eMedicine Specialties > Orthopedic Surgery > Hand & Upper Extremity
Torticollis: Treatment
Updated: Feb 5, 2008
Treatment
Medical Therapy
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 toxin15 or phenol.
Physical therapy includes stretching exercises, massage, local heat, analgesics, sensory biofeedback, and transcutaneous electrical nerve stimulation (TENS).
Surgical Therapy
Surgical therapy may consist of the following:
- Unipolar sternocleidomastoid release
- Bipolar sternocleidomastoid release
- Selective denervation
- Dorsal cord stimulation
Preoperative Details
A preoperative EMG may be helpful in defining the exact muscles and nerves involved.
Intraoperative Details
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.
Though 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.2,16 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
Selective denervation was first developed in the early 1980s by Claude Bertrand, MD, and his colleagues in Montreal, Canada.17,18,19 It is primarily used in the treatment of torticollis, and varying success rates have been reported since its introduction. 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 prior to 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.
Postoperative Details
Follow-up
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 three 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.
Complications
Complications of the above procedures include injury to spinal accessory nerve or nearby vasculature including the jugular veins and carotid artery. Other complications include neck muscle atrophy, loss of muscle control, instability, variable numbness or sensory loss, pain, and neck deformity.
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References
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Further Reading
Keywords
wryneck, spasmodic torticollis, cervical dystonia, loxia, congenital muscular torticollis, neck pain, twisted neck
