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Congenital muscular torticollis.
Last reviewed: 05.07.2025
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Neck deformations of various clinical, etiological and pathogenesis types, united by the leading symptom - incorrect position of the head (its deviation from the midline of the body), are known under the general name "torticollis" (torticollis, sphzre obstipum). Symptoms of torticollis, treatment tactics and prognosis largely depend on the cause of the disease, the degree of involvement of the bone structures of the skull, the functional state of the muscles, soft tissues, and the nervous system.
Congenital muscular torticollis is a persistent shortening of the sternocleidomastoid muscle, accompanied by a tilt of the head and limited mobility in the cervical spine, and in severe cases, deformation of the skull, spine, and shoulders.
Causes congenital torticollis
The causes and pathogenesis of torticollis have not yet been fully established. Several theories have been proposed to explain the cause of congenital muscular torticollis:
- traumatic birth injury;
- ischemic muscle necrosis;
- infectious myositis;
- prolonged tilted position of the head in the uterine cavity.
Morphological studies and the study of the clinical features of congenital muscular torticollis conducted by numerous authors do not allow preference to be given to any of the listed theories.
Considering that a third of patients with congenital muscular torticollis have congenital developmental anomalies (congenital hip dislocations, developmental anomalies of the feet, hands, visual organ, etc.), and more than half of mothers have a history of pathological pregnancy and complications during childbirth, S.T. Zatsepin suggests considering this pathology as a shortening of the sternocleidomastoid muscle, which developed as a result of its congenital underdevelopment, as well as trauma to it during childbirth and in the postpartum period.
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Symptoms congenital torticollis
Depending on when the symptoms of torticollis appear, it is customary to distinguish two of its forms: early and late.
Early congenital muscular torticollis is detected in only 4.5-14% of patients; already from birth or in the first days of life, shortening of the sternocleidomastoid muscle, tilted position of the head, and asymmetry of the face and skull are detected.
In the late form, observed in the vast majority of patients, clinical signs of deformation increase gradually. At the end of the 2nd or beginning of the 3rd week of life, patients develop a dense thickening in the middle or middle-lower third of the muscle. Thickening and compaction of the muscle progress and reach a maximum by 4-6 weeks. The size of the thickening can vary from 1 to 2-3 cm in diameter. In some cases, the muscle takes the form of a light, displaceable spindle. The skin over the compacted part of the muscle is unchanged, there are no signs of inflammation. With the appearance of thickening, a tilt of the head and its rotation to the opposite side, limitation of head movement become noticeable (an attempt to bring the child's head to the middle position causes anxiety and crying). In 11-20% of patients, as the thickening of the muscle decreases, its fibrous degeneration occurs. The muscle becomes less extensible and elastic, lags in growth from the muscle on the opposite side. When examining the child from the front, asymmetry of the neck is noticeable, the head is tilted towards the altered muscle and turned in the opposite direction, and in a pronounced form it tilts forward.
When examined from behind, neck asymmetry, head tilt and rotation, higher position of the shoulder girdle and scapula on the side of the altered muscle are noticeable. Palpation reveals tension of one or all legs of the sternocleidomastoid muscle, their thinning, increased density. The skin above the tense muscle is raised in the form of a "wing". Secondary deformations of the face, skull, spine, and shoulder girdle develop and worsen. The severity of the secondary deformations that have formed is directly dependent on the degree of muscle shortening and the age of the patient. With long-standing torticollis, severe asymmetry of the skull develops - the so-called "scoliosis of the skull". Half of the skull on the side of the altered muscle is flattened, its height is less on the side of the altered muscle than on the unchanged half. The eyes and eyebrows are located lower than on the unchanged side. Attempts to maintain a vertical head position contribute to the raising of the shoulder girdle, deformation of the clavicle, lateral displacement of the head towards the affected side of the shortened muscle. In severe cases, scoliosis develops in the cervical and upper thoracic spine with a convexity towards the unchanged muscle. Subsequently, a compensatory arc is formed in the lumbar spine,
Congenital muscular torticollis with shortening of both sternocleidomastoid muscles is extremely rare. In these patients, secondary facial deformities do not develop, a sharp limitation of the amplitude of head movement and curvature of the spine in the sagittal plane are noted. On both sides, tense, shortened, dense and thinned legs of the sternocleidomastoid muscle are determined.
Torticollis with congenital pterygoid folds of the neck
Torticollis of this form develops due to the uneven arrangement of the cervical folds; this is a rare form of pterygium coli.
Symptoms of torticollis
The characteristic clinical symptom of the disease is the presence of B-shaped skin folds extending from the lateral surfaces of the head to the shoulders, and a short neck. There are anomalies in the development of muscles and the spine.
Treatment of torticollis
Treatment of this form of torticollis is carried out using plastic surgery of skin folds with counter triangular flaps, which allows for a good cosmetic result.
Torticollis in developmental anomalies of the 1st cervical vertebra
Rare developmental anomalies of the 1st cervical vertebra can lead to the development of severe progressive torticollis.
Symptoms of torticollis
The main symptoms of this form of torticollis are head tilt and rotation, expressed to varying degrees, asymmetry of the skull and face. In young children, the head can be passively brought to the average physiological position; with age, the deformation progresses, becomes fixed and cannot be passively eliminated.
Diagnosis of torticollis
The sternocleidomastoid muscles are not changed, sometimes hypoplasia of the muscles along the back of the neck is noted. Neurological symptoms are characteristic: headache, dizziness, symptoms of pyramidal insufficiency, phenomena of brain compression at the level of the occipital foramen.
X-rays of the cervical spine and the two upper vertebrae, taken "through the mouth", help to clarify the diagnosis.
Treatment of torticollis
Conservative treatment of this form of torticollis consists of immobilization during sleep with a Shantz collar with the head tilted to the opposite side, massage and electrical stimulation of the neck muscles on the opposite side.
In progressive forms of the disease, posterior spondylodesis of the upper cervical spine is indicated. In severe cases, deformation correction is first performed with a gallo apparatus, and the second stage is occipitospondylodesis of three to four upper vertebrae with bone auto- or allografts.
Forms
Torticollis in congenital wedge-shaped vertebrae and hemivertebrae is usually diagnosed at birth.
Symptoms of torticollis
The tilted position of the head, facial asymmetry, and limited movement in the cervical spine are noteworthy. With passive correction of the abnormal position of the head, there are no changes in the muscles. With age, the curvature usually progresses to a severe degree.
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Treatment of torticollis
Treatment of this form of torticollis is only conservative: passive correction and holding the head in a vertical position with a Shantz collar.
Diagnostics congenital torticollis
Differential diagnostics of torticollis is carried out with aplasia of the sternocleidomastoid muscle, developmental anomalies of the trapezius muscle and the muscle that lifts the scapula, bone forms of torticollis, acquired torticollis (with Triesel's disease, extensive damage to the skin of the neck, inflammatory processes of the sternocleidomastoid muscle, injuries and diseases of the cervical vertebrae, paralytic torticollis, compensatory torticollis in diseases of the inner ear and eyes, idiopathic spasmodic torticollis).
Treatment congenital torticollis
Conservative treatment of muscular torticollis is the main method of treating this disease. Started from the moment of detection of symptoms of torticollis, consistent and complex treatment allows to restore the shape and functions of the affected muscle in 74-82% of patients.
Redressing exercises are aimed at restoring the length of the sternocleidomastoid muscle. When performing exercises, it is necessary to avoid rough, violent movements, since additional trauma aggravates pathological changes in muscle tissue. For passive correction of the altered muscle, the child is placed with the healthy half of the neck against the wall, and the altered half - towards the light.
Neck massage is aimed at improving the blood supply to the affected muscle and increasing the tone of the healthy overstretched muscle. To maintain the achieved correction after the massage and redressing exercises, it is recommended to hold the head with a soft Shantz collar.
Physiotherapeutic treatment of torticollis is carried out to improve the blood supply to the affected muscle, resorption of scar tissue. From the moment of detection of torticollis, thermal procedures are prescribed: paraffin applications, sollux, UHF. At the age of 6-8 weeks, electrophoresis with potassium iodide, hyaluronidase is prescribed.
Surgical treatment of torticollis
Indications for surgical treatment of torticollis:
- torticollis that does not respond to treatment during the first 2 years of a child’s life;
- recurrence of torticollis after surgical treatment.
Currently, the most common technique, widely used to eliminate congenital torticollis, is open intersection of the legs of the altered muscle and its lower part (Mikulich-Zatsepin operation).
Technique of the operation. The patient is placed on his back, a dense pillow 7 cm high is placed under the shoulder, the head is tilted back and turned to the side opposite to the operation. A horizontal skin incision is made 1-2 cm proximal to the clavicle in the projection of the legs of the shortened muscle. Soft tissues are dissected layer by layer. A Cocker probe is placed under the altered legs of the muscle, and the legs are crossed one by one above it. If necessary, the cords, additional legs, and posterior leaflet of the superficial fascia of the neck are dissected. The superficial fascia is dissected in the lateral triangle of the neck. The wound is sutured; in rare cases, when it is not possible to eliminate the contracture of the altered muscle, as recommended by Zatsepin, by crossing it in the lower section, the operation is supplemented by crossing the sternocleidomastoid muscle in the upper section, in more detail the mastoid process according to Lange.
Postoperative treatment of torticollis
The main tasks of the postoperative period are to maintain the achieved hypercorrection of the head and neck, prevent the development of scars, restore the tone of the overstretched muscles of the healthy half of the neck. Develop the correct stereotype of the head position.
To prevent recurrence of torticollis and prevent vegetative-vascular disorders, a functional method of patient management in the postoperative period is necessary. The first 2-3 days after surgery, the head is fixed in the hypercorrected position with a soft bandage of the Shantz type. On the 2nd-3rd day after surgery, a thoracocervical plaster cast is applied in the position of the maximum possible tilt of the head toward the unaffected muscle. On the 4th-5th day after surgery, exercises are prescribed aimed at increasing the tilt of the head toward the unchanged muscle. The increased tilt of the head achieved during the exercises is fixed with pads placed under the edge of the bandage on the side of the affected muscle.
On the 12th-14th day, electrophoresis with hyaluronidase is prescribed to the area of the postoperative scar. The period of immobilization with a plaster cast depends on the severity of the deformation and the age of the patient, on average it is 4-6 weeks. Then the plaster cast is replaced with a Shants collar (asymmetric pattern) and conservative treatment of torticollis is carried out, including massage (relaxing - on the affected side, toning - on the healthy side), thermal procedures on the affected muscle area, therapeutic exercise. To prevent the development of scars, physiotherapy is recommended: electrophoresis with potassium iodide, hyaluronidase. Mud therapy and paraffin applications are indicated. The goal of treatment at this stage is to increase the amplitude of head movements, restore muscle tone and develop new motor skills.
The disease torticollis requires dispensary observation, which is carried out during the first year of life once every 2 months, the second - once every 4 months. After surgical treatment during the first year, an examination is carried out once every 3 months. After conservative and surgical treatment of torticollis is completed, children are subject to dispensary observation until the end of bone growth.