Torticollis Treatment & Management
- Author: Michael C Kruer, MD; Chief Editor: Selim R Benbadis, MD more...
A comprehensive approach to the medical care of torticollis includes several treatment goals. All underlying reversible causes of torticollis should be explored and treated appropriately.
Medications include nonsteroidal anti-inflammatory drugs (NSAIDs), benzodiazepines and other muscle relaxants, anticholinergics, and local intramuscular injections of botulinum toxin,[17, 34, 35, 36] or phenol. Physical therapy includes stretching exercises, massage, local heat, analgesics, sensory biofeedback, and transcutaneous electrical nerve stimulation (TENS).
When conservative treatment measures fail, patients may undergo brain stimulation procedures, a sternocleidomastoid release, selective denervation, or dorsal cord stimulation. Surgical therapy may consist of the following:
Unipolar sternocleidomastoid release
Bipolar sternocleidomastoid release
Dorsal cord stimulation
In torticollis, the conventional dopamine agonists and antagonists are not effective (dopamine receptors D1=D2), as distinguished from the L-dopa–responsive dystonias (a set of inherited generalized dystonias). Anticholinergics (eg, trihexyphenidyl, benztropine) may be somewhat effective but are typically less so than in generalized or torsion dystonias.
Try unconventional dopamine agonists (dopamine receptors D2 >D1, such as pramipexole or ropinirole) or antagonists with D2, D3, D4 blocking activity, such as olanzapine or risperidone, or try glutamate release inhibitors (eg, riluzole) or glutamate receptor blockers (eg, high-dose amantadine, lamotrigine, memantine).
Botulinum toxin injection is the current popular treatment of choice. Selective medication choices may include clonazepam, especially if blepharospasm is part of the syndrome, or baclofen, especially if oromandibular dystonia is part of the syndrome.
Nonspecific medication choices include propranolol or primidone if prominent oscillatory components, or nonsteroidal anti-inflammatory drugs (NSAIDs) for arthritic components.
Patients may respond well to sensory feedback training. Muscle relaxation techniques may be tried. Cervical braces occasionally are made that reproduce the tactile advantage of a sensory trick, which controls movement and/or reduces dystonia.
Typically, surgical care has been tried as a last resort for patients whose symptoms are refractory to botulinum injections; however, advances in brain stimulation technology and popular use has encouraged US Food and Drug Administration (FDA) approval for stimulator use, especially in the subthalamic nucleus (STN), as follows:
Selective ramisectomy for cervical musculature (late delayed recurrence can be a problem)
Deep brain stimulator electrode implants in the globus pallidus (GP) or the STN to control contralateral dystonia
Other procedures such as sternocleidomastoid release (unipolar/bipolar), selective denervation, or dorsal cord stimulation may be indicated. Preoperative electromyography (EMG) may be helpful in defining the exact muscles and nerves involved.
Surgery is contraindicated in patients in whom underlying reversible causes have not been excluded and in those in whom conservative therapy has not been attempted. In congenital muscular torticollis, a trial of nonoperative treatment for 12-24 months is allowed before surgical intervention is pursued, because 90% of these patients respond to passive stretching within the first year of life.
Stereotactic neurosurgery using brain stimulator technology is now a subspecialty that was originally confined to conditions of Parkinson disease (STN or GP placement) and non-Parkinsonian tremor (ventrointermediated thalamic nucleus [VIM] or STN placement) but has been expanded to include FDA-approved brain stimulator applications for dystonia (STN or GP placement) and experimental adaptations to Tourette syndrome (STN or GP placement), obsessive-convulsive disorder (OCD) and major affective disorders (cingulate placement), and phantom pain.
Torticollis involves cervical dystonia and, as such, qualifies as a candidate for consideration of treatment with deep brain stimulation. Now FDA approved, deep brain stimulation (DBS) should be considered a competitive option to botulinum injections in consultation with a stereotactic neurosurgeon familiar with this application.
Stereotactic procedures targeting the pallidofugal fibers or Forel field have not had results encouraging enough for them to become widely accepted.
Sternocleidomastoid muscle release is often used in congenital muscular torticollis. For mild deformity, unipolar release of the muscle is performed distally. For moderate and severe torticollis, bipolar technique is used to release the muscle proximally and distally.
Although sternocleidomastoid release is described mainly for congenital torticollis, it may also be used in the other forms as well. Some patients may ultimately require a combination of several different surgical procedures for correction of torticollis.
Unipolar sternocleidomastoid release for congenital muscular torticollis
Make an incision 5 cm long just superior and parallel to the medial end of the clavicle and to the depth of the tendons of the sternal and clavicular attachments of the sternocleidomastoid muscle. Incise the tendon sheath longitudinally and pass a hemostat or other blunt instrument posterior to the tendons. Next, using traction on the hemostat, draw the tendons outside the wound and then superior and inferior to the hemostat; clamp them and resect 2.5 cm of their inferior ends. If contracted, divide the platysma muscle and adjacent fascia. Next, with the patient's head turned toward the affected side and the chin depressed, explore the wound digitally for any remaining bands of contracted muscle or fascia and, if any are found, divide them under direct vision until the deformity can, if possible, be overcorrected.
If overcorrection is not possible after this procedure, make a small transverse incision inferior to the mastoid process and carefully divide the muscle near the bone. Take care to avoid damaging the spinal accessory nerve. Close the wound or wounds and apply a bulky dressing that holds the head in the overcorrected position.
Bipolar sternocleidomastoid release
The bipolar sternocleidomastoid release, as described by Ferkel et al, for congenital muscular torticollis involves making a short transverse proximal incision behind the ear and dividing the sternocleidomastoid muscle insertion transversely just distal to the tip of the mastoid process.[7, 40] With this limited incision, the spinal accessory nerve is avoided, although the possibility that the nerve may take an anomalous route should be considered. Next, make a distal incision 4-5 cm long in line with the cervical skin creases 1 fingerbreadth proximal to the medial end of the clavicle and the sternal notch. Divide the subcutaneous tissue and platysma muscle, exposing the clavicular and sternal attachments of the sternocleidomastoid muscle. Carefully avoid the anterior and external jugular veins and the carotid vessels and sheath during the dissection.
Next, cut the clavicular portion of the muscle transversely and perform a Z-plasty on the sternal attachment in order to preserve the normal V-contour of the sternocleidomastoid muscle in the neckline. Obtain the desired degree of correction by manipulating the head and neck during the release. Occasionally, release of additional contracted bands of fascia or muscle is necessary before closure. Close both wounds with subcuticular sutures.
Selective denervation is primarily used in the treatment of torticollis, and varying success rates have been reported since its introduction in the early 1980s by Claude Bertrand, MD, and his colleagues in Montreal, Canada.[41, 42, 43] Denervation involves resecting the nerves that supply the specific muscles involved and is irreversible. Because of this, an EMG is sometimes performed to correctly identify all muscles involved before the procedure.
Selective denervation using the Bertrand method involves dissection through fascial planes to expose and section the posterior primary rami throughout all cervical levels. Preoperative EMG isolates the exact muscles involved and their nerve supply, and only the involved segments are denervated. Once the nerve supply has been cut, the associated muscles will atrophy permanently.
Dorsal cord stimulation
In dorsal cord stimulation, the electrodes are inserted into the subarachnoid space laterally at the C1-C2 level, with a monopolar electrode threaded down to the C4-C5 level for a 7-10–day trial of stimulation. About two thirds of the patients have improvement in their symptoms, and most patients respond best to higher frequencies between 1100 and 1500 Hz. Patients who have significant relief and tolerate stimulation are considered candidates for permanent dorsal column stimulator electrode implantation. The epidural electrode is placed midline at the C1-C2 level and sutured in place so that it cannot become dislodged with neck movement.
As with any surgical procedure within the calvarium, the possibility of bleeding or infection exists, but in the hands of a subspecialty trained stereotactic neurosurgeon, this is less than 2-3%. Previously, electrode displacement was a risk due to translational forces, but this problem has been overcome by proper technical advance in mechanical stabilization. Other complications include injury to spinal accessory nerve or nearby vasculature (including the jugular veins and carotid artery), neck muscle atrophy, loss of muscle control, instability, variable numbness or sensory loss, pain, and neck deformity.
Certain neuropsychiatric conditions may occur in a minority of postsurgical cases but are typically corrected by recalibration of impulse parameters (pulse width, frequency, and amplitude). These behavioral side effects include visual hallucinations, obsessive gambling, hypersexuality, and depression. This same set of issues occurs with medication adjustment in anti-Parkinson medications.
Electromagnetic field precautions post surgery
Patients must be wary of any interaction with major electromagnetic fields associated with electrical generators in industrial applications, field detectors used in library screening to prevent book stealing, and metal detectors in general. Preflight check-in to airlines or other security checkpoints should avoid electromagnetic probes or wands that can turn off the deep brain stimulator (DBS). Nevertheless, the patient has a handheld magnetic trigger and can either turn on or off the pacemaker controller.
Magnetic resonance imaging (MRI) has special considerations because of massive fluctuations of magnetic fields that can cause the generator to cycle on and off. Before scanning, the pacemaker should be turned off (the patient can do this), and the amplitude setting of the controller should be set to zero (done by a physician or technician with special interrogator needs). Recycling at zero amplitude is not problematic.
Similar issues occur if electroconvulsive therapy is anticipated. When electric cardioversion is needed in a cardiopulmonary resuscitation (CPR) emergency, postsurvival adjustments can be made to maximize motor performance and the status of the DBS being on or off should not detract from needed lifesaving measures.
Regular outpatient visits are needed for routine medication checkups, repeat botulinum toxin injections, or recalibration of deep brain stimulation settings.
For unipolar sternocleidomastoid release, physical therapy that includes manual stretching of the neck to maintain the overcorrected position is begun 1 week after surgery. Manual stretching should be continued 3 times daily for 3-6 months. The use of plaster casts or braces is usually unnecessary.
For bipolar sternocleidomastoid release, physical therapy involving range of motion and muscle stretching and strengthening is started early. A cervical collar may be used for the first 6-12 weeks after surgery.
Macias C, Gan V. Congenital torticollis in children [database online]. Waltham, Mass: UpToDate; 2007.
Tindall GT, Cooper PR. Spasmodic torticollis. Tindall GT,. Cooper PR, Barrow DL, eds. Practice of Neurosurgery. Philadelphia, Pa: Lippincott, Williams & Wilkins; 1996. Vol 3: 2636, 2807, 2969, 3236-7.
Wilkins RH, Rengachary SS. Spasmodic torticollis. Wilkins RH, Rengachary SS, eds. Neurosurgery. 2nd ed. New York, NY: McGraw-Hill; 1996. 4159-61.
Jankovic J, Leder S, Warner D, Schwartz K. Cervical dystonia: clinical findings and associated movement disorders. Neurology. 1991 Jul. 41(7):1088-91. [Medline].
Chan J, Brin MF, Fahn S. Idiopathic cervical dystonia: clinical characteristics. Mov Disord. 1991. 6(2):119-26. [Medline].
Campana BA, Rosen P. Soft tissue spine injuries and back pain. Rosen P, Barkin R, eds. Emergency Medicine. 4th ed. New York, NY: McGraw-Hill; 1998. 881.
Canale ST. Congenital muscular torticollis. Canale ST, Daugherty K, Jones L eds. Campbell's Operative Orthopaedics. 9th ed. St Louis, Mo: Mosby-Year Book; 1998. 1064-7.
Chang A, Rosen P. Torticollis. Rosen P, Barkin RM, Hayden SR, Schaider JJ, Wolfe R, eds. The 5 Minute Emergency Medicine Consult. Philadelphia, Pa: Lippincott, Williams & Wilkins; 1999. 1138-9.
Harrigan RA, Brady WJ, Tintinalli JE. Antipsychotics/adverse effects. Emergency Medicine: A Comprehensive Study Guide. 5th ed. New York, NY: McGraw-Hill; 2000. 1086.
Jones ET, Mayer P, Weinstein S. The neck/torticollis. Weinstein SL, Buckwalter JA, Turek SL, eds. Turek's Orthopaedics: Principles and Their Application. 5th ed. Philadelphia, Pa: Lippincott-Raven; 1994. 341-5.
Li Sergio, Harwood-Nuss AL. Torticollis. Harwood-Nuss Al, Linden CH, eds. Harwood-Nuss' The Clinical Practice of Emergency Medicine. 2nd ed. Philadelphia, Pa: Lippincott, Williams & Wilkins; 1996. 1170-1.
Robin NH. Congenital muscular torticollis. Pediatr Rev. 1996 Oct. 17(10):374-5. [Medline].
Stevens P, Downey C, Boyd V, Cole P, Stal S, Edmond J, et al. Deformational plagiocephaly associated with ocular torticollis: a clinical study and literature review. J Craniofac Surg. 2007 Mar. 18(2):399-405. [Medline].
Schertz M, Zuk L, Zin S, Nadam L, Schwartz D, Bienkowski RS. Motor and cognitive development at one-year follow-up in infants with torticollis. Early Hum Dev. 2008 Jan. 84(1):9-14. [Medline].
Snyder EM, Coley BD. Limited value of plain radiographs in infant torticollis. Pediatrics. 2006 Dec. 118(6):e1779-84. [Medline].
Herman MJ. Torticollis in infants and children: common and unusual causes. Instr Course Lect. 2006. 55:647-53. [Medline].
Oleszek JL, Chang N, Apkon SD, Wilson PE. Botulinum toxin type a in the treatment of children with congenital muscular torticollis. Am J Phys Med Rehabil. 2005 Oct. 84(10):813-6. [Medline].
Minihane KP, Grayhack JJ, Simmons TD, Seshadri R, Wysocki RW, Sarwark JF. Developmental dysplasia of the hip in infants with congenital muscular torticollis. Am J Orthop (Belle Mead NJ). 2008 Sep. 37(9):E155-8; discussion E158. [Medline].
von Heideken J, Green DW, Burke SW, et al. The relationship between developmental dysplasia of the hip and congenital muscular torticollis. J Pediatr Orthop. 2006 Nov-Dec. 26(6):805-8. [Medline].
Sobolewski BA, Mittiga MR, Reed JL. Atlantoaxial rotary subluxation after minor trauma. Pediatr Emerg Care. 2008 Dec. 24(12):852-6. [Medline].
Naumann M, Pirker W, Reiners K, et al. Imaging the pre- and postsynaptic side of striatal dopaminergic synapses in idiopathic cervical dystonia: a SPECT study using [123I] epidepride and [123I] beta-CIT. Mov Disord. 1998 Mar. 13(2):319-23. [Medline].
Horstink CA, Booij J, Berger HJC. Striatal D2 receptor loss in writer's cramp. Mov Disord. 1996. 11:P784.
Perlmutter JS, Stambuk M, Markham J. Quantified binding of [F18]spiperone in focal dystonia. Mov Disord. 1996. 11:P819.
Cummings JL. D-3 receptor agonists: combined action neurologic and neuropsychiatric agents. J Neurol Sci. 1999 Feb 1. 163(1):2-3. [Medline].
Hasegawa J, Tateda M, Hidaka H, et al. Retropharyngeal abscess complicated with torticollis: case report and review of the literature. Tohoku J Exp Med. 2007 Sep. 213(1):99-104. [Medline].
Harries PG. Retropharyngeal abscess and acute torticollis. J Laryngol Otol. 1997 Dec. 111(12):1183-5. [Medline].
Sanuki T, Isshiki N. Outcomes of type II thyroplasty for adductor spasmodic dysphonia: analysis of revision and unsatisfactory cases. Acta Otolaryngol. 2009 Nov. 129(11):1287-93. [Medline].
Salvia P, Champagne O, Feipel V, Rooze M, de Beyl DZ. Clinical and goniometric evaluation of patients with spasmodic torticollis. Clin Biomech (Bristol, Avon). 2006 May. 21(4):323-9. [Medline].
Consky EA, Lang AE. Clinical assessments of patients with cervical dystonia. Jankovic J, Hallett M, eds. Therapy with Botulinum Toxin. New York: Marcel Dekker; 1994: 211-237.
Jankovic J, Tsui J, Bergeron C. Prevalence of cervical dystonia and spasmodic torticollis in the United States general population. Parkinsonism Relat Disord. 2007 Oct. 13(7):411-6. [Medline].
Jahanshahi M, Marion MH, Marsden CD. Natural history of adult-onset idiopathic torticollis. Arch Neurol. 1990 May. 47(5):548-52. [Medline].
Comella CL, Tanner CM, DeFoor-Hill L, Smith C. Dysphagia after botulinum toxin injections for spasmodic torticollis: clinical and radiologic findings. Neurology. 1992 Jul. 42(7):1307-10. [Medline].
Jankovic J. Can peripheral trauma induce dystonia and other movement disorders? Yes!. Mov Disord. 2001 Jan. 16(1):7-12. [Medline].
Lew MF, Chinnapongse R, Zhang Y, Corliss M. RimabotulinumtoxinB effects on pain associated with cervical dystonia: results of placebo and comparator-controlled studies. Int J Neurosci. 2010 Apr. 120(4):298-300. [Medline].
Truong D, Brodsky M, Lew M, et al. Long-term efficacy and safety of botulinum toxin type A (Dysport) in cervical dystonia. Parkinsonism Relat Disord. 2010 Jun. 16(5):316-23. [Medline].
Quagliato EM, Carelli EF, Viana MA. A prospective, randomized, double-blind study comparing the efficacy and safety of type a botulinum toxins botox and prosigne in the treatment of cervical dystonia. Clin Neuropharmacol. 2010 Jan-Feb. 33(1):22-6. [Medline].
Kim MY, Kwon DR, Lee HI. Therapeutic effect of microcurrent therapy in infants with congenital muscular torticollis. PM R. 2009 Aug. 1(8):736-9. [Medline].
Petronic I, Brdar R, Cirovic D, et al. Congenital muscular torticollis in children: distribution, treatment duration and outcome. Eur J Phys Rehabil Med. Dec 15 2009. [Medline].
Perlmutter JS, Mink JW. Deep brain stimulation. Annu Rev Neurosci. 2006. 29:229-57. [Medline].
Ferkel RD, Westin GW, Dawson EG, Oppenheim WL. Muscular torticollis. A modified surgical approach. J Bone Joint Surg Am. 1983 Sep. 65(7):894-900. [Medline].
Bertrand C, Molina-Negro P, Bouvier G, Gorczyca W. Observations and analysis of results in 131 cases of spasmodic torticollis after selective denervation. Appl Neurophysiol. 1987. 50(1-6):319-23. [Medline].
Bertrand CM, Molina-Negro P. Selective peripheral denervation in 111 cases of spasmodic torticollis: rationale and results. Adv Neurol. 1988. 50:637-43. [Medline].
Bertrand CM. Selective peripheral denervation for spasmodic torticollis: surgical technique, results, and observations in 260 cases. Surg Neurol. 1993 Aug. 40(2):96-103. [Medline].