Torticollis Differential Diagnoses

Author: Michael C Kruer, MD; Chief Editor: Selim R Benbadis, MD more...

Updated: Mar 6, 2012

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Diagnostic Considerations

Distinguishing acute cervical trauma from traumatic torticollis may be difficult, but this is a recurring theme for car accident victims with persisting whiplash symptoms or for patients with industrial injuries when legal interest or chronic pain is an issue. Precise chronologic history is required in providing testimony to distinguish acute cervical trauma from posttraumatic torticollis. To maintain credibility during testimony, consistent statements of chronology are critical and must be prepared by careful review of the medical record by the physician giving testimony.

With postconcussive syndrome, whiplash head and neck injury from rapid acceleration and/or deceleration involves sprained and painful neck muscles, usually on both sides and the posterior muscles, along with global headache, inability to concentrate, and often dizziness and blurred vision.

Although beginning a few days or immediately following whiplash or other trauma, acute posttraumatic torticollis can be defined clearly only when the postconcussive syndrome is minimal. When the postconcussive syndrome is of great magnitude and persistent, acute posttraumatic torticollis can be identified clearly only after the acute strain and other postconcussive symptoms are eliminated in time or by analgesic medication (short-term narcotics or nonsteroidal anti-inflammatory drugs [NSAIDs]). "Residuals" of consistent abnormal head and neck posture with marked limitation of motion are not from the postconcussive syndrome (which is self-limited) but rather from acute posttraumatic torticollis (which is likely to be a chronic syndrome requiring botulinum toxin or a D2 agonist for long-term treatment).

Delayed posttraumatic torticollis is not a recurrence of the postconcussive or whiplash syndrome in the absence of a new injury but an identifiable torticollis syndrome with persistent abnormal posture of head and neck with major limitation in motion. The history of a previous whiplash or postconcussive syndrome establishes the original trauma that may eventually lead to torticollis due to intracranial brain changes in physiology as a delayed response to the original trauma.

Other conditions that should be considered in the evaluation of torticollis include the following:

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: Sandifer syndrome is a term used to describe gastroesophageal reflux with abnormal posturing including torticollis in infants; torticollis occurs intermittently and can alternate sides; other symptoms of reflux may be present including regurgitation, anorexia, irritability, anemia, failure to thrive, coughing, asthma, and hoarseness; treatment is antireflux therapy
Anterior horn disease
Radiculopathy
C1 and C2 fractures
Movement disorders in individuals with developmental disabilities

Differential Diagnoses

Proceed to Workup

Contributor Information and Disclosures

Author

Michael C Kruer, MD Assistant Professor, Departments of Pediatrics and Neurosciences, Sanford School of Medicine, University of South Dakota; Physician in Pediatric Neurology and Neurogenetics, Sanford Children's Specialty Clinic, Sanford Children's Hospital

Michael C Kruer, MD is a member of the following medical societies: American Academy for Cerebral Palsy and Developmental Medicine, American Academy of Neurology, American Academy of Pediatrics, American Society of Human Genetics, Child Neurology Society, and Society for Neuroscience

Disclosure: EMD/Serono Grant/research funds Grant PI

Coauthor(s)

Norman C Reynolds Jr, MD Neurologist, Veterans Affairs Medical Center of Milwaukee; Clinical Professor, Medical College of Wisconsin

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.

Jianxin Ma, MD Assistant Professor, Department of Neurology and Department of Physical Medicine and Rehabilitation, State University of New York Upstate Medical University

Disclosure: Nothing to disclose.

Chief Editor

Selim R Benbadis, MD Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, Tampa General Hospital, University of South Florida College of Medicine

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: UCB Pharma Honoraria Speaking, consulting; Lundbeck Honoraria Speaking, consulting; Cyberonics Honoraria Speaking, consulting; Glaxo Smith Kline Honoraria Speaking, consulting; Pfizer Honoraria Speaking, consulting; Sleepmed/DigiTrace Honoraria Speaking, consulting

Additional Contributors

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