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Torticollis
 A torticollis can occur at different ages and can be the result of diffferent patholgies ; mostly it is seen in adults as the result of a big internal derangement.
There are specific reduction patterns.
(Part I, p268-270 ; Part II, p66)
Torticollis (2)
Congenital torticollis
Painless contracture of the sternocleidomastoid muscle : the neck is fixed in side flexion toward one side and rotation towards the opposite side.
There should be an early treatment by muscle stretching and maintaining the neck in the overcorrected position.
In neglected cases with permanent postural deformity and facial asymmetry : surgery (adolescent).
Acute torticollis in children
* Sudden, almost painless, limitation in a child between 5-10 y. old, usually after a sore throat. The resisted neck tests are slightly painful.
The cause is probably a swollen gland under the sternocleidomastoid muscle, which causes reflex spasm. There is a spontaneous recovery in about two weeks.
* Afebrile otitis media and retropharyngeal abscess : neck pain ; the neck is kept immobile by muscle spasm, with limitation of movement in every direction.
Acute torticollis in adults and adolescents
* This is usually caused by a disc protrusion ; there is a lateral deviation in pure side flexion without rotation.
* Differential diagnosis :
Pfeiffer's disease
- a glandular inflammation caused by a virus, lasting a few weeks
- slight ache and a stiff neck
- a full rather than a partial articular pattern
- the end-feel is normal
- the resisted neck tests hurt more than the passive tests.
Meningitis
- acute neck- and headache with nausea
- perhaps vomiting and fever
- deviation in extension
- clear dural symptoms and signs : SLR ++ !
Spasmodic torticollis
* Inspection provides the diagnosis : sudden twist of the head, always in the same direction, by an apparently irresistable active movement.
It is more a social inconvenience than a real pain problem.
* The patient, or the examiner, can prevent movement by manual pressure or, when the head is already twisted, can bring it back in the neutral position. As in neurological hypertonus, a strong resistance is felt at first but then the muscles gradually give.
* There exist several hypotheses to explain this disorder : psychogenic, encephalitis, extra-
pyramidal lesion.
* Treatment :
- to teach the patient to move the head in the opposite direction when he feels the start
of the involuntary rotation, so that the head does not move
- hypnotism
- surgery (denervation of the spinal accessory nerve).
Spastic torticollis
* This is not an intermittent rotation of the head as in the previous case, but a permanent fixation of the head in side flexion and rotation towards the same side.
* The patient has great difficulty in bringing the head back to the neutral position and, as soon as he relaxes, the head twists again. In supine lying, the muscle spasm abates and the patient can move freely.
* Treatment : surgery.
Hysterical torticollis
* This is easy to detect : we find the wrong antalgic posture, indicating that the lesion is not organic (e.g. shrugging one shoulder and flexing the neck towards that side).
* The muscle contraction can be overcome by sustained, persuasive, passive pressure.
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