WRY-NECK (TORTICOLLIS)
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What is Wry-Neck (Torticollis)?
Torticollis, also known as "wry-neck," is a condition where a kid's head and neck are cocked to one-side in a locked position.
Children can either can be born with this condition or it can be acquired between the ages of 8-12 years old.
In kids that are born with torticollis, the condition is associated with a "packaging problem" during pregnancy (meaning there wasn’t enough room in the womb while the fetus was growing, and the head got pushed to one side in the cramped space... and over time the primary muscle controlling neck movement, the sternoclidomastoid muscle (aka the SCM) develops a fibrotic scar on the side the neck is facing). You can actually feel a bump (scar tissue) in the muscle in about 20% of cases.
When torticollis is acquired in young children its associated with inflammation of that same neck muscle, the SCM, which causes muscle spasms that pull the head and neck to one side. The inflammation of this muscle is associated with a recent upper respiratory tract infection or tonsillar infection...which causes inflamed lymph nodes (lymphadenitis and drainage of the pharyngeal venous plexis) that irritate the nearby muscle. This is also called Grisel’s Syndrome.
Diagnosing Wry-Neck (Torticollis):
Recognizing torticollis is usually straightforward because of the obvious abnormal position of the head and neck. But doctors dont just stop there and say "yes you have torticollis". The important part of diagnosis is understanding its cause and the severity.
Doctors will get x-rays of the neck to see if the cervical vertebre (neck bones) have moved out of position due to the muscle spasm. If the muscle is contracted with great force, for a prolonged amount of time, the neck bones can actually become displaced (the formal name for this is "atlantoaxial rotatory subluxation"). This displacement can occur in varying degrees of severity, from no changes to a partial dislocation (unilateral facet jump with < 5 mm anterior shift measured by the ADI on x-ray) to a full dislocation (bilateral facet jump causing > 5 mm anterior shift). When translation of C1 is over 5 mm there is a risk for neurologic injury. Often times they will also obtain a CAT scan if they are concerned about changes in the position of the neck bones.
Because torticollis can be associated with abnormal position of the vertebrae, it is important for doctors to perform a full neurologic exam to evaluate any injury to the spinal cord (although risk of this is quite low, even in severe conditions).
How is Wry-Neck (Torticollis) treated?
Over 90% of cases of genstational torticollis (a baby born with the condition) resolve by messaging and stretching the neck to relax the muscle contracture. To think of things in a positive light, the baby gets the pleasure of receiving many neck messages a day (I know a lot of people who wish they could get a doctor's note for that!).
In children that acquire torticollis, the treatment depends on how long the neck has been in spasm.
If its been under one week, then pain medication, anti-inflammatories, and stretching will reliably provide successful treatment. If its been between one to four weeks, then the head is placed into a sling for gentle traction while the child is given muscle relaxants and pain medication.
If its been over a month then halo traction is required, which uses pins to hold very tight traction at the skull. On the very rare occasion that there is spinal instability or the neck has been malpositioned for over 3 months, then a spine surgery is indicated to correct the displaced neck bones and protect the spinal cord.
What is the long term outcome?
Usually this condition is caught early and treated successfully with over the counter medication. Most children do very well with little risk of recurrence.
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References
1) Bredenkamp JK, Maceri DR. Inflammatory torticollis in children. Arch Otolaryngol Head Neck Surg 1990;116(3):310–313. full article. etio inflam torticollis.
2) Neal, K. Atlantoaxial rotatory subluxation in children. JAAOS. June 2015; 23(6); p. 382-92. full article. summary of acquired subluxation.
3) Tauchi, R et al. Surgical treatment for chronic atlantoaxial rotatory fixation in children. JPO 2013;22(5):404–408. full article. posterior fusion in 6 patients.
4) Fielding JW, Hawkins RJ. Atlanto-axial rotatory fixation. Fixed rotatory subluxation of the atlanto-axial joint. JBJS Am 1977;59(1):37–44. full article. classification system based on CT scan.
5) Philips WA, Hensinger RN. The management of rotatory atlanto-axial subluxation in children. J Bone Joint Surg Am 1989;71(5):664–668. full article. most acquired torticollis requires traction for resolution. full article. 23 kids. 16/16 treated with traction improved when sx were <4 weeks, 4/7 improved when sx were >4 weeks, the other 3 req. surgery.
6) Beier AD et al. Rotatory subluxation: Experience from the Hospital for Sick Children. J Neurosurg Pediatr 2012;9(2):144–148. full article. collar effective in majority of patients treated with <4 weeks sx.
7) Tang SF et al. Longitudinal followup study of ultrasonography in congenital muscular torticollis. CORR 2002; Oct(403); p. 170-85. full article. muscle changes in torticollis.
8) Bedenkamp JK et a. Congenital muscular torticollis. A spectrum of disease. Arch Otolaryngol Head Neck Surg. 1990; 116(2): 212-6. full article. summary of treatment.
9) Do TT. Congenital muscular torticollis: current concepts and review of treatment. Curr Opin Ped. 2006; 18(1): 26-9. full article. summary of diagnosis.
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