What Is Idiopathic Torticollis?
Torticollis can occur in any individual after an injury to the muscle, nervous system, or blood supply. However, in most cases, the exact cause of torticollis (also known as the wry neck) is unknown and is called idiopathic torticollis. Torticollis generally leads to a tilting of the top of the head to one side and the chin to the other, leading to a painful condition. Sometimes the pain is severe and can interfere with the daily activities of the patient.
Sometimes it resolves without treatment but has a chance of recurrence. Its management involves medications and therapies to relieve stiffness and pain. Surgery is also performed in some cases to correct the condition. In most patients, the treatment is successful if it is provided at an early stage, particularly in the case of children.
Torticollis can be of two types, namely acquired or congenital. Congenital muscular torticollis (CMT) is one of the common congenital deformities, generally seen during the first week after birth. It occurs due to shortening or contracture of the sternocleidomastoid muscle, causing the head to tilt towards the affected side. However, there is a certain amount of rotation towards the contralateral side. Mostly, congenital muscular torticollis can be treated non-surgically.
What Are the Indications of Torticollis?
The indications for surgical management include the following:
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Torticollis in children above twelve months.
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Limited head movement due to persistent sternocleidomastoid contracture.
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Progressive facial hemihypoplasia (a rare condition where one side or part of the body grows significantly more than the other caused by an over-production of soft tissue or bone) causes persistent sternocleidomastoid contracture.
Surgical management of congenital muscular torticollis is usually not done until the child is at least one year old or when conservative methods like physiotherapy are unsuccessful. The management of torticollis in children is usually non-operative and consists of only parental physiotherapy.
How Is Torticollis Diagnosed?
Torticollis is diagnosed mostly through physical examination. Imaging techniques can also be used where required, including radiography (X-ray), computed tomography (CT), and ultrasound imaging. This helps to identify anatomic abnormalities. Laboratory blood analysis can also be used for screening metabolic or genetic factors.
How Is Idiopathic Torticollis Managed Surgically?
Surgery is advised for the management of idiopathic torticollis in the following cases
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If torticollis does not resolve after twelve months of physical therapy.
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Patients who show facial asymmetry during the follow-up period.
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For achieving good cosmetic results and improving functionality.
Procedure:
Surgical treatment involves the administration of general anesthesia. A transverse skin incision of around three to four centimeters is made about one centimeter over the clavicular and sternal origins of the affected muscle.
The platysma (muscle lying deep to the subcutaneous fascia and fat) is divided carefully through the line of incision. This helps to avoid injury to the external jugular vein. The two heads of the sternocleidomastoid muscles are made free by dissection. The surgery involves the division of the muscle with the help of diathermy to prevent bleeding. Then the platysma skin is closed with continuous 4-0 nonabsorbable skin suture and sutured with absorbable 4-0 skin suture.
Torticollis can be managed surgically through the following endoscopic techniques.
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The surgical correction of muscular torticollis was described by Sasaki et al. through endoscopic tenotomy (a technique to treat pain in one of the tendons) of the sternocleidomastoid.
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A para-axillary subcutaneous endoscopic approach (PASEA) to congenital muscular torticollis was described by Tokar et al. This method is a good alternative method for minimally invasive pediatric surgery.
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A stealth surgery or subcutaneous endoscopic surgery is a good option with trans axillary subcutaneous endoscopic sternocleidomastoid muscle division.
Untreated long-standing torticollis in adults is not very common, and surgery is not usually helpful as in such cases, it can be hazardous with a number of complications as the anatomy is disturbed with limited access. Craniofacial deformities and facial asymmetry might not get corrected even after surgery in these cases.
Further, the ocular and vestibular reflexes of the patient might adapt to the deformed head position because of delayed treatment. This can be disturbed by changes in the head position suddenly. The possibility of recurrence of deformity might be seen. Moreover, stretching of the contracted soft tissue greater than an inch may lead to paralysis of the spinal accessory nerve.
What Is the Aim of Surgery for the Management of Torticollis?
The aim of surgery for the management of torticollis:
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To provide long-term neck mobility and cosmetic restoration.
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To inhibit the development of craniofacial deformity and upper cervical scoliosis (abnormal curvature of the spine laterally).
Is Long-Term Monitoring Required After Surgical Management of Torticollis?
Long-term monitoring is generally required after surgical management of torticollis, which involves regular visits by the patient to the healthcare professional. It requires regular medical checkups, administration of botulinum toxin injections if required, or access to deep brain stimulation.
One week after the surgery, physical therapy is initiated that involves manual stretching of the neck in the case of unipolar sternocleidomastoid release for maintaining the overcorrected position. This manual stretching therapy must be continued thrice a day for three to six months. In most cases, plaster casts or braces are not used.
In the case of bipolar sternocleidomastoid release, physical therapy involves various muscle stretching and strengthening physical theories. A cervical collar may be advised for the first 6 to 12 weeks after surgery.
Conclusion
The incidence of congenital torticollis is between 0.3 and 2 percent of live births. It occurs after an injury to the sternocleidomastoid muscle during parturition (childbirth). However, the exact etiology is still unknown. Other causes of torticollis include intrauterine malpositioning, ischemia, hereditary factors, compartment syndrome, and neurogenesis.
The diagnosis is difficult at birth, leading to varying severity. If the condition is not treated timely, scarring may be seen, causing restricted motion, asymmetry of the skull and facial structures, and ophthalmic (eye) abnormalities. Early diagnosis and physical therapy are important in muscle contracture. The majority of patients with torticollis can be treated successfully with physiotherapy if the diagnosis is made at an early stage. The exact pathology varies in different patients and must be evaluated before deciding on the appropriate surgical procedure.
