You are in: eMedicine Specialties > Orthopedic Surgery > HAND AND UPPER EXTREMITY TorticollisArticle Last Updated: Feb 5, 2008AUTHOR AND EDITOR INFORMATIONSection 1 of 11
  Author: Gurdeep S Othee, MD, Staff Physician, Department of Emergency Medicine, Medical College of Georgia Gurdeep S Othee is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians Coauthor(s): Carl R Menckhoff, MD, FACEP, FAAEM, Associate Professor, Department of Emergency Medicine, Medical College of Georgia; Lorenzo L Pacelli, MD, Consulting Surgeon, Division of Orthopedic Surgery, Section of Upper Extremity Surgery, Scripps Clinic Editors: Joseph E Sheppard, MD, Director of Hand and Upper Extremity, Associate Professor, Department of Orthopedic Surgery, University of Arizona; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Michael Yaszemski, MD, PhD, Associate Professor, Departments of Orthopedic Surgery and Bioengineering, Mayo Foundation, Mayo Medical School; Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital; Harris Gellman, MD, Consulting Surgeon, Broward Hand Center, Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami School of Medicine Author and Editor Disclosure Synonyms and related keywords: wryneck, spasmodic torticollis, cervical dystonia, loxia, congenital muscular torticollis, neck pain, twisted neck INTRODUCTIONSection 2 of 11
  Torticollis is a condition that causes the neck to involuntarily twist to one side secondary to contraction of the neck muscles. The ear is tilted toward the contracted muscle and the chin is facing the opposite direction. Torticollis is derived from the Latin, tortus, meaning twisted and collum, meaning neck. It is a symptom of diverse conditions. Some of the more common causes include congenital problems, trauma, and infections. 1, 2, 3, 4, 5, 6, 7, 8 When conservative treatment measures fail, patients may undergo a sternocleidomastoid release, selective denervation, or dorsal cord stimulation. For excellent patient education resources, visit eMedicine's Back, Ribs, Neck, and Head Center. Also, see eMedicine's patient education article Torticollis. ProblemTorticollis results in a fixed or dynamic posturing of the head and neck in tilt, rotation, and flexion. Spasms of the sternocleidomastoid, trapezius, and other neck muscles, usually more prominent on one side than the other, cause turning or tipping of the head.7, 8 FrequencyCongenital muscular torticollis occurs in fewer than 0.4% of newborns.2 For noncongenital muscular torticollis, the average age of onset is 40 years. Women are affected twice as often as men.9 EtiologyLocal etiology in adults
Compensatory etiology in adults
Central etiology in adults
Pediatric local etiology
Pediatric compensatory etiology
Pediatric central etiology
PathophysiologyCongenital muscular torticollis is believed to be caused by local trauma to the soft tissues of the neck just before or during delivery.2 The most common explanation involves birth trauma with resultant hematoma formation followed by muscular contracture. These children often have undergone breech or difficult forceps delivery. The fibrosis in the muscle may be due to venous occlusion and pressure on the neck in the birth canal because of cervical and skull position. Another hypothesis includes malposition in utero resulting in intrauterine or perinatal compartment syndrome. Up to 20% of children with congenital muscular torticollis have congenital dysplasia of the hip as well.11, 12, 13, 14, 15 In noncongenital torticollis, the pathophysiology depends on the underlying cause. ClinicalThe patient's head is rotated and twisted to one direction, and the chin is pointed toward the opposite shoulder. Intermittent painful spasms of the sternocleidomastoid, trapezius, and other neck muscles may occur. The neck movements vary from jerky to smooth. The symptoms are usually worsened by standing, walking, and stressful situations. In the congenital form, the first sign may be a firm nontender enlargement of the sternocleidomastoid muscle visible at birth. This mass, which is more often localized near the clavicular attachment of the sternocleidomastoid muscle, usually enlarges during 4-6 weeks of life and then gradually decreases in size. By age 4-6 months, the mass is usually absent, and the only clinical finding is the contracture of the sternocleidomastoid muscle and the torticollis posture. Psychological factors such as depression or anxiety also may play a role. A very careful history should be taken, and thorough physical examination should be performed to try to discover the cause. INDICATIONSSection 3 of 11
For patients in whom conservative measures have failed, including physical therapy and medications, sternocleidomastoid release, selective denervation, or dorsal cord stimulation may be indicated. In congenital muscular torticollis, a trial of nonoperative treatment for 12-24 months is allowed before surgical intervention is pursued, because 90% of these patients respond to passive stretching within the first year of life. RELEVANT ANATOMYSection 4 of 11
CONTRAINDICATIONSSection 5 of 11
Surgery is contraindicated in patients in whom underlying reversible causes have not been excluded and in those in whom conservative therapy has not been attempted. WORKUPSection 6 of 11
Lab Studies
Imaging Studies
Other Tests
TREATMENTSection 7 of 11
Medical therapyAll underlying reversible causes of torticollis should be explored and treated appropriately. Medications include nonsteroidal anti-inflammatory drugs (NSAIDs), benzodiazepines and other muscle relaxants, anticholinergics, and local intramuscular injections of botulinum toxin15 or phenol. Physical therapy includes stretching exercises, massage, local heat, analgesics, sensory biofeedback, and transcutaneous electrical nerve stimulation (TENS). Surgical therapySurgical therapy may consist of the following:
Preoperative detailsA preoperative EMG may be helpful in defining the exact muscles and nerves involved. Intraoperative detailsSternocleidomastoid muscle release is often used in congenital muscular torticollis. For mild deformity, unipolar release of the muscle is performed distally. For moderate and severe torticollis, bipolar technique is used to release the muscle proximally and distally. Though sternocleidomastoid release is described mainly for congenital torticollis, it may also be used in the other forms as well. Some patients may ultimately require a combination of several different surgical procedures for correction of torticollis. Unipolar sternocleidomastoid release for congenital muscular torticollis Make an incision 5 cm long just superior and parallel to the medial end of the clavicle and to the depth of the tendons of the sternal and clavicular attachments of the sternocleidomastoid muscle. Incise the tendon sheath longitudinally and pass a hemostat or other blunt instrument posterior to the tendons. Next, using traction on the hemostat, draw the tendons outside the wound and then superior and inferior to the hemostat; clamp them and resect 2.5 cm of their inferior ends. If contracted, divide the platysma muscle and adjacent fascia. Next, with the patient's head turned toward the affected side and the chin depressed, explore the wound digitally for any remaining bands of contracted muscle or fascia and, if any are found, divide them under direct vision until the deformity can, if possible, be overcorrected. If overcorrection is not possible after this procedure, make a small transverse incision inferior to the mastoid process and carefully divide the muscle near the bone. Take care to avoid damaging the spinal accessory nerve. Close the wound or wounds and apply a bulky dressing that holds the head in the overcorrected position. Bipolar sternocleidomastoid release The bipolar sternocleidomastoid release, as described by Ferkel et al, for congenital muscular torticollis involves making a short transverse proximal incision behind the ear and dividing the sternocleidomastoid muscle insertion transversely just distal to the tip of the mastoid process.2, 16 With this limited incision, the spinal accessory nerve is avoided, although the possibility that the nerve may take an anomalous route should be considered. Next, make a distal incision 4-5 cm long in line with the cervical skin creases 1 fingerbreadth proximal to the medial end of the clavicle and the sternal notch. Divide the subcutaneous tissue and platysma muscle, exposing the clavicular and sternal attachments of the sternocleidomastoid muscle. Carefully avoid the anterior and external jugular veins and the carotid vessels and sheath during the dissection. Next, cut the clavicular portion of the muscle transversely and perform a Z-plasty on the sternal attachment in order to preserve the normal V-contour of the sternocleidomastoid muscle in the neckline. Obtain the desired degree of correction by manipulating the head and neck during the release. Occasionally, release of additional contracted bands of fascia or muscle is necessary before closure. Close both wounds with subcuticular sutures. Selective denervation Selective denervation was first developed in the early 1980s by Claude Bertrand, MD, and his colleagues in Montreal, Canada.17, 18, 19 It is primarily used in the treatment of torticollis, and varying success rates have been reported since its introduction. Denervation involves resecting the nerves that supply the specific muscles involved and is irreversible. Because of this, an EMG is sometimes performed to correctly identify all muscles involved prior to the procedure. Selective denervation using the Bertrand method involves dissection through fascial planes to expose and section the posterior primary rami throughout all cervical levels. Preoperative EMG isolates the exact muscles involved and their nerve supply, and only the involved segments are denervated. Once the nerve supply has been cut, the associated muscles will atrophy permanently. Dorsal cord stimulation In dorsal cord stimulation, the electrodes are inserted into the subarachnoid space laterally at the C1-C2 level, with a monopolar electrode threaded down to the C4-C5 level for a 7-10 day trial of stimulation. About two thirds of the patients have improvement in their symptoms, and most patients respond best to higher frequencies between 1100 and 1500 Hz. Patients who have significant relief and tolerate stimulation are considered candidates for permanent dorsal column stimulator electrode implantation. The epidural electrode is placed midline at the C1-C2 level and sutured in place so that it cannot become dislodged with neck movement. Postoperative detailsFollow-upFor unipolar sternocleidomastoid release, physical therapy that includes manual stretching of the neck to maintain the overcorrected position is begun 1 week after surgery. Manual stretching should be continued three times daily for 3-6 months. The use of plaster casts or braces is usually unnecessary. For bipolar sternocleidomastoid release, physical therapy involving range of motion and muscle stretching and strengthening is started early. A cervical collar may be used for the first 6-12 weeks after surgery. COMPLICATIONSSection 8 of 11
Complications of the above procedures include injury to spinal accessory nerve or nearby vasculature including the jugular veins and carotid artery. Other complications include neck muscle atrophy, loss of muscle control, instability, variable numbness or sensory loss, pain, and neck deformity. OUTCOME AND PROGNOSISSection 9 of 11
Ninety percent of patients with congenital muscular torticollis respond to passive stretching within the first year of life. For patients who undergo selective denervation, 65-80% experience satisfactory results, and these patients can be expected to maintain their improvement. No long-term prognosis for sternocleidomastoid release is available in the current literature. FUTURE AND CONTROVERSIESSection 10 of 11
Stereotactic procedures targeting the pallidofugal fibers or Forel field have not had results encouraging enough for them to become widely accepted. REFERENCESSection 11 of 11
Article Last Updated: Feb 5, 2008 |
