Torticollis Workup

  • Author: Michael C Kruer, MD; Chief Editor: Selim R Benbadis, MD   more...
 
Updated: Mar 6, 2012
 

Approach Considerations

When a positive family history suggests a familial dystonia rather than idiopathic cervical dystonia, DNA tests for specific genetic dystonias are available that detect causative mutations. 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).

Magnetic resonance imaging (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. Cranial imaging (computed tomography [CT] scanning or MRI) of cervical dystonias is indicated when the physical examination includes abnormal long tract findings (eg, in pyramidal tracts), ophthalmoplegia, and/or dementia.

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 for these studies are to plan botulinum toxin injections, which, if too extensive, may worsen the swallowing mechanism.

Electromyography is useful in distinguishing myopathic from neuropathic processes, as follows:

  • 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).
Proceed to Treatment & Management
 
 
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

Disclosure: Nothing to disclose.

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.

Harris Gellman, MD Consulting Surgeon, Broward Hand Center; Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami School of Medicine

Harris Gellman, MD is a member of the following medical societies: American Academy of Medical Acupuncture, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Surgery of the Hand, and Arkansas Medical Society

Disclosure: Nothing to disclose.

Carl R Menckhoff, MD, FACEP, FAAEM Associate Professor, Department of Emergency Medicine, Medical College of Georgia

Carl R Menckhoff, MD, FACEP, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians

Disclosure: Nothing to disclose.

Gurdeep S Othee, MD Staff Physician, Department of Emergency Medicine, Medical College of Georgia

Gurdeep S Othee, MD is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians

Disclosure: Nothing to disclose.

Lorenzo L Pacelli, MD Consulting Surgeon, Division of Orthopedic Surgery, Section of Upper Extremity Surgery, Scripps Clinic

Lorenzo L Pacelli, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Joseph E Sheppard, MD Professor of Clinical Orthopedic Surgery, Chief of Hand and Upper Extremity Service, Department of Orthopedic Surgery, University of Arizona Health Sciences Center, University Physicians Healthcare

Joseph E Sheppard, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Society for Surgery of the Hand, and Orthopaedics Overseas

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Michael Yaszemski, MD, PhD Associate Professor, Departments of Orthopedic Surgery and Bioengineering, Mayo Foundation, Mayo Medical School

Disclosure: Nothing to disclose.

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Female patient presenting with torticollis. Image courtesy of Danette C Taylor, DO, MS.
Female patient presenting with torticollis. Image courtesy of Danette C Taylor, DO, MS.
Female patient presenting with torticollis. Image courtesy of Danette C Taylor, DO, MS.
A 69-year-old woman presents with torticollis and a fever.
Pallidal outflow pathways from basal ganglia to thalamus. E = excitatory; i = inhibitory; STN = subthalamic nucleus. Image courtesy of Norman C. Reynolds, MD, and Wisconsin Medical Journal.
Soft-tissue neck radiograph demonstrates retropharyngeal abscess appearing as torticollis.
 
 
 
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