What is Torticollis? (Its Causes, Types, Treatment, Complications & Prevention)
Torticollis
Defination:
Torticollis is a symptom related to turning or bending of the neck. Many different causes are possible Torticollis (wryneck) is due to a spasmodic condition of the cervical muscles, chiefly those supplied by the spinal accessory nerves. The name is derived from two Latin words,
Tortus =twisted
Collum= neck.
CAUSE:
- In newborns, Torticollis usually results from injury during labour and delivery or the infant’s position in the utreus. Less often, it is caused by birth defects.
- In older children, torticollis may result from injuries to the neck muscles, common infections, or other causes.
- Torticollis refers to a symptom rather than a distinct disease process
- It can be caused by a wide variety of conditions (over 80 causes have been described) which range from relatively simple self limited to life-threatening
- May be congenital or acquired
- Occurs more frequently in children than in adults
- The right side is affected in 75% of patients
What does it look like?
- Abnormal twisting of the neck. Usually, child’s head is tipped toward one side, with the chin pointing in the other direction.
- Painful spasms of the neck muscles may occur.
- Other symptoms may be present, depending on the cause.
- For example, there may be a tender lymph node (gland) if the cause is infection.
Types of torticollis
Temporary torticollis
This type of wry neck usually disappears after one or two days. It can be due to:
- swollen lymph nodes
- an ear infection
- a cold
- an injury to your head and neck that causes swelling
Fixed torticollis
Fixed torticollis is also called acute torticollis or permanent torticollis. It’s usually due to a problem with the muscular or bone structure.
Muscular torticollis
This is the most common type of fixed torticollis. It results from scarring or tight muscles on one side of the neck.
Klippel-Feil syndrome
This is a rare, congenital form of wry neck. It occurs when the bones in your baby’s neck form incorrectly, notably due to two neck vertebrae being fused together. Children born with this condition may have difficulty with hearing and vision.
Cervical dystonia
This rare disorder is sometimes referred to as spasmodic torticollis. It causes neck muscles to contract in spasms. If you have cervical dystonia, your head twists or turns painfully to one side. It may also tilt forward or backward. Cervical dystonia sometimes goes away without treatment, but there’s a risk of recurrence.
Cervical dystonia can happen to anyone. However, it’s most commonly diagnosed in people who are roughly ages 40 to 60. It also affects more women than men.
The type of torticollis
(can be described depending on the positions of the head and neck.)
Laterocollis : the head is tipped toward the shoulder
Rotational torticollis : the head rotates along the longitudinal axis
Anterocollis : forward flexion of the head and neck[6]
Retrocollis : hyperextension of head and neck backward[7]
Causes of Torticollis
- Congenital muscular torticollis
- Acquired torticollis
1. Congenital muscular torticollis (CMT)
- CMT refers to muscular disorders causing torticollis at birth or shortly after due to unilateral shortening of the sternocleidomastoid muscle.
- More common in males and on the right side.
- The affected muscle develops fibrotic changes which can be associated with a mass (fibromatosis colli) or without a mass
- Presentation is usually during the first 4 weeks of life with torticollis and / or nontender neck mass.
- Thought to be caused by intrauterine and perinatal events. Risk factors for CMT include overcrowding environments ,first-born, oligohydramnios, breech presentation and difficult delivery.
Ultrasound (US) is the imaging modality of choice for initial investigation.
- There is diffuse or focal enlargement of the sternocleidomastoid muscle.
- Focal mass is usually hypoechoic and homogenous
- The mass usually resolve within the first year of life with conservative treatment.
- the condition is treated with physical therapies, such as stretching to release tightness, strengthening exercises to improve muscular balance, and handling to stimulate symmetry.
- A Collar is sometimes applied.
- About 5–10% of cases fail to respond to stretching and require surgical release of the muscle
Acquired torticollis
The most common etiologies
- self-limiting
- Trauma,
- infections
- inflammatory conditions,
- central nervous system tumors or lesions
1- self-limiting
- A self-limiting spontaneously occurring form of torticollis with one or more painful neck muscles is by far the most common (‘stiff neck’) and will pass spontaneously in 1–4 weeks.
- Usually the sternocleidomastoid muscle or the trapezius muscle is involved.
- colds or unusual postures are implicated; however in many cases no clear cause is found.
2- Trauma
- Occipital condyle fracture and facet dislocation may present with torticollis
- Atlanto-axial rotatory fixation (AARF) of C2
- Spontaneous spinal epidural hematoma is a rare disorder which might manifest with painful torticollis followed by weakness and sensory loss and is mostly common at the cervico-thoracic level
- Subarachnoid hemorrhage
- CT is the modality of choice in most trauma cases.
- MRI is indicated in any case of concern for ligamentous injury or when there is a neurologic deficit.
3- Infection and inflammation
- Head and neck and spinal column infections may cause torticollis either by muscular or ligamentous irritation or from direct spinal disease.
Infectious and Inflammatory Causes of Torticollis
- CNS related
– Meningitis
- Head and Neck related
– Upper respiratory infections
– Otitis media
– Mastoiditis/Bezold’s abscess
– Cervical adenitis
– Retropharyngeal abscess
- Spine related
– Vertebral osteomyelitis and/or discitis
– Epidural abscess
– Rheumatoid arthritis
Infection
- Lateral neck X RAY radiograph will show increased soft tissue thickness anterior to the C spine in retropharyngeal abscess
- US may show superficial lymphadenitis and abscess.
- CT is used to visualize the deep neck spaces and for pre-surgical planning.
- MRI is useful in spinal column infections due to its increased sensitivity and its ability to show soft tissue and epidural extension
4- Tumors
- Tumors of the CNS, spine and neck may cause torticollis
- CNS tumors are usually in the posterior fossa or C spine.
- The common presentation of C spine tumor is pain due to dural irritation.
- Posterior fossa tumors ( CERBELLAR tumor) may also have signs of increased intracranial pressure.
- In any case of insidious development of torticollis the possibility of a tumor should be considered.
- MRI is the imaging modality of choice
Other causes
- The use of certain drugs, such as antipsychotics , Antiemetics , Neuroleptic Class and Phenothiazines , can cause torticollis.
Investigations
- Cervical spine X-ray ( suspcious of fracture/dislocations , if there is spine tenderness, persistent symptoms)
- Ultrasound and CT can be helpful in patients in whom retropharyngeal inflammation is suspected
- CT/MRI: helpful to determine the extent of certain lesions, to rule out atlantoaxial subluxation if plain films are equivocal, and to assess patients with neurologic deficits
Treatment:
Treatment for torticollis depends on the cause:
- For newborns with torticollis, gentle motion of the head and neck is recommended to stretch the muscles. Often, a physical therapist is involved. To avoid injury, this should be done only as recommended by a doctor.
- For older children with torticollis related to infection or inflammation, treatment may include:
- Antibiotics for the specific infection.
- Rest.
- Anti-inflammatory medications (such as ibuprofen).
- Passive motion to keep the muscles from getting stiff.
- However, the motion should not be painful, and you should never use force to move the neck.
- If the cause is related to trauma (even sleeping position)
- treatments may include:
- Muscle relaxants such as Valium (generic name: diazepam) Passive motion.
- A soft collar or brace to support the neck.
Complications:
Complications may include:
- Muscle swelling due to constant tension
- Nervous system symptoms due to pressure on nerve roots
Prevention:
Torticollis is usually an unexpected, unpreventable problem. Identifying and treating the cause may prevent complications related to abnormal movement and positioning of the neck. While there is no known way to prevent this condition, early treatment may prevent it from getting worse.
Outlook (prognosis):
The
condition may be easier to treat in infants and children. If torticollis
becomes chronic numbness and tingling may develop due to pressure on the nerve
roots in the neck. The muscle itself may become large (hypertrophic) due to
constant stimulation and exercise.
Conclusion
- Torticollis is a clinical sign that might signify an underlying disorder.
- In newborn infants with CMT, ultrasound is preferred and often diagnostic.
- In older children CT is used to diagnose traumatic insult, neck infection and vertebral anomalies.
- MRI is used to diagnose inflammatory and infectiouc spinal disorders and in cases in which CNS or neck malignancy is suspected.
