Torticollis Differential Diagnoses

Updated: Oct 22, 2018
  • Author: Michael C Kruer, MD; Chief Editor: Selim R Benbadis, MD  more...
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DDx

Diagnostic Considerations

Distinguishing acute cervical trauma from traumatic torticollis may be difficult, but this is a recurring theme for car accident victims with persisting whiplash symptoms or for patients with industrial injuries when legal interest or chronic pain is an issue. Precise chronologic history is required in providing testimony to distinguish acute cervical trauma from posttraumatic torticollis. To maintain credibility during testimony, consistent statements of chronology are critical and must be prepared by careful review of the medical record by the physician giving testimony.

With postconcussive syndrome, whiplash head and neck injury from rapid acceleration and/or deceleration involves sprained and painful neck muscles, usually on both sides and the posterior muscles, along with global headache, inability to concentrate, and often dizziness and blurred vision.

Although beginning a few days or immediately following whiplash or other trauma, acute posttraumatic torticollis can be defined clearly only when the postconcussive syndrome is minimal. When the postconcussive syndrome is of great magnitude and persistent, acute posttraumatic torticollis can be identified clearly only after the acute strain and other postconcussive symptoms are eliminated in time or by analgesic medication (short-term narcotics or nonsteroidal anti-inflammatory drugs [NSAIDs]). "Residuals" of consistent abnormal head and neck posture with marked limitation of motion are not from the postconcussive syndrome (which is self-limited) but rather from acute posttraumatic torticollis (which is likely to be a chronic syndrome requiring botulinum toxin or a D2 agonist for long-term treatment).

Delayed posttraumatic torticollis is not a recurrence of the postconcussive or whiplash syndrome in the absence of a new injury but an identifiable torticollis syndrome with persistent abnormal posture of head and neck with major limitation in motion. The history of a previous whiplash or postconcussive syndrome establishes the original trauma that may eventually lead to torticollis due to intracranial brain changes in physiology as a delayed response to the original trauma.

Other conditions that should be considered in the evaluation of torticollis include the following:

  • Spinal deformity: Early childhood "dropped head syndrome" seen in myopathies and myasthenia, may mimic anterocollis

  • Juvenile cerebral palsy with cervical dystonia

  • Phenothiazine-induced acute dystonic reactions of childhood

  • Juvenile-onset Wilson disease: Often dystonic rather than dyskinetic

  • Juvenile-onset Huntington disease: Often dystonic and cervical

  • Acquired dystonia of childhood, such as hematoma or other tumor of sternocleidomastoid muscle

  • Gastroesophageal reflux (Sandifer syndrome) producing rapid flexion and odd postures reminiscent of torticollis subtypes: Sandifer syndrome is a term used to describe gastroesophageal reflux with abnormal posturing including torticollis in infants; torticollis occurs intermittently and can alternate sides; other symptoms of reflux may be present including regurgitation, anorexia, irritability, anemia, failure to thrive, coughing, asthma, and hoarseness; treatment is antireflux therapy

  • Anterior horn disease

  • Radiculopathy

  • C1 and C2 fractures

  • Movement disorders in individuals with developmental disabilities

Differential Diagnoses