Brief Discussion: Infantile

Torticollis

Presented by:
Dr. Abhishek Kumar
15/07/08

Moderators:
Dr. Surendra. U. Kamath
Dr. Anup Kumar

Latin :Twisted neck

Cheselden (1749)

Definition : Rotational deformity of cervical

spine thatsecondarily causes :
Turning
tilting and
deformity of head.

Differential Diagnosis
Infantile torticollis
Congenital.
Traumatic.
Myositis.
Spasmodic.
Infection.
Paralytic torticollis (rare, eg.Poliomyelitis).
Sprengels deformity.

Congenital Muscular Torticollis

(CMT)

Postulations:
Intrauterine malposition.
Clotting of terminal vessels to the
muscle during labor.
Tumor formation of SCM.
Compartment syndrome of SCM muscle.

Associated Syndrome
1. Metatarsus adductus.
2. DDH/CDH
3. CTEV

Pathology
At birth or within 2 weeks of birth,
a hard fusiform swelling develops
within the SCM.
Lower third.
Right side.

Pathology

Maximum size within 1-2 months

Remains same size or becomes smaller

Gradually disappear within 1 year

Pathology
If it doesnt happen
Fibrous shortening of muscle
&
neighbouring structure
(cervical fascia and scalene muscle)

Contracted

Clinical Features:
1.At birth or soon infants head gradually tilt
to one side and rotate to opposite side.
2. SCM muscle become taut, short and
prominent which is easily demonstrated on
attempting passive correction of rotation
and tilt.

Clinical Features
3. Even without swelling and being non
tender, muscle may be rigid & non elastic to
palpate.
4. With time, facial & occular asymmetry &
deformity of cervical vertebra occurs which
may become permanent.

Evaluation & Investigations

History :Developmental milestones

Examination: -Head to toe

-CNS
-Ocular.

Evaluation & Investigations

Imaging:
Cervical spine radiograph needed if
- typical SCM muscle contracture is absent.
- deformity does not respond to usual
conservative measures.

Evaluation & Investigations

Imaging:
MRI of spinal cord and brainstem
- Developmental delays
- Neck is moderately or severely twisted & the
doctor can find no explanation for it.

Prognosis
CMT did not resolve spontaneously if
permitted beyond the age of 1 year.
Children treated in the 1st year of life had
better results than those treated later.

Prognosis
Good Prognosis: Restriction of neck motion < 30
-No facial asymmetry

Bad Prognosis : Restriction of neck motion > 30

(beginning of treatment)
-Facial asymmetry.

Prognosis
Grouping the patient for prognostication:
1. SCM tumor group
2. Muscular group
3. Postural torticollis

Prognosis
Grouping the patient for prognostication:
1. SCM tumor group : Clinically palpable tumor
2. Muscular group : Clinically thickened and
tightened SCM.
3. Postural torticollis : Postural head tilt and
-Clinical features of torticollis
- Without tightness or tumor

Prognosis
Factors contributing to increase duration of
treatment:

Clinical group (Tumor > Muscular)

Difficulty during birth.

Involvement of Right side

Rotational deformity>15 degrees.

Older age at presentation

Treatment Options

1. Conservative.
2. Surgical.

Conservative treatment
Indications:
1.Less than 1year of age.
2. All the cases lower 3rd & majority of
middle 3rd SCM involvement
3. Postural torticollis and selected cases
of tumor and muscular group.

Conservative treatment

Parents are instructed to stretch the

contracted SCM by rotating infants
chin to ipsilateral shoulder and
simultaneously tilting the head towards
contralateral shoulder.

Surgery
Indication:
1. Child presented beyond 1 year of life.
2.Majority of upper third SCM involvement
and minority of middle third SCM
involvement.
3. Approximately 8% of tumor group and
3% of muscular group.

Surgery
Surgery done till 12 years of age
produced as good a result as
operation earlier because
asymmetry of face and skull could
still correct itself during the
remaining period of growth.

Surgical Technique
1. Unipolar release.
2. Bipolar release.
3. Modified bipolar release.
4. Endoscopic release of SCM muscle

Unipolar Release
Indicated for mild deformity
Distal tenotomy of SCM
near sternoclavicular
attachment.

Disadvantages:
Teethering of scar to the deep structures.
Reattachment of clavicular & sternal head of the SCM
muscle.
Loss of contour of muscle.
Failure to correct the tilt of head.
Failure of facial asymmetry to correct.

Failures are least after 1 year, therefore unipolar release

is recommended between 1-4 years of age.

After-treatment:
At 1 week postop, manual stretching
of neck to maintain overcorrected
position is begun and continued 3

Bipolar Release
Indicated for severe
cervical deformity or
after failed unipolar
release.
Clavicular and mastoid attachment of
SCM muscle is cut.

Modified Z-Plasty (Frekel)

Indication: patients
older than 6 years.
Bipolar + Zplasty in
sternal origin

Aftertreatment:
Muscle stretching, strengthening
and active range of motion
exercises.
Head-halter traction or a cervical
collar can be given in 1st 6-12
weeks postop.

Treatment For Aquired Torticollis

Identification of underlying cause of the disorder.
Application of heat, traction to the cervical spine,
and massage.
Stretching exercises and neck braces.
Drugs :Anticholinergics(baclofen)
-Injection of botulinum toxin repeated every
3month
Surgical treatments are rarely used.

If Torticollis is not corrected at the

right time.
1. With time deformity becomes

incorrectible.
2. Asymmetric shoulder, plagiocephaly,
facial asymmetry.
3. Macular fixation resulting in diplopia.

Thank You..