Torticollis

Torticollis is a condition characterized by an abnormal, asymmetrical head or neck position. It can be congenital or acquired and may involve muscular, neurological, or skeletal abnormalities. Early recognition and management are essential to prevent complications and improve functional outcomes.

Definition and Classification

Definition

Torticollis, also known as wry neck, refers to a condition in which the head is tilted to one side and the chin is rotated to the opposite side. This abnormal posture results from shortening or excessive contraction of neck muscles, most commonly the sternocleidomastoid.

Types of Torticollis

• Congenital Torticollis: Present at birth, often due to sternocleidomastoid muscle fibrosis or birth trauma.
• Acquired Torticollis: Develops after birth, caused by trauma, infection, inflammation, or neurological conditions.
• Spasmodic Torticollis (Cervical Dystonia): Involuntary, sustained contraction of neck muscles, often with pain and abnormal movements.
• Postural or Positional Torticollis: Temporary head tilt caused by sleeping position or minor musculoskeletal strain, usually self-limiting.

Etiology and Risk Factors

Congenital Causes

• Muscular abnormalities, particularly fibrosis or shortening of the sternocleidomastoid muscle
• Birth trauma, including difficult or assisted deliveries
• Skeletal malformations affecting cervical vertebrae

Acquired Causes

• Neurological disorders, such as cerebral palsy or dystonia
• Infections affecting the neck, including upper respiratory tract infections or abscesses
• Trauma or cervical spine injury
• Drug-induced causes, particularly from neuroleptics or certain antiemetics
• Inflammatory conditions, such as cervical arthritis or rheumatologic disease

Risk Factors

• Perinatal factors, including intrauterine malposition or difficult labor
• Genetic predisposition in some congenital or familial cases
• Environmental factors that affect posture or musculoskeletal development

Pathophysiology

The abnormal head and neck posture seen in torticollis results from a combination of muscular, neurological, and skeletal factors. The underlying mechanism varies depending on the type of torticollis.

• Muscular involvement: Shortening or fibrosis of the sternocleidomastoid muscle is the most common cause in congenital cases. Other muscles such as the trapezius and levator scapulae may also contribute to abnormal positioning.
• Neurological mechanisms: In acquired or spasmodic torticollis, dysfunction in the basal ganglia, cervical spinal nerves, or peripheral nerves can lead to involuntary muscle contraction and abnormal postures.
• Biomechanical alterations: Cervical spine deformities, vertebral rotation, or asymmetrical growth can exacerbate the head tilt and limit neck range of motion over time.

Clinical Presentation

Symptoms

• Head tilt to one side with rotation of the chin to the opposite side
• Neck stiffness or discomfort, especially with movement
• Limited range of motion of the cervical spine
• In some cases, associated neurological signs such as tremors or abnormal movements

Physical Examination Findings

• Palpation reveals tightness or thickening of the affected sternocleidomastoid muscle
• Assessment shows reduced lateral flexion and rotation toward the affected side
• Postural analysis may reveal compensatory shoulder elevation or spinal curvature
• Observation for facial asymmetry or plagiocephaly in pediatric patients

Diagnostic Evaluation

Clinical Diagnosis

Diagnosis of torticollis is primarily clinical, based on patient history and physical examination. Key aspects include age of onset, presence of pain, head posture, and muscle tightness.

Imaging Studies

• Ultrasound: Particularly useful in infants to assess the sternocleidomastoid muscle for fibrosis or masses.
• X-ray of the cervical spine: Evaluates vertebral alignment, congenital anomalies, and skeletal deformities.
• MRI or CT: Recommended if neurological causes or complex cervical abnormalities are suspected.

Laboratory Tests

• Inflammatory markers may be measured if infection or arthritis is suspected
• Genetic testing may be indicated in rare syndromes or familial cases

Management

Non-Surgical Management

• Physical therapy: Stretching and strengthening exercises for the affected neck muscles to improve range of motion.
• Botulinum toxin injections: Used in spasmodic torticollis to reduce involuntary muscle contractions.
• Orthoses or positioning devices: May be used in infants or mild cases to correct posture.
• Medications: Muscle relaxants and analgesics can help manage pain and reduce muscle spasm.

Surgical Management

• Muscle release or lengthening procedures for severe congenital or persistent cases.
• Spinal surgeries may be considered in patients with significant cervical deformities.

Rehabilitation and Follow-Up

• Long-term physiotherapy is often required to maintain neck mobility and prevent recurrence.
• Regular follow-up to monitor posture, muscle function, and complications such as facial asymmetry.

Complications

• Facial asymmetry and plagiocephaly: Common in infants with untreated congenital torticollis due to persistent head tilt.
• Chronic pain: Muscle strain and cervical spine stress can lead to ongoing discomfort.
• Cervical spine deformities: Long-standing torticollis may cause vertebral rotation, scoliosis, or other structural changes.
• Functional limitations: Reduced neck mobility can affect daily activities, sports, and occupational tasks.

Prognosis

The prognosis of torticollis varies depending on the type, cause, and timing of treatment. Early recognition and intervention generally lead to excellent outcomes, particularly in congenital cases managed with physical therapy.

• Factors influencing recovery include age at diagnosis, severity of muscle involvement, and presence of skeletal abnormalities.
• Long-term outcomes are generally favorable in congenital torticollis with early treatment, while acquired or neurological forms may require ongoing management.
• Recurrence is uncommon with proper therapy but may occur in severe or untreated cases.

Prevention

• Perinatal care strategies: Proper positioning during pregnancy and careful handling during delivery may reduce the risk of congenital torticollis.
• Early intervention and physical therapy: Prompt identification of head tilt in infants allows for stretching exercises that prevent muscle shortening and deformity.
• Awareness and ergonomic practices: Encouraging proper posture in children and adults, avoiding prolonged neck strain, and modifying work or sleep positions can help prevent acquired torticollis.

References

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3. Kim HJ, Park MS, Chung CY. Spasmodic torticollis: clinical features and treatment. J Clin Neurol. 2006;2(4):215-221.
4. Lee JH, Chung MS, Park MS. Congenital muscular torticollis: current concepts and treatment. J Orthop Surg (Hong Kong). 2013;21(1):85-89.
5. Ryan P, Denny M, Stack R. Acquired torticollis in children and adults. BMJ. 2016;354:i4460.
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8. Wilson J, Bogduk N. Cervical dystonia and torticollis: anatomy, pathophysiology, and management. Muscle Nerve. 2010;41(5):613-623.