Torticollis


Background

Pathophysiology

Causes

Disposition


 

CONGENITAL TORTICOLLIS: ACQUIRED TORTICOLLIS:
  • Neck deformity that involves shortening of the sternocleidomastoid (SCM) muscle resulting in limited neck rotation and lateral flexion.
  • Infants tilt their head toward the side of the shortened muscle and rotate to the contralateral side.
  • Plagiocephaly and craniofacial deformities can be associated with congenital muscular torticollis (CMT) and can perpetuate one another.
  • Developmental hip dysplasia can be associated with CMT.
  • It is important to rule out nonmuscular causes such as ocular, vertebral, and neurologic.
  • Treatment includes caregiver education on positioning and physical therapy; onabotulinumtoxinA (formerly known as botulinum toxin type A), injections, or surgery are reserved for recalcitrant cases
  • A rare, typically idiopathic, brain disorder causing involuntary neck movements.
  • Often associated with pain.
  • Patients may be able to relieve their symptoms by touching their neck, head, or face in a certain way (sensory trick).
  • Targeted intramuscular injection of botulinum toxin is the therapy with the best proven efficacy. Oral medications, selective peripheral denervation, and surgery may also have a role in the treatment of the disease.

 

SYMPTOMS/EXAM SYMPTOMS/EXAM
  • twin birth
  • nonvaried supine sleep and resting position
  • decreased prone awake time
  • head tilt
  • head rotated with decreased active rotation to affected side
  • decreased head righting to contralateral side
  • sternocleidomastoid (SCM) mass
  • ipsilateral shoulder elevation
  • plagiocephaly/craniofacial asymmetry
  • hypertropia on contralateral side
  • hip click or asymmetry
  • involuntary twisting or deviation of the neck
  • neck pain
  • presence of sensory trick
  • abnormal head posture
  • otherwise normal neurologic exam
  • head tremor
  • insidious onset
  • headache
  • asymmetrical hypertrophy of neck muscles
  • normal ROM of neck (early in course)
DIAGNOSIS DIAGNOSIS
1st Tests To Order
cervical spine x-ray


Other Tests to Consider
neck ultrasound
skull x-ray
cervical/cranial MRI
 
1st Tests To Order
clinical diagnosis

Other Tests to Consider
cervical x-rays
MRI brain
MRI neck
DYT-1 gene
serum ceruloplasmin, urinary copper excretion
EMG
 
DIFFERENTIAL DIFFERENTIAL
  • Superior oblique palsy
  • CNS tumor
  • Vertebral anomaly
  • Craniosynostosis
  • Arthritis of cervical spine
  • Neck Mass
  • Cerebral mass, lesion or infarct
  • Posterior fossa mass
  • Retropharyngeal abscess
  • Parkinsonian syndromes
  • Huntington disease
  • Tic disorder
  • Dopa-responsive dystonia
  • Trochlear nerve palsy
  • Primary torsion dystonia (DYT-1)
  • Wilson disease
  • Psychogenic dystonia
TREATMENT TREATMENT
Ongoing:
inadequate head control or age <5 months
physical therapy + home program
cranial molding orthosis

good head control and age >5 months
physical therapy + home program
cranial molding orthosis
onabotulinumtoxinA injection
cranial molding orthosis
sternocleidomastoid muscle release
 
Acute:
without pain or functional impairment
observation
physical therapy

with functional impairment or pain or diminished quality of life
oral medication (Baclofen, tizanidine)
physical therapy
intramuscular botulinum toxin
physical therapy

Ongoing:

refractory to therapy with botulinum toxin
deep brain stimulation
physical therapy
radiofrequency ablation
physical therapy
injected phenol
physical therapy
baclofen injection via continuous pump infusion
physical therapy
 



 



Congenital Tortiollis: