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Innate muscular torticum
Last reviewed: 23.04.2024
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Different in the clinic, etiology and pathogenesis of neck deformity, united by a leading symptom - an incorrect position of the head (its deviation from the midline of the body), are known under the general name "torticolis" (torticolis, sphege obstipum). Symptoms of torticollis, treatment tactics and prognosis but largely depend on the cause of the disease, the degree of interest in the skull's skull structures, the functional state of the muscles, soft tissues, and the nervous system.
Congenital muscular torticollis - persistent shortening of the sternocleidomastoid muscle, accompanied by the inclination of the head and restriction of mobility in the cervical spine, and in severe cases deformation of the skull, spine, and shoulder-blades.
Causes of the congenital torticollis
The causes and pathogenesis of torticollis have not been fully established to date. Several theories have been proposed, which explain the cause of the development of congenital muscular torticollis:
- traumatic injury at birth;
- ischemic necrosis of the muscle;
- infectious myositis;
- oblique long position of the head in the uterine cavity.
Morphological studies conducted by numerous authors and studying the features of the clinical course of congenital muscular torticollis do not allow choosing any of the listed theories.
Considering that a third of patients with congenital muscular torticollis are diagnosed with congenital developmental anomalies (congenital hip dislocations, abnormalities in the development of the feet, brushes, organ of vision, etc.), and more than half of the mothers have an anamnesis indicating a pathological course of pregnancy and complications during childbirth, S.T. Zatsepin suggests treating this pathology as a shortening of the sternocleidomastoid muscle, which developed as a result of her congenital underdevelopment, as well as her trauma during childbirth and in the postpartum period.
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Symptoms of the congenital torticollis
Depending on when the symptoms of torticollis appear, it is customary to distinguish between its two forms: early and late.
Early congenital muscular torticollis is detected only in 4,5-14% of patients, already from birth or in the first days of life, a shortening of the sternocleidomastoid muscle, an oblique position of the head, asymmetry of the face and skull.
In the late form, which is noted in the overwhelming majority of patients, the clinical signs of deformation increase gradually. At the end of the 2nd or the beginning of the 3rd week of life, a thick consistency thickens in the middle or middle-lower third of the muscle. Thickening and thickening of the muscle progress and reach a maximum value by 4-6 weeks. Dimensions of the thickening can range from 1 to 2-3 cm and diameter. In some cases, the muscle acquires the appearance of a lightly displaced spindle. Skin over the condensed part of the muscle is not changed, signs of inflammation are absent. With the appearance of a thickening, the inclination of the head becomes noticeable and its turn in the opposite direction, limiting the movement of the head (attempting to lift the child's head to the middle position causes anxiety and crying). In 11-20% of patients, as the muscle thickens, its fibrous degeneration occurs. The muscle becomes less tensile and elastic, lags behind in growth from the muscle of the opposite side. When the child is visually examined from the front, the asymmetry of the neck is noticeable, the head is tilted toward the altered muscle and turned in the opposite direction, and with a pronounced shape, it tilts forward.
When viewed from behind, asymmetry of the neck, tilt and turn of the head, higher standing of the shoulder and shoulder blades on the side of the altered muscle are noticeable. When palpation note the tension of one or all legs of the sternocleidomastoid muscle, their thinning, increased density. The skin above the strained muscle is raised in the form of a "curtain". Develop and aggravate secondary deformities of the face, skull, spine, and shoulder-straps. The severity of the formed secondary deformations is directly related to the degree of shortening of the muscle and the age of the patient. With long-term curvature, a severe asymmetry of the skull develops - the so-called "scoliosis of the skull". Half of the skull from the side of the altered muscle is flattened, its height is less from the side of the altered muscle than on the unchanged half. Eyes, eyebrows, are located lower than on the unchanged side. Attempts to maintain the vertical position of the head contribute to the uplift of the shoulder girdle, deformation of the clavicle, lateral movement of the head towards the defeat of the shortened muscle. In severe cases, scoliosis develops in the cervical and upper thoracic parts of the spine with a bulge in the direction of the unchanged muscle. In the future, a compensatory arc is formed in the lumbar spine,
Congenital muscular torticollis with a shortening of both sternocleidomastoid muscles are extremely rare. In these patients, secondary deformities of the face do not develop, note a sharp limitation of the amplitude of the movement of the head and curvature of the spine in the sagittal plane. On both sides, the sternum, shortened, dense and thinned legs of the sternocleidomastoid muscle are determined.
Krivosheya with congenital pterygoid folds of the neck
The torticollis of this form develops due to the uneven arrangement of the cervical folds, this is a rare form of the pterygium neck (pterygium salt).
Symptoms of torticollis
A characteristic clinical symptom of the disease is the presence of skin folds. In the form of a triangle extending from the side surfaces of the head to the shoulder, and a short neck. There are abnormalities in the development of muscles and spine.
Treatment of torticollis
Treatment of torticollis of this form is carried out with the help of plasty of skin folds with counter triangular flaps, which allows obtaining a good cosmetic result.
Krivosheya with anomalies of development of the 1st cervical vertebra
Rarely occurring anomalies in the development of the 1st cervical vertebra can lead to the development of severe progressive torticollis.
Symptoms of torticollis
The main symptoms of torticollis of this form are the inclination of the head and its rotation, expressed to varying degrees, skull and face asymmetry. In young children, the head can be passively withdrawn into the average physiological position, with age the deformation progresses, acquires a fixed character and is not passively eliminated.
Diagnosis of torticollis
The thoracic-clavicular-mastoid muscles are not changed, sometimes they mark muscle hypoplasia on the posterior surface of the neck. Characteristic neurological symptoms: headache, dizziness, symptoms of pyramidal insufficiency, the phenomenon of compression of the brain at the level of the occipital opening.
Radiographs of the cervical spine and the two upper vertebrae, performed "through the mouth," make it possible to clarify the diagnosis.
Treatment of torticollis
Conservative treatment of torticollis of this form consists in immobilization for the period of sleep by the collar of Shantz with the inclination of the head in the opposite direction, massage and electrostimulation of the neck muscles from the opposite side.
With progressive forms of the disease, posterior spondylodesis of the superior cervical spine is shown. In severe cases, the correction of the deformity is preliminarily carried out by the gallo-apparatus, and the second stage is performed by the occipitospondylodesis of the three or four upper vertebrae with bone autologous or allo transplants.
Forms
The torticollis with congenital wedge-shaped vertebrae and semi-vertebrae is usually diagnosed at birth.
Symptoms of torticollis
Attention is drawn to the oblique position of the head, the asymmetry of the face, the restriction of movements in the cervical spine. With passive correction of the abnormal position of the head, there is no change on the part of the muscles. With age, the curvature usually progresses to a severe degree.
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Treatment of torticollis
Treatment of torticollis of this form is only conservative: passive correction and keeping the head upright with the collar of Shantz.
Diagnostics of the congenital torticollis
Differential diagnosis of torticollis is performed with aplasia of the sternocleidomastoid muscle, anomalies in the development of the trapezius muscle and the muscle that lifts the scapula, the bony forms of torticollum acquired by torticollis (with Trizel's disease, extensive neck skin lesions, sternocleidomastoid muscle inflammation, trauma and diseases of the cervical vertebrae, paralytic crooked, compensatory torticollis with diseases of the inner ear and eyes, idiopathic spasmodic torticollis).
Treatment of the congenital torticollis
Conservative treatment of muscular torticollis is the main method of treatment of this disease. Beginning with the detection of symptoms, curved, consistent and complex treatment allows the recovery of the shape and function of the affected muscle in 74-82% of patients.
Redressing exercises are aimed at restoring the length of the sternocleidomastoid muscle. When carrying out exercises, it is necessary to avoid gross violent movements, since additional trauma aggravates pathological changes in muscle tissue. For a passive correction of the altered muscle, the child is laid in a healthy half of the neck to the wall, and changed to the light.
Neck massage is aimed at improving the blood supply of the altered muscle and increasing the tone of a healthy overstretched muscle. To maintain the achieved correction after the massage and dressing exercises recommend to keep the head with a soft collar of Shantz.
Physiotherapeutic treatment of torticollis is performed in order to improve blood supply to the affected muscle, resorption of scar tissue. Since the detection of torticollis, thermal procedures have been prescribed: paraffin baths, salliks, 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;
- relapse of torticollis after surgical treatment.
Currently, the most common technique, widely used to eliminate congenital torticollis, is the open intersection of the legs of the altered muscle and its lower part (the Mikulich-Zatsepin operation).
Operation technique. The patient is placed on his back, a tight cushion 7 cm high is placed under the foreleg, the head is turned back and turned and the opposite side is turned. The horizontal cut of the skin is 1-2 cm proximal to the clavicle in the projection of the legs of the shortened muscle. Split soft tissue. Under the modified legs of the muscle, the Cocker's probe is inserted, the legs are alternately crossed over it. If necessary cut the strands, additional legs, posterior leaf of the superficial fascia of the neck. Dissect the superficial fascia in the lateral triangle of the neck. The wound is sutured, in rare cases, when the contracture of the altered muscle is removed, as recommended by Zatsepin, by crossing it in the lower part fails, the operation is complemented by the intersection of the sternocleidomastoid muscle in the upper part in more detail than the mastoid process along the Lange.
Postoperative treatment of torticollis
The main tasks of the postoperative period are the preservation of the achieved hypercorrection of the head and neck, the prevention of the development of scars, the restoration of the tone of the overstretched muscles of the healthy half of the neck. Development of the correct stereotype of the position of the head.
To prevent the recurrence of torticollis and prevent vegetative-vascular disorders, a functional technique for managing patients and the postoperative period is necessary. The first 2-3 days after the operation, the head in the hypercorrection position is fixed with a soft bandage of the Shantz type. On 2-3 days after the operation, in the position of the maximum possible inclination of the head towards the unaffected muscle, a thoraco-cervical gypsum bandage is applied. On the 4th-5th day after the operation, exercises are prescribed to increase the inclination of the head toward the unchanged muscle. The increased inclination of the head achieved during the exercise is fixed by the pelots brought under the edge of the bandage on the side of the affected muscle.
On the 12-14th day, electrophoresis with hyaluronidase is prescribed for the postoperative scar area. The period of immobilization with a plaster bandage depends on the severity of strain and the patient's age, on average it is 4-6 weeks. Next, the plaster bandage is replaced with the Shantz collar (asymmetric pattern) and conservative treatment of torticollis is carried out, including massage (relaxing on the side of the lesion, 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 treatment and paraffinic applications are indicated. The task of treatment at this stage is to increase the amplitude of the head movements, restore muscle tone and develop new motor skills.
Disease of torticollis requires dispensary observation, which is carried out during the first year of life 1 time in 2 months, the second - 1 time in 4 months. After surgical treatment during the first year, the examination is performed once every 3 months. After conservative and surgical treatment of torticollis is over, children are subject to follow-up until the end of bone growth.