Torticollis Treatment in Singapore


  • A limitation of motion of the cervical spine that causes the head to be held in a tilted position
  • May result from muscular, skeletal, or neurologic abnormalities (Fig. 1)
  • Classification :
    • Congenital abnormalities
    • Acquired abnormalities
  • Synonyms: Skeletal wry neck; Congenital wry neck; Cock-robin deformity; Sandifer syndrome (torticollis resulting from gastroesophageal reflux disease and hiatal hernia)
General Prevention
The condition cannot be prevented, but prompt referral and treatment may preclude the need for surgery.
  • The most common cause is rotatory subluxation of the atlantoaxial joint, an acquired condition.
  • Congenital muscular torticollis usually is evident in the first 6-8 weeks of life.
  • Other causes may appear throughout childhood or may become evident well into adulthood.
  • Males and females are affected equally.
  • Because of the multiple causes, it is difficult to give a specific figure for incidence.
  • It affects an estimated 1 per 100 to 1 per 1,000 patients.
    Fig. 1. Torticollis typically produces lateral flexion to 1 side and rotation to the other.
Risk Factors
  • Local trauma to the infant’s neck during delivery, especially during a difficult delivery
  • For atlantoaxial rotatory subluxation: Upper respiratory infection, pharyngitis, or trauma
  • Multiple congenital causes of torticollis exist, of which a few have a genetic predisposition.
  • Skeletal dysplasias are the most common genetic syndromes associated with torticollis.
  • Congenital muscular torticollis is caused by contracture of the sternocleidomastoid muscle.
  • Congenital bony torticollis may be secondary to occipitocervical abnormalities.
  • Acquired torticollis may result from neurogenic, traumatic, inflammatory, or idiopathic causes (see Differential Diagnosis).
  • Bony abnormalities: Atlanto-occipital synostosis, basilar impression, odontoid abnormalities, cervical hemivertebrae, or asymmetry of occipital condyles
  • Atlantoaxial rotatory subluxation, the most common bony abnormality, is characterized by rotatory displacement of C1 on C2 and may be congenital or secondary to inflammation or trauma.
Signs and Symptoms
  • Hallmark sign: Tilting of the head to 1 side with limitation of ROM
  • Usually the patient rotates the head away from the neutral (straight) position, but not toward it.
  • Patients may present with a neck mass (contracted sternocleidomastoid muscle).
  • Neck pain is a common complaint, but it usually occurs in adults.
  • Patients also may complain of occipital pain, vertigo, or dizziness aggravated by certain movements of the head.
  • If torticollis persists beyond infancy, secondary asymmetry of the cranium (plagiocephaly) may remain.
Physical Exam
  • The patient’s head is tilted, with the ear toward the involved side and the chin rotated away, with limitation of ROM toward the corrected position.
  • In some cases of muscular torticollis, a palpable mass may be present on the involved side (contracted sternocleidomastoid muscle).
  • Remodeling of the head or face may result from pressure while sleeping.
  • A short, broad neck with a low hairline may be seen in patients with bony abnormalities or Klippel-Feil syndrome.
  • No specific laboratory tests, unless an inflammatory or neoplastic origin is being considered
  • Ophthalmologic, audiologic, and gastroenterologic evaluations sometimes are needed if no obvious skeletal causes are seen.
  • AP and lateral radiographs of the cervical spine should be obtained for any patient with torticollis to identify bony abnormalities.
  • CT is used to evaluate rotatory subluxation, dislocation, or fracture.
  • MRI is used if a neurologic lesion of the brainstem or neck is suspected.
Pathological Findings
In congenital muscular torticollis, the sternocleidomastoid muscle is fibrotic, replaced by scar tissue in a nonspecific fashion.
Differential Diagnosis
  • Neurogenic causes:
    • Spinal cord tumors of the cervical spine
    • Cerebellar tumors
    • Syringomyelia
    • Ocular dysfunction
  • Traumatic causes:
    • Subluxations
    • Fractures and dislocations of the occipitocervical junction
  • Inflammatory causes:
    • Cervical adenitis
    • Rheumatoid arthritis
  • Idiopathic causes:
    • Atlantoaxial rotatory subluxation or displacement

Torticollis Treatment

General Measures
  • Congenital muscular torticollis:
    • Responds to stretching exercises in nearly 100% of patients treated before 1 year of age
    • Positioning of toys in the crib will encourage the child to stretch the involved side.
  • Atlantoaxial rotatory subluxation:
    • Patients usually recover with physical therapy if the condition is detected within the 1st week of onset.
    • Use of a soft collar and analgesics is for patients with atlantoaxial rotatory subluxation patients.
    • Patients with recalcitrant cases may require muscle relaxants and a hard collar or brace.
    • If treatment is delayed, traction or even surgery is required.

  • Contact sports and vigorous athletics should be restricted until the condition has been treated.
  • Specifics depend on the underlying cause.
Special Therapy
Physical Therapy
  • Stretching exercises may be beneficial in patients with muscular torticollis or recent-onset rotatory subluxation.
  • Specific instructions should be given to the therapist.
Analgesics (acetaminophen, ibuprofen)
  • Congenital muscular torticollis that is refractory to stretching may require release of the sternocleidomastoid muscle.
  • Severe atlantoaxial rotatory subluxation or other severe bony abnormality may require fusion of C1 and C2.
Most cases resolve spontaneously or with treatment.
  • Fixed subluxation
  • Plagiocephaly (in late-treated muscular torticollis)
Patient Monitoring
  • Neurologic status should be followed closely.
  • Bony abnormalities, such as rotatory subluxation, may require repeated CT scans.
  • 754.1 Congenital torticollis
  • 847.0 Traumatic torticollis
Patient Teaching
  • Once the cause is known, anatomic models may be used to explain the cause of the torticollis to patients and families.
  • Patients and families should be made aware of the usual course of the condition and the possible need for different methods of therapy.
Q: When is congenital torticollis usually 1st evident clinically?
A: In the first 6-8 weeks of life.
Q: What does a neck mass in a patient with torticollis often represent?
A: A contracted sternocleidomastoid muscle. However, additional evaluation may be required in some cases to rule out other causes.

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