracture.

Important acquired cause in children: Atlantoaxial rotatory subluxation, often after trauma or an upper respiratory infection.

Key examination: Assess cervical ROM, palpate the sternocleidomastoid, look for plagiocephaly, and perform a complete neurologic examination.

Imaging: Plain cervical radiographs for bony abnormalities; CT for suspected C1–C2 rotatory subluxation or fracture; MRI for suspected spinal cord, brainstem, or other neurologic disease.

Initial treatment: Early muscular torticollis responds to stretching and positioning; recent atlantoaxial rotatory subluxation may respond to analgesics, therapy, and cervical immobilization.

Surgery: Reserved for persistent muscular contracture or irreducible/fixed atlantoaxial abnormalities.

Red flags: New neurologic deficits, severe pain, trauma, fever, progressive deformity, or acquired torticollis without an obvious benign explanation.

Key Principle

Torticollis is a clinical posture characterized by lateral head tilt with rotation of the chin in the opposite direction.

It may arise from:

Muscular, skeletal, neurologic, inflammatory, traumatic, ocular, or gastrointestinal causes.

In infants, the most common form is:

Congenital muscular torticollis, which usually responds well to early:

Stretching and positioning.

In older children with acute painful torticollis, especially after:

Trauma or upper respiratory infection, consider:

Atlantoaxial rotatory subluxation.

Persistent, painful, neurologically abnormal, or atypical torticollis requires evaluation for an underlying:

Structural or neurologic cause.