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Brief Discussion: Infantile Torticollis
Presented by:Dr. Abhishek Kumar15/07/08
Moderators:Dr. Surendra. U. KamathDr. Anup Kumar
Latin :“Twisted neck”
Cheselden (1749) Definition : Rotational deformity of cervical spine that secondarily causes :
Turningtilting anddeformity of head.
Congenital. Traumatic. Myositis. Spasmodic. Infection. Paralytic torticollis (rare, eg.Poliomyelitis). Sprengel’s deformity.
Differential Diagnosis Infantile torticollis
Postulations:
Congenital Muscular Torticollis
Intrauterine malposition.
Clotting of terminal vessels to the muscle during labor.
Tumor formation of SCM.
Compartment syndrome of SCM muscle.
(CMT)
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 doesn’t happen Fibrous shortening of muscle
& neighbouring structure
(cervical fascia and scalene muscle)
Contracted
Clinical Features:
1.At birth or soon infant’s 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
PrognosisGrouping 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
PrognosisFactors 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 treatmentIndications: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 infant’s
chin to ipsilateral shoulder and
simultaneously tilting the head towards
contralateral shoulder.
SurgeryIndication: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.
SurgerySurgery 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 Technique1. 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
times daily for 3-6 months.
Bipolar Release
• Indicated for severe cervical deformity or after failed unipolar release.
• Clavicular and mastoid attachment of SCM muscle is cut.
Indication: patients older than 6 years.
Bipolar + Zplasty in sternal origin
Modified Z-Plasty (Frekel)
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…..