B10 Torticollis

Question 1

What is torticollis?

Answer 1

A painful contraction of muscles (usually SCM) resulting in an unnatural head position

AKA wry neck

Question 2

What is the most common head position that presents for Torticollis?

Answer 2

Rotated and flexed

Question 3

What are the two etiologies of congenital torticollis?

Answer 3

• birth trauma (muscular lesion, short/missing SCM)

- bony anomaly (hemi vertebrae, congenital fusion of c-spine vertebra, etc)

Question 4

What percentage of patients with congenital muscular torticollis respond to passive stretching within the first year of life?

Answer 4

90%

Question 5

Some patients undergo selective denervation for torticollis instead of passive stretching. What percentage of these patients experience satisfactory results?

Answer 5

65-80%

Question 6

What is AARS? Why is it important?

Answer 6

atlantoaxial rotary subluxation which can present similar to torticollis and therefore is important to rule out

Question 7

What causes AARS?

Answer 7

It is thought to be precipitated by retropharyngeal edema leading to laxity of ligaments at C1-C2. This can occur after:

• Minor surgery
• Pharyngeal surgery
• Inflammatory process
• Upper respiratory tract infection

Question 8

What are the 4 different types of torticollis and which is most common?

Answer 8

• non-traumatic/uncomplicated acute torticollis (most common)
• traumatic acute torticollis
• cervical dystonia/spasmodic torticollis
• post traumatic/delayed dystonia

Question 9

What type of torticollis develops overnight and results in painful, palpable neck spasms the following morning?

Answer 9

Acute uncomplicated/non-traumatic torticollis

Question 10

What is the treatments for Acute uncomplicated/non-traumatic torticollis?

Answer 10

It is usually self-limited and resolves on its own in days to weeks. If treated, conservative care can be done:

• PIR, reciprocal inhibition, etc. to relax the SCM spasm
• manipulate joint dysfunction if present
• analgesics as needed

Question 11

What is the relationship between Acute uncomplicated/non-traumatic torticollis and joint dysfunction?

Answer 11

Upper cervical spine joint dysfunction can result in reflex spasm of the SCM and other cervical muscles, resulting in torticollis. Upper cervical may reflex directly to CN XI

Question 12

What type of torticollis results from blunt trauma to the head and neck, such as concussion or whiplash?

Answer 12

Acute traumatic torticollis

Question 13

What is the first step in treatment of acute traumatic torticollis?

Answer 13

Immobilize and take radiographs

Question 14

Torticollis can be secondary to what life-threatening diseases?

Answer 14

• Retropharyngeal abscess
• spinal epidural hematomas
• tumors

Question 15

Why is it important to rule out infectious cause of torticollis first?

Answer 15

Because retropharyngeal abscess is potentially life-threatening

Question 16

Who typically gets retropharyngeal abscesses?

Answer 16

Children aged 2-4 but incidence in adults is increasing

Question 17

What is the typical presentation of torticollis secondary to retropharyngeal abscess?

Answer 17

• neck discomfort
• fever
• stridor (harsh vibration when breathing)
• dysphagia (difficulty swallowing)
• drooling
• odynophagia (painful swallowing)
• respiratory distress

Question 18

Other than spinal epidural hemoatomas, tumors and retropharyngeal abscesses, what other non-life threatening diseases can torticollis be secondary to?

Answer 18

• upper respiratory infection
• tooth infection
• pharyngitis
• tonsillitis
• systemic infection
• meningitis
• osteomyelitis
• upper lobe pneumonia
• neurogenic from viral infection of CN XI
• psychiatric disease

Question 19

What medications can cause torticollis?

Answer 19

• dopamine receptor blockers
• metoclopramide
• phenytoin
• carbamazepine

Question 20

What mechanical neck lesions can cause torticollis?

Answer 20

• spondylolysis
• scar tissue
• ligamentous laxity in atlantoaxial region

Question 21

What is dystonia?

Answer 21

A movement disorder that causes involuntary muscle contractions resulting in twisting and/or repetitive movements that are sometimes painful

Question 22

What is the theory behind the cause of dystonia?

Answer 22

Researchers think it is due to a problem in the part of the brain that handles messages about muscle contractions. Thalamic or basal ganglia lesion has been suspected.

Question 23

What are some additional symptoms associated with dystonia?

Answer 23

• tremors
• voice problems
• dragging foot

Question 24

What are the three different types of cervical dystonia?

Answer 24

• idiopathic spasmodic torticollis
• post traumatic torticollis
• UMNL of cranial nerve XI

Question 25

A chronic, slowly progressive form of torticollis that is characterized by having an acquired, nontraumatic origin and consists of episodic tonic and/or clonic involuntary contractions of neck muscles.

Answer 25

Idiopathic spasmodic torticollis

Question 26

Who typically gets idiopathic spasmodic torticollis?

Answer 26

- females | - 30-60 years old

Question 27

What are some additional symptoms that can occur with idiopathic spasmodic torticollis?

Answer 27

- dystonic symptoms can progress to hand, arm or oromandicular region (32%) - dysphagia - tremor (71%) - pain (68%)

Question 28

What activities worsen the symptoms of torticollis and dystonia (Both varieties)?

Answer 28

- standing - walking - emotional stress

Question 29

What finding from the history can help distinguish idiopathic and delayed post-traumatic spasmodic torticollis from acute traumatic and acute non-traumatic torticollis?

Answer 29

Patients reporting the presence of sensory tricks that reduce head and neck movements would indicated spasmodic torticollis/dystonia over acute torticollis

Question 30

What is the prognosis for idiopathic spasmodic torticollis?

Answer 30

Symptoms last more than 6 months and result in considerable somatic and psychologic disability.

Question 31

Of patients with cervical dystonia, what percentage | experience spontaneous self-limited remissions that may be quite brief or last as long as 2-3 years?

Answer 31

10-20%

Question 32

Posttraumatic cervical dystonia has a delayed onset. How long does it take for symptoms to occur?

Answer 32

days to weeks and as long as 3-12 months after head | and neck trauma

Question 33

With torticollis, the primary goal of physical examination is to differentiate between acute torticollis and cervical dystonia, rule out disease, atlas subluxation, fracture and structural instability. What physical exam procedures should be done to do this?

Answer 33

- take temperature - examine throat - ausculatate - observe for craniofacial asymmetry - observe for head and UE tremors - palpate lymph nodes - perform neuro ortho exam - assess SCM - palpate spine, especially upper cervicals

Question 34

What ancillary studies should be done in the management of torticollis?

Answer 34

None are usually necessary - Xray if there has been trauma, atlas subluxation is suspected of retropharyngeal infection is suspected - MRI or CT if CNS disease is suspected

Question 35

What is the treatment for dystonia?

Answer 35

- lengthen SCM - decrease fibrosis - Heat - Electrotherapy (but not over anterior neck)

Question 36

What is the prognosis for dystonia?

Answer 36

May self resolve or take up to 12 months to resolve with treatment

Question 37

What are some medical interventions for dystonia?

Answer 37

- Botox injections - NSAIDs - muscle relaxants - anticholinergics