Pediatric Torticollis Surgery 

The earliest description of torticollis dates back to writings from the ancient Greek civilization. According to Plutarch, Alexander the Great may have had torticollis.

Torticollis is a result of unilateral tightness and shortening of one sternocleidomastoid muscle. A visible or sometimes palpable swelling, often referred to as a sternomastoid tumor, appears in a part of the muscle in infants aged 2-3 weeks. It often persists until they are aged 1 year. It is rarely bilateral and may be seen in older children in whom the mass was not previously identified.

Frequency

Torticollis occurs in 0.4% of all births.

The etiology is incompletely understood, although several theories have been postulated.^{[1, 2]} Reports on the familial transmission of congenital muscular torticollis have been few. An idiopathic intrauterine embryopathy or the intrauterine development of sternocleidomastoid compartment syndrome may be responsible for the sternomastoid fibrosis.

An end-arterial branch of the superior thyroid artery supplies the middle part of the sternocleidomastoid muscle. Obliteration of this end artery may be responsible for the development of muscle fibrosis. As an alternative, primary trauma that temporarily and acutely obstructs the veins may lead to intravascular clotting in the obstructed venous tree. In infants, this clotting is evidenced by the development of a sternocleidomastoid mass, which eventually disappears and is replaced by fibrous tissue.

Abnormalities in the basal ganglia may be involved in the pathophysiology of spasmodic torticollis.^[3] On the other hand, some vestibular abnormalities have also been reported that cannot solely be explained as being secondary to abnormal head and neck movements in spasmodic torticollis but seem to be more intimately related to its pathophysiology. In this respect, abnormal interaction of vestibular signals with higher-order motor commands and disrupted central vestibular processing, which are perhaps caused by subtle imbalances in the vestibular system, seem to be of particular importance.^[4]

The mass is generally 1-3 cm in diameter. It is a painless swelling in the substance of the sternocleidomastoid muscle and develops in neonates aged 2-3 weeks. In infants, the tumor is hard, and the patient's head is tilted and flexed to the side of the fibrosis. However, in older children, the tumor is less discrete than it is in younger children, and the sternocleidomastoid muscle appears thickened and foreshortened along its entire length. This thickening restricts rotation and lateral flexion of the neck. This rotation and lateral flexion of the neck is largely responsible for the gradual increase in positional plagiocephaly.^{[5, 6]}

Older children compensate for the head tilt by elevating their shoulder to maintain a horizontal plane of vision. The head tilting is further compensated by twisting the neck and back, if required, to maintain a straight line of sight. These compensatory mechanisms do not occur in infants, who do not need to maintain a horizontal plane of vision until they stand up. Also, in older patients, muscular spasms play a role or accompany torticollis.

It is important to differentiate muscular from nonmuscular torticollis. Congenital muscular torticollis is benign; missing a case of nonmuscular torticollis is potentially life-threatening.^[7]

Management for torticollis is primarily nonoperative, generally consisting of parental physiotherapy.

Rare indications for surgical management include persistent sternocleidomastoid contracture limiting head movement, persistent sternocleidomastoid contracture accompanied by progressive facial hemihypoplasia, and torticollis in children older than 12 months.

Surgical management of congenital muscular torticollis is generally avoided until the child is aged at least 1 year,^[8] until conservative methods (eg, physiotherapy) are unsuccessful, and until other differential diagnoses are excluded.