Two of the most common disorders of the spine in children are torticollis and scoliosis. Today’s post will focus on torticollis.
The most common differential diagnoses for torticollis are: benign paroxysmal torticollis, neurogenic torticollis, osseous torticollis, reflex torticollis (infection), trauma, muscular torticollis (congenital and postural), psychogenic torticollis, and ocular torticollis.
Benign paroxysmal torticollis usually presents with episodes of head tilting, which may be accompanied by irritability, vomiting, pallor, vertigo, ataxia, dystonia, reduced muscle tone, migraine headaches, motor delays (fine or gross motor skills). It usually lasts hours to days, but usually doesn’t last more than a week. It can recur from every few days to every few months, and improves over two years usually ending by age 3. It is frequently found in children who have family history of migraine (it is considered an age-sensitive, migraine-related disorder – migraine aura equivalent).
Neurogenic torticollis presents as an acute episode of torticollis that usually occurs in older children with neurologic abnormalities (it can be caused by tumors located at the posterior fossa or cervical nerve root, or any irritation of the cranial nerve X – accessory nerve). It can be accompanied by dystonia/tics, and/or ocular disturbances (strabismus, nystagmus).
Osseous torticollis usually caused by a congenital cervical spinal malformation and in this case the passive range of motion of the neck is limited without tightness or thickening of the sternocleidomastoid (SCM) muscle. This condition is also known as Klipple-Feil syndrome.
Reflex torticollis (infectious): caused by inflammation or suppuration in the neck, enlarged cervical lymph nodes (cervical lymphadenitis – often in age 1 to 5 years), tumor in the tonsil/neck/pharynx, retropharyngeal abscess, and osteomyelitis of cervical spine are the most common examples.
Trauma: usually caused by misalignment/subluxation of the atlanto-occipital or atlas-axis joints, cervical muscular injury, and cervical spine fractures.
Muscular (aka myogenic) torticollis: congenital and acquired (postural) torticollis.
With congenital muscular torticollis the muscle SCM may present with or without a tumor and a mass in SCM is usually felt. The SCM muscle is altered into a cordlike, nonfunctional muscle, distorting the head and neck posture, and affecting the normal growth of the face. It is usually seen with babies in breach positions and difficult deliveries. Research shows that 20% of children that suffers from congenital muscular torticollis may have developmental dysplasia of the hip, and 10% have a family history of torticollis. In 75% of cases the right side is affected (which means the baby turns his/her head to the left). Congenital torticollis can also be caused by muscle damage during labor. It is also seen in children who present with Pterygium Colli (webbed neck), and Noonan syndrome. Babies suffering from congenital muscular torticollis may have their heads tilted or rotated, limited range of neck motion, contracture of the SCM muscle, a firm, non-tender, mobile mass within SCM, plagiocephaly (asymmetrical distortion of the skull), facial asymmetry.
With postural torticollis the muscle SCM is tight and thicker than usual and there is no palpable mass. It is usually a painless condition, typically found during infancy, resolved within a few months and no surgery required. The potential complications of postural torticollis are: cervical scoliosis, facial asymmetry and plagiocephaly. Possible effects of torticollis include: persistent primitive reflexes, delayed head and neck righting reflex (reflex that corrects the body’s orientation when taken out of its normal position), poor stabilization and control of head/neck (also known as head lag), asymmetrical motions usually favoring one side, and delayed sensory and motor milestones.
Psychogenic torticollis: torticollis that is psychogenic in origin (eg: hysteria – usually in older children).
Ocular torticollis: torticollis due to a high degree of astigmatism or to paralysis of ocular muscles (usually in older children).
Other conditions/diseases: hiatal hernia with reflux (also known as Sandfer’s syndrome*, see description below), rheumatoid arthritis, soft tissue tumors of the neck.
*characterized by gastrointestinal symptoms and associated neurological features. Classical symptoms: spasmodic torticollis and dystonia, nodding and rotation of the head, neck extension, gurgling, squirming movements of the limbs, and severe hypotonia.
A pediatric chiropractor will perform a thorough examination on the infant/child’s head and neck, shoulder girdle, look for any bone or soft tissue trauma or disorder, perform a neurological examination, as well as a hip examination, evaluation of the baby’s balance and body control, spinal strength, head righting reactions, facial symmetries, and some other tests as needed.
The treatment should involve physical therapy to correct the torticollis. Surgery is rarely required. It is important that the parents be attentive when the baby’s head tilt or rotation was first noticed, and if the infant moves head and neck in all directions or favors only one direction. The parents should also be aware of any head or neck trauma, infections (sick or febrile). The type of delivery is also of importance – C-section, vaginal, forceps-assisted, vacuum-assisted. Be aware of family history is also important – family history of torticollis, migraine.
The treatment can include muscle stretching, passive repositioning of head and neck, joint mobilization, gentle manipulation, as well as parents education regarding reposition of toys and crib to stimulate infants. In some cases a tubular orthosis for torticollis (TOT collar) will be necessary, and it is usually combined with regular stretch. For the most severe cases of plagiocephaly a plagiocephaly helmet will be prescribed.
The prognosis for congenital muscular torticollis is very good, 90% of the children respond to conservative treatment, and the condition is usually resolved in most children by 1,5 to 2 years of age. Once the SCM muscle is treated and released, the asymmetry of head and face is corrected overtime.
Dr. D Muller, BSc, DC, Webster Certified, ICPA Member
*Special thanks to Dr. Zylich and his amazing lectures at CMCC.