Torticollis is a disease in which there is a tilt of the head with its simultaneous rotation in the opposite direction. It occurs due to pathological changes in the bones, nerves and soft tissues of the neck. It can be congenital or acquired. It is manifested by a fixed or non-fixed change in the position of the head. The pathology may result in deformities of the skull and spine, neurological disorders, intellectual development disorders, decreased memory and attention, and deterioration of respiratory function. The diagnosis is made based on the examination data, the results of radiography and other studies. Therapeutic tactics depend on the cause of torticollis, both conservative and surgical treatment is possible.
Torticollis is a pathological condition accompanied by a tilt of the head with its simultaneous turn in the other direction. It is a widespread pathology of newborns, but it can also occur at an older age. It includes a group of diseases with similar symptoms. The cause of torticollis is the defeat of one or more anatomical structures of the neck, most often this condition occurs with pathological changes in the sternocleidomastoid muscle. Depending on the cause of the disease, children’s orthopedists, pediatric surgeons, infectious disease specialists, neurologists and other specialists can treat torticollis.
Congenital torticollis is formed in the prenatal period. The cause of development may be the wrong position of the fetus, the wrong structure of the mother’s pelvis, infectious diseases, some hereditary diseases and chromosomal mutations. It is the third most common congenital anomaly of the musculoskeletal system after clubfoot and congenital hip dislocation. Girls suffer more often than boys.
The cause of the development of acquired torticollis may be pathological childbirth, accompanied by umbilical cord entanglement, ischemia or injury to the neck muscles. In older age, neck curvature can occur as a result of injuries, infectious diseases and diseases of the nervous system. The most common and most easily curable form of acquired torticollis is a curvature of the neck as a result of rotational subluxation C1.
Congenital variants of the disease include idiopathic, myogenic, osteogenic, neurogenic and arthrogenic forms of pathology.
Idiopathic torticollis – a slight unfixed tilt of the head is detected. The causes of the formation are unknown, but it has been established that pathology occurs more often with complicated childbirth and pathological pregnancy. Palpation determines the sternocleidomastoid muscle of normal length and shape, which is in a state of excessive tension. In children with idiopathic torticollis, segmental insufficiency of the cervical spine and perinatal encephalopathy are also often detected.
Myogenic torticollis is the most common form of torticollis. It develops as a result of compaction and shortening of the sternocleidomastoid muscle. Congenital muscular torticollis can be early and late. Early is detected at birth, late – at the age of 3-4 weeks. The cause of development may be a transverse position or pelvic diligence of the fetus, in which the baby’s head remains bent to the shoulder for a long time – this position causes a decrease in elasticity and fibrosis of the muscle. When examined, the child’s head is tilted towards the affected muscle and turned in the opposite direction.
Palpation reveals a uniform compaction of muscle tissue or a local compaction of a rounded shape at the border of the middle and lower third of the muscle. Attempts at passive movements are painful. Untreated myogenic torticollis is the cause of curvature of the spine, impaired development of the skull and the shoulder girdle. The child’s face becomes asymmetrical, the bones on the side of the lesion flatten, the ear, eyebrow and eye drop in comparison with the healthy half. Sometimes there is a bilateral myogenic torticollis, accompanied by a tilt of the head to the sternum and a sharp restriction of movements.
Osteogenic torticollis (Klippel-Feil disease) develops with congenital pathology of the cervical vertebrae. It is possible to reduce the size and / or shape of the vertebrae or their fusion into a single block. On examination, shortening and deformation of the neck is revealed; the head is pulled into the shoulders, often turned to the side; limitation of neck mobility; reduction of the hairline on the back of the head. The curvature of the neck is often combined with other anomalies of skeletal development. Osteogenic torticollis itself, as a rule, does not cause pain, but it can cause the development of radiculitis of the cervical spine.
Neurogenic torticollis occurs due to dystonic syndrome, in which there is an increase in muscle tone in one half of the body with a decrease in the other. Pathology is accompanied by similar disorders in the trunk and limbs: the leg on the side of the lesion is bent, the handle is bent and clenched into a fist, the trunk is curved. Active and passive movements in the neck are preserved, but at rest the baby’s head “goes” into a vicious position.
Arthrogenic torticollis develops due to congenital rotational subluxation of the I cervical vertebra.
Acquired torticollis can be installation, compensatory, reflex, traumatic and infectious. In addition, there is a torticollis with spinal tumors; a hysterical form of the disease, which in some cases can be detected with hysterical psychosis; dermatogenic torticollis, which occurs with rough scars on the skin; desmogenic curvature of the neck, formed as a result of inflammation and scar degeneration of tissues (muscles, ligaments, fiber, lymph nodes); myogenic torticollis, formed after inflammation of the neck muscles (myositis), and a neurogenic form of the disease, which can develop with cerebral palsy or become the outcome of a neuroinfection.
Installation torticollis – develops if the baby is in the wrong position in the crib for a long time. There are no pathological changes in organs and tissues.
Compensatory and reflex torticollis. Reflex curvature of the neck can occur with purulent processes in the neck, perichondritis of the ribs, inflammation of the mastoid process (mastoiditis) and middle ear (otitis) – in such cases, to reduce pain, the patient tilts his head to the side. Compensatory torticollis can develop with strabismus and diseases of the inner ear (labyrinthitis). In the first case, the tilt of the head allows better use of the available field of view, in the second – to reduce dizziness. Movements in the cervical spine with compensatory and reflex forms of torticollis are preserved in full.
Traumatic osteoarticular torticollis – occurs acutely, the cause is a fracture of the I cervical vertebra. It is accompanied by sharp soreness, restriction of movements in the cervical region, pain during palpation, the development of pyramidal insufficiency and bulbar syndrome. Another type of acquired osteoarticular torticollis is subluxation C1, which can form at any age, but is more often detected in children. The reason for the subluxation is a sharp turn of the head in everyday life or during sports.
Non-traumatic (infectious) osteoarticular torticollis – can be detected in osteomyelitis, bone tuberculosis and tertiary syphilis. The cause of development is melting or pathological fractures of the cervical vertebrae.
The diagnosis of congenital torticollis is established by a specialist in the field of traumatology and orthopedics, pediatrics, pediatric surgery on the basis of anamnesis, examination data and cervical spine x-ray. During the examination of the baby, the doctor finds out what the birth was – normal or pathological, whether there were problems during pregnancy, when parents noticed a curvature of the neck – from the first days of life or after a certain period of time, etc. To exclude disorders from the nervous system, a neurologist’s examination is prescribed. If necessary, to assess the condition of the soft tissue structures of the child’s neck, they are sent for an MRI.
The list of diagnostic techniques for suspected acquired torticollis depends on the anamnesis and the nature of the pathology. X-ray examination is included in the mandatory examination plan, and both radiography of the cervical spine and radiography of the first or second cervical vertebrae can be prescribed. If strabismus is indicated, an ophthalmologist’s consultation is indicated, if tuberculosis is suspected, a phthisiologist’s consultation is indicated, if syphilis is suspected, a venereologist’s consultation is indicated, if hysterical– a psychiatrist’s consultation is indicated.
Treatment of congenital myogenic pathology can be both conservative and operative. In the early stages, electrophoresis with lidase and potassium iodide, UHF, special corrective exercises and massage are used. In most cases, it takes 5-6 months to completely eliminate the pathology. If conservative therapy is ineffective, a surgical operation is performed by crossing the heads of the sternocleidomastoid muscle. If the shortening of the affected muscle is 40 percent or more compared to the healthy side, plastic surgery is performed. In the postoperative period, a plaster is applied, which is replaced a month later with a Trench collar. With acquired muscular torticollis, similar therapeutic techniques are used.
With congenital neurogenic torticollis, drug therapy, physiotherapy, physical therapy and massage are used. In case of neck curvature resulting from neuroinfection, antibiotics, muscle relaxants and anticonvulsants are prescribed. After the inflammation subsides, the patient is recommended to wear a Trench collar and sent to physical therapy. In severe cases, surgical correction is performed.
With congenital osteogenic torticollis (Klippel-Feil disease), exercise therapy and massage are prescribed. To reduce the cosmetic defect, the high-placed upper ribs are sometimes removed. In case of traumatic curvature of the neck, developed as a result of a fracture, traction with a Glisson loop and plaster bandages are used, if necessary, surgical operations are performed. In case of torticollis due to subluxation of C1, traumatologists perform closed reduction using a Glisson loop and impose a Trench collar. In the long-term period after injury, in the presence of organic changes in the spine, neck and shoulder girdle, electropulse therapy, electrophoresis, massage and physical therapy are prescribed.
Desmogenic and dermatogenic torticollis are eliminated surgically by excising scar tissue and performing plastic surgery with auto-, allo- or xenografts. In case of tumors and infectious bone lesions, the main pathology is treated, and subsequently reconstructive operations are performed.
Prognosis and prevention
Prevention is determined by the etiology of the disease. The prognosis depends on the causes of the development and duration of the pathology. Most congenital and acquired forms of torticollis with early adequate treatment are well amenable to correction. The exception is Klippel–Feil disease, in which there is a pronounced restriction of movement. An untreated curvature of the neck can cause a violation of the child’s development, the formation of gross cosmetic defects and subsequent disability. The vicious position of the neck leads to dystrophic degeneration of the muscles, prevents the normal development of the skull and causes progressive facial asymmetry.
Excessive pressure on the vessels of the neck, delivering blood to the brain, initially causes migraine–like headaches, and then – and disorders of brain functions. Children suffer from intellectual development. In adults, attention and memory deteriorate. Due to the change in the position of the trachea, the functions of external respiration decrease, with congenital pathology and torticollis that occurred at an early age, there may be a lag in the growth of the chest on the side of the lesion. Otitis media and sinusitis often develop, hearing worsens, strabismus forms.