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Torticollis, also known as twisted neck, is a condition that causes an abnormal, asymmetrical head or neck position. It is characterised by involuntary contractions of neck muscles, resulting in considerable somatic and psychologic disability. The primary muscles involved in torticollis include the sternocleidomastoid, splenius, trapezius, scapula, scalenes, and platysma. In congenital torticollis, the sternocleidomastoid muscle is tight and shortened, requiring stretching exercises and repositioning to gradually lengthen it. Treatment for torticollis may include physical therapy, trigger point injections, and in severe cases, surgery to lengthen the affected muscle.
| Characteristics | Values |
|---|---|
| Definition | An abnormal, asymmetrical head or neck position, which may be due to a variety of causes. |
| Synonyms | Intermittent torticollis, cervical dystonia, idiopathic cervical dystonia, twisted neck, wry neck |
| Causes | Upper respiratory and soft-tissue infections of the neck, injury to the neck muscle, nerve damage, abnormal positioning or "crowding" of the baby in the uterus, vision problems, basal ganglia circuit abnormalities, etc. |
| Symptoms | Head tilt, rotation, flexion, extension, neck spasms, neck pain, vomiting, pallor, irritability, ataxia, drowsiness, etc. |
| Treatment | Stretching exercises, massage, repositioning, helmet therapy, botulinum toxin injections, surgery |
| Prevention | No known way to prevent congenital muscular torticollis. |
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What You'll Learn
The sternocleidomastoid muscle
The sternocleidomastoid (SCM) muscle is a powerful neck muscle that allows you to bend your neck and turn or tilt your head. It is the most targeted muscle involved in torticollis, a condition commonly known as twisted neck, which causes the head to be rotated, tilted, or leaning forward or backward.
The SCM is a two-headed neck muscle that extends from the mastoid process at the base of the skull to the collarbones (clavicles) and breastbone (sternum). The sternal head originates from the manubrium of the sternum, while the clavicular head originates from the medial third of the clavicle. These two heads join to form one muscle belly that inserts on the lateral surface of the mastoid process of the temporal bone and the lateral half of the superior nuchal line of the occipital bone. The SCM is easily visible and palpable, and you can feel it on both sides of your neck.
Injuries, tension, and strain within the SCM can lead to pain and stiffness, and in some cases, trigger points may develop in multiple places within the muscle. Shortened SCM muscles can cause torticollis, resulting in the head naturally turning or tilting to one side. Treatment for torticollis includes stretching, physical therapy, and osteopathic manipulation. Surgery may be required if more conservative treatments are unsuccessful or if there is severe structural damage, such as a major tear or a tumor.
The SCM plays a crucial role in various functions beyond neck movement. It helps stabilize the neck, aids in breathing by lifting the sternum and clavicle to expand the thoracic cavity, and supports the temporomandibular joint (TMJ) for proper jaw function. Additionally, the SCM is important in the formation of the triangles of the neck and is closely associated with neurovascular structures passing through the neck.
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Spasms and contractions
The primary muscle involved in torticollis is the sternocleidomastoid, which is located in the anterior region of the neck. This muscle is responsible for turning the head to one side and bending the neck forward. In cases of torticollis, the sternocleidomastoid muscle is shortened, leading to abnormal contractions and spasms. The muscle receives signals from nerves in the neck and head to contract and move properly, but in torticollis, these signals are disrupted, leading to abnormal movements.
Other muscles involved in torticollis include the splenius, trapezius, scapula, scalenes, and platysma. These muscles can also experience spasms and contractions, contributing to the abnormal head and neck positioning characteristic of torticollis. The trapezius muscle, in particular, is often involved in the spasms and contractions associated with torticollis, as it works in conjunction with the sternocleidomastoid muscle to control neck movements.
The underlying cause of the spasms and contractions in torticollis is often unknown, but it is believed to be related to abnormal positioning or injury to the neck muscles. In some cases, torticollis can be caused by damage to the trochlear nerve, which supplies the superior oblique muscle of the eye. When this nerve is damaged, the eye is affected, and the person will turn their head away from the affected side to compensate, leading to the characteristic head tilt of torticollis.
Treatment for torticollis aims to address the spasms and contractions by stretching and relaxing the affected neck muscles. Passive stretching, massage, and physical therapy are commonly used to relieve muscle spasms and contractions and improve range of motion. In severe cases, surgery may be performed to lengthen the shortened sternocleidomastoid muscle. Early treatment is crucial to prevent the condition from worsening and to improve the chances of recovery.
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Surgical treatments
Surgical Options
Surgical options include unipolar/bipolar sternocleidomastoid muscle lengthening, "Z" lengthening, and radical resection of SCM. Sternocleidomastoid muscle release is often used in congenital muscular torticollis. For mild deformities, unipolar release of the muscle is performed distally. Bipolar techniques are used for moderate and severe cases, where the muscle is released proximally and distally.
Brain Stimulation
In some cases, surgery may involve destroying some of the nerves in the neck muscles or using brain stimulation procedures such as deep brain stimulation (DBS). DBS is considered a competitive option to botulinum toxin injections and should be discussed with a stereotactic neurosurgeon.
Timing of Surgery
The timing of surgery depends on the age of the patient and the severity of the condition. Surgery is often considered a last resort, with conservative treatments such as physical therapy, stretching, and medication being attempted first. In infants, surgery is typically not pursued until after a trial of non-operative treatment for 12-24 months, as 90% of patients respond to passive stretching within the first year of life. For children, surgery is usually performed around the age of six if it is required.
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Non-surgical treatments
Torticollis is a rare condition that causes involuntary head tilting due to tightened neck muscles or another underlying condition. It is also known as wry neck or twisted neck. The sternocleidomastoid is the most targeted muscle in cases of torticollis. Other muscles involved include the splenius, the trapezius, the scapula, the scalenes, and the platysma.
- Physical therapy: This includes stretching exercises, massage, local heat, sensory biofeedback, and transcutaneous electrical nerve stimulation (TENS). Passive stretching and positioning are often used in infants and small children, and parents can be taught to perform these exercises at home.
- Medication: Nonsteroidal anti-inflammatory drugs (NSAIDs), muscle relaxants, anticholinergics, and local intramuscular injections of botulinum toxin can be used to treat torticollis.
- Lifestyle changes: Taking frequent breaks, especially when working at a computer or after travelling long distances, sleeping with a small pillow for neck support, avoiding carrying heavy bags on one shoulder, and quitting smoking can help manage neck pain associated with torticollis.
- Alternative therapies: Treatments such as osteopathy or remedial massage can help relieve neck and shoulder pain.
In most cases, torticollis can be treated without surgery, and early treatment is associated with better outcomes. However, if non-surgical treatments are ineffective, surgical options may be considered, including selective denervation, dorsal cord stimulation, and brain stimulation procedures.
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Causes and diagnosis
Torticollis, also known as twisted neck or wry neck, is a painful condition that causes an abnormal, asymmetrical head or neck position. It can be congenital or acquired. Congenital torticollis occurs when there is a reduced length and increased tone of the sternocleidomastoid (SCM) muscle on one side of the neck. This condition is typically diagnosed at or soon after birth and is more common in first-born children, who have less space in the uterus. It can be caused by abnormal positioning, such as a breech position, or by trauma or injury to the neck muscle.
Acquired torticollis can develop later in infancy, childhood, or adulthood and may be associated with various conditions that require specialised treatment. It can be caused by damage to the trochlear nerve (fourth cranial nerve), which supplies the superior oblique muscle of the eye, resulting in vision problems. Other causes of acquired torticollis include spinal deformities, infections, trauma, and abnormalities in the blood and nerve supply to the SCM muscle.
Diagnosis of torticollis involves a thorough neurological examination to evaluate for associated conditions such as developmental dysplasia of the hip, clubfoot, or vision problems. Radiographs, MRI scans, and ultrasonography can be used to visualise muscle tissue and rule out bony abnormalities. In children, evaluation by an optometrist or ophthalmologist may be necessary to ensure that torticollis is not caused by vision problems. Treatment for torticollis aims to stretch and lengthen the shortened SCM muscle through passive stretching, positioning, and physical therapy. In some cases, surgery may be required to lengthen the SCM muscle or correct underlying spinal issues.
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Frequently asked questions
The sternocleidomastoid muscle, which is located in the anterior region of the neck, is the most targeted muscle in cases of torticollis.
Torticollis, also known as twisted neck, is an extremely painful, dystonic condition defined by an abnormal, asymmetrical head or neck position.
Treatments for torticollis include stretching exercises, surgery, botulinum toxin injections, and trigger point injections.
