Tort Final

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…..