Pediatric Torticollis Surgery Treatment & Management
- Author: Amulya K Saxena, MD, PhD; Chief Editor: Marleta Reynolds, MD more...
Medical management of torticollis involves conservative treatment. Sternocleidomastoid fibrosis spontaneously resolves in the vast majority of infants. A large prospective study demonstrated that controlled manual stretching is safe and effective in the treatment of congenital muscular torticollis when a patient is seen before the age of 1 year.[14, 15]
Physiotherapy may be recommended; however, little evidence shows that this alters the course of the condition if the patient is older than 1 year. Evidence-based guidelines for the use of physical therapy in patients with congenital muscular torticollis have been developed by the Section on Pediatrics of the American Physical Therapy Association.
Published data demonstrate that patients with a thicker sternocleidomastoid, a lower birth weight, and a history of breech delivery have a longer rehabilitation duration.[17, 18]
Kinesiology taping is another approach that is sometimes adopted in conservative management. When applied on the affected side, it has an immediate effect on the muscle function scores for the muscular imbalance in the lateral flexors of the neck.
Botulinum toxin type A has been injected into the sternocleidomastoid for the treatment of congenital muscular torticollis in pediatric and adult patients. However, modest benefit with improved range of motion has been observed in very few patients.
Only about 4-5% of patients are surgically treated, generally after the age of 1 year.
Successful bilateral pallidal stimulation has been reported in a patient with Meige syndrome and spasmodic torticollis.
Patients whose pathology does not resolve after 12 months of physical therapy or who develop facial asymmetry or plagiocephaly during the follow-up period should undergo surgery to achieve the best cosmetic result.[22, 23] In delayed cases, additional surgery may be needed for the best cosmetic and functional result.
Surgery is performed with the patient under general anesthesia. A 3- to 4-cm transverse skin incision is made about 1 cm over the sternal and clavicular origins of the affected muscle. The platysma is carefully divided along the line of incision to avoid injury to the external jugular vein. The two heads of the sternocleidomastoid are dissected free. The muscle is divided with diathermy to prevent bleeding. The platysma is then sutured with absorbable 4-0 skin suture, and the skin is closed with continuous 4-0 nonabsorbable skin suture.
Surgical treatment of torticollis by means of an endoscopic or minimal access approach has been reported. Sasaki et al described surgical correction of muscular torticollis via endoscopic tenotomy of the sternocleidomastoid. Tokar et al described the use of a para-axillary subcutaneous endoscopic approach (PASEA) to treat congenital muscular torticollis and found it to be an alternative worth considering for surgeons with experience in pediatric minimally invasive surgery.
Ekici et al described an approach to surgical management of congenital muscular torticollis that used the Z-plasty technique.
Follow-up should be continued until the torticollis resolves completely, until head and neck movement normalize, and until cervical and thoracic scoliosis is resolved in older children.
Hematomas may develop because of inadequate hemostasis during surgery. Incomplete division may cause the condition to persist.
Outcome and Prognosis
Recurrent torticollis after surgery is rare, with a frequency of approximately 5%. Even in patients older than school age and those who have finished growth, sufficient unipolar or bipolar release of the sternocleidomastoid and intensive postoperative care can generally be expected to yield satisfactory treatment results.
Secondary effects of untreated torticollis include the following:
Plagiocephaly is an asymmetric skull deformity in infants that is caused by flattening of one occiput that leads to secondary flattening of the contralateral forehead. After the torticollis resolves, the plagiocephaly resolves; however, several years may pass before it disappears. Although torticollis can predispose to plagiocephaly without synostosis (PWS), torticollis appears to result from plagiocephaly in a large proportion of cases of plagiocephaly with scoliosis.
Facial hypoplasia is inhibition in the growth of the mandible and maxilla due to muscle inactivity. Clinically significant facial hemihypoplasia develops over 8 months; however, it is obvious in patients at the age of 2-3 years. Facial hypoplasia improves as the child grows, after the torticollis resolves.
Musculoskeletal effects include the compensatory ipsilateral elevation of the shoulder, as well as cervical and thoracic scoliosis. Wasting of additional muscles in the neck may be present as a consequence of sternocleidomastoid inactivity.
Congenital muscular torticollis has also been reported to be a significant risk factor for later neurodevelopmental conditions (eg, attention-deficit hyperactivity disorder [ADHD], developmental coordination disorder, language impairment, and autistic spectrum disorder), with disorders presenting at different stages of development.
Bredenkamp JK, Hoover LA, Berke GS, Shaw A. Congenital muscular torticollis. A spectrum of disease. Arch Otolaryngol Head Neck Surg. 1990 Feb. 116(2):212-6. [Medline].
Davids JR, Wenger DR, Mubarak SJ. Congenital muscular torticollis: sequela of intrauterine or perinatal compartment syndrome. J Pediatr Orthop. 1993 Mar-Apr. 13(2):141-7. [Medline].
Munchau A, Bronstein AM. Role of the vestibular system in the pathophysiology of spasmodic torticollis. J Neurol Neurosurg Psychiatry. 2001 Sep. 71(3):285-8. [Medline].
Munchau A, Corna S, Gresty MA, et al. Abnormal interaction between vestibular and voluntary head control in patients with spasmodic torticollis. Brain. 2001 Jan. 124(Pt 1):47-59. [Medline].
Hummel P, Fortado D. Impacting infant head shapes. Adv Neonatal Care. 2005 Dec. 5(6):329-40. [Medline].
Mikov A. Torticollis in an infant. Am Fam Physician. 2007 Oct 15. 76(8):1197-8. [Medline].
Do TT. Congenital muscular torticollis: current concepts and review of treatment. Curr Opin Pediatr. 2006 Feb. 18(1):26-9. [Medline].
Morrison DL, MacEwen GD. Congenital muscular torticollis: observations regarding clinical findings, associated conditions, and results of treatment. J Pediatr Orthop. 1982. 2(5):500-5. [Medline].
Chen MM, Chang HC, Hsieh CF, et al. Predictive model for congenital muscular torticollis: analysis of 1021 infants with sonography. Arch Phys Med Rehabil. 2005 Nov. 86(11):2199-203. [Medline].
Dudkiewicz I, Ganel A, Blankstein A. Congenital muscular torticollis in infants: ultrasound-assisted diagnosis and evaluation. J Pediatr Orthop. 2005 Nov-Dec. 25(6):812-4. [Medline].
Parikh SN, Crawford AH, Choudhury S. Magnetic resonance imaging in the evaluation of infantile torticollis. Orthopedics. 2004 May. 27(5):509-15. [Medline].
Hwang JH, Lee HB, Kim JH, Park MC, Kwack KS, Han JD, et al. Magnetic resonance imaging as a determinant for surgical release of congenital muscular torticollis: correlation with the histopathologic findings. Ann Rehabil Med. 2012 Jun. 36(3):320-7. [Medline]. [Full Text].
Celayir AC. Congenital muscular torticollis: early and intensive treatment is critical. A prospective study. Pediatr Int. 2000 Oct. 42(5):504-7. [Medline].
Cheng JC, Wong MW, Tang SP, et al. Clinical determinants of the outcome of manual stretching in the treatment of congenital muscular torticollis in infants. A prospective study of eight hundred and twenty-one cases. J Bone Joint Surg Am. 2001 May. 83-A(5):679-87. [Medline].
Tatli B, Aydinli N, Caliskan M, et al. Congenital muscular torticollis: evaluation and classification. Pediatr Neurol. 2006 Jan. 34(1):41-4. [Medline].
Kaplan SL, Coulter C, Fetters L. Physical therapy management of congenital muscular torticollis: an evidence-based clinical practice guideline: from the Section on Pediatrics of the American Physical Therapy Association. Pediatr Phys Ther. 2013 Winter. 25(4):348-94. [Medline].
Jung AY, Kang EY, Lee SH, Nam DH, Cheon JH, Kim HJ. Factors that affect the rehabilitation duration in patients with congenital muscular torticollis. Ann Rehabil Med. 2015 Feb. 39(1):18-24. [Medline]. [Full Text].
Han JD, Kim SH, Lee SJ, Park MC, Yim SY. The thickness of the sternocleidomastoid muscle as a prognostic factor for congenital muscular torticollis. Ann Rehabil Med. 2011 Jun. 35(3):361-8. [Medline]. [Full Text].
Öhman A. The Immediate Effect of Kinesiology Taping on Muscular Imbalance in the Lateral Flexors of the Neck in Infants: A Randomized Masked Study. PM R. 2014 Dec 12. [Medline].
Collins A, Jankovic J. Botulinum toxin injection for congenital muscular torticollis presenting in children and adults. Neurology. 2006 Sep 26. 67(6):1083-5. [Medline].
Opherk C, Gruber C, Steude U, et al. Successful bilateral pallidal stimulation for Meige syndrome and spasmodic torticollis. Neurology. 2006 Feb 28. 66(4):E14. [Medline].
Sonmez K, Turkyilmaz Z, Demirogullari B, et al. Congenital muscular torticollis in children. ORL J Otorhinolaryngol Relat Spec. 2005. 67(6):344-7. [Medline].
Wei JL, Schwartz KM, Weaver AL, Orvidas LJ. Pseudotumor of infancy and congenital muscular torticollis: 170 cases. Laryngoscope. 2001 Apr. 111(4 Pt 1):688-95. [Medline].
Sasaki S, Yamamoto Y, Sugihara T, Kawashima K, Nohira K. Endoscopic tenotomy of the sternocleidomastoid muscle: new method for surgical correction of muscular torticollis. Plast Reconstr Surg. 2000 Apr. 105(5):1764-7. [Medline].
Tokar B, Karacay S, Arda S, Alici U. Para-axillary subcutaneous endoscopic approach in torticollis: tips and tricks in the surgical technique. Eur J Pediatr Surg. 2015 Apr. 25(2):165-70. [Medline].
Ekici NY, Kizilay A, Akarcay M, Firat Y. Congenital muscular torticollis in older children: treatment with Z-plasty technique. J Craniofac Surg. 2014 Sep. 25(5):1867-9. [Medline].
Cheng JC, Tang SP, Chen TM, Wong MW, Wong EM. The clinical presentation and outcome of treatment of congenital muscular torticollis in infants--a study of 1,086 cases. J Pediatr Surg. 2000 Jul. 35(7):1091-6. [Medline].
Shim JS, Noh KC, Park SJ. Treatment of congenital muscular torticollis in patients older than 8 years. J Pediatr Orthop. 2004 Nov-Dec. 24(6):683-8. [Medline].
van Vlimmeren LA, Helders PJ, van Adrichem LN, Engelbert RH. Torticollis and plagiocephaly in infancy: therapeutic strategies. Pediatr Rehabil. 2006 Jan-Mar. 9(1):40-6. [Medline].
de Chalain TM, Park S. Torticollis associated with positional plagiocephaly: a growing epidemic. J Craniofac Surg. 2005 May. 16(3):411-8. [Medline].
Chate RA. Facial scoliosis from sternocleidomastoid torticollis: long-term postoperative evaluation. Br J Oral Maxillofac Surg. 2005 Oct. 43(5):428-34. [Medline].
Schertz M, Zuk L, Green D. Long-term neurodevelopmental follow-up of children with congenital muscular torticollis. J Child Neurol. 2013 Oct. 28(10):1215-21. [Medline].