eMedicine Specialties > Neurology > Movement and Neurodegenerative Diseases

Torticollis: Differential Diagnoses & Workup

Author: Norman C Reynolds Jr, MD, Neurologist, Veterans Affairs Medical Center of Milwaukee
Coauthor(s): Jianxin Ma, MD, Staff Physician, Department of Physical Medicine and Rehabilitation, Johns Hopkins University Hospital
Contributor Information and Disclosures

Updated: Dec 10, 2008

Differential Diagnoses

Anterior Horn Disease
Radiculopathy
Cerebral Palsy
Tardive Dyskinesia
Essential Tremor
Torticollis
Movement Disorders in Individuals with Developmental Disabilities
Wilson Disease
Multiple Sclerosis
Myasthenia Gravis
Parkinson Disease

Other Problems to Be Considered

Spinal deformity - Early childhood "dropped head syndrome" seen in myopathies and myasthenia, may mimic anterocollis
Juvenile cerebral palsy with cervical dystonia
Phenothiazine-induced acute dystonic reactions of childhood
Juvenile-onset Wilson disease - Often dystonic rather than dyskinetic
Juvenile-onset Huntington disease - Often dystonic and cervical
Acquired dystonia of childhood, such as hematoma or other tumor of sternocleidomastoid muscle
Gastroesophageal reflux (Sandifer syndrome) producing rapid flexion and odd postures reminiscent of torticollis subtypes

Workup

Laboratory Studies

When a positive family history suggests a familial dystonia rather than idiopathic cervical dystonia, DNA tests for specific genetic dystonias are available that use polymerase chain reaction to detect the DNA in blood samples.

Imaging Studies

  • Plain cervical spine films are useful in distinguishing sequelae of bony buildup and scoliosis or spondylosis secondary to chronic dystonia from structural changes of the spine that may mimic cervical dystonia per se (ie, nondystonic torticollis).
  • MRI of the cervical cord is useful in documenting cord impingement leading to either spinal stenosis or multiple radiculopathy, all of which can be secondary to bony changes from chronic dystonia.
  • Contrast swallowing studies can be performed in consultation with a speech pathologist to evaluate and treat patients for swallowing disorders that accompany cervical dystonia. Indications are to plan botulinum toxin injections, which, if too extensive, may worsen the swallowing mechanism.
  • Cranial imaging (CT or MRI) of cervical dystonias is indicated when the physical examination includes abnormal long tract findings (eg, in pyramidal tracts), ophthalmoplegia, and/or dementia.

Procedures

  • Electromyography is useful in distinguishing myopathic from neuropathic processes.
    • Myopathic upper girdle muscles versus dystonic hypertrophied upper girdle muscles
    • Multiple cervical root entrapment (polyradiculopathy) versus brachial plexus or single nerve involvement versus combinations of the above associated with bony cervical changes from dystonia
    • Anterior horn disease shows fibrillations in involved root distributions (eg, amyotrophic lateral sclerosis, Charcot-Marie-Tooth disease).

More on Torticollis

Overview: Torticollis
Differential Diagnoses & Workup: Torticollis
Treatment & Medication: Torticollis
Follow-up: Torticollis
Multimedia: Torticollis
References
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References

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  16. Sa DS, Mailis-Gagnon A, Nicholson K, Lang AE. Posttraumatic painful torticollis. Mov Disord. Dec 2003;18(12):1482-91. [Medline].

  17. Tolosa ES, Marti MJ. Adult-onset idiopathic torsion dystonias. In: Watts RL, Koller WC. Movement Disorders, Neurologic Principles and Practice. Part III. 1996. New York: McGraw-Hill; 429-41.

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Further Reading

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Keywords

retrocollis, anterocollis, laterocollis, rotational torticollis, spasmodic torticollis, cervical dystonia, idiopathic cervical dystonia, segmental dystonia of head and neck, head and neck dystonia, head tremor, head tilt, head jerks, head spasms

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Contributor Information and Disclosures

Author

Norman C Reynolds Jr, MD, Neurologist, Veterans Affairs Medical Center of Milwaukee
Norman C Reynolds Jr, MD is a member of the following medical societies: American Academy of Neurology, Association of Military Surgeons of the US, Movement Disorders Society, Sigma Xi, and Society for Neuroscience
Disclosure: Nothing to disclose.

Coauthor(s)

Jianxin Ma, MD, Staff Physician, Department of Physical Medicine and Rehabilitation, Johns Hopkins University Hospital
Disclosure: Nothing to disclose.

Medical Editor

Stephen T Gancher, MD, Adjunct Associate Professor, Department of Neurology, Oregon Health Sciences University
Stephen T Gancher, MD is a member of the following medical societies: American Academy of Neurology, American Neurological Association, and Movement Disorders Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Nestor Galvez-Jimenez, MD, MSc, MHA, Chairman, Department of Neurology, Program Director, Movement Disorders, Department of Neurology, Division of Medicine, Cleveland Clinic Florida
Nestor Galvez-Jimenez, MD, MSc, MHA is a member of the following medical societies: American Academy of Neurology, American College of Physicians, and Movement Disorders Society
Disclosure: Nothing to disclose.

CME Editor

Selim R Benbadis, MD, Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, University of South Florida School of Medicine, Tampa General Hospital
Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Selim R Benbadis, MD, Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, University of South Florida School of Medicine, Tampa General Hospital
Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, and American Medical Association
Disclosure: Nothing to disclose.

 
 
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