Spine Paed

Paediatric torticollis

Congenital and acquired torticollis: types, examination, stretching and surgical release.

14 questions 1 source pages

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Q1What are the causes of torticollis?▸

Congenital (usually painless): CMT, Klippel-Feil
Acquired osseous (usually painful): AARI (trauma, tumour, infection, odontoid hypoplasia in Down's/achondroplasia, JRA/RA)
Non-osseous: ENT, eye (squint), CNS (Arnold Chiari), postural (usually painless), neck burns

Q2Describe the Fielding CT classification of atlantoaxial rotatory instability.▸

1: Unilateral subluxation with intact transverse ligament (dens is the pivot)
2: Unilateral anterior subluxation 3-5mm (opposite facet acts as pivot)
3: Bilateral anterior subluxation >5mm
4: Posterior subluxation

Q3How does management of AARI depend on timing?▸

<1 week: soft neck collar, analgesics
1-4 weeks: Halter traction (2-3kg), 1hr off/3hr on cycle, until reduced, then SOMI 4wk
>4 weeks: halo traction 4 weeks, high chance of failure then OT fusion C1-2
Other OT indications: irreducible >3 months, neurological deficit, recurrent

Q4What are the indications and types of surgery for congenital muscular torticollis?▸

Presentation >1 year
>15 degree head tilt/lag with tumour
Failed conservative management x6 months
Unipolar release: sternal head <3yo, sternal + clavicular head 3-6yo
Bipolar release >6-10 years (alternative Z plasty)
Dangers: greater auricular nerve (surface), CNXI (deep), facial nerve (anterior)

Q5What are the dangers of bipolar release?▸

Q6What is the evidence for conservative management of CMT (Cheng 2001)?▸

800 patients with onset <1 year
95% good response to physiotherapy (flexion, rotation, tilting), mean follow-up 4.5 years
Poor prognostic factors: 15deg rotation deficit, SCM tumour, late presentation (present >1yo) (also stated as >15 degree rotation deficit, SCM tumour, late presentation >1 year)

Q7What are the clinical features of the torticollis patient shown?▸

Q8What history is important in torticollis?▸

Perinatal history: oligohydramnios, breech, first born; known congenital conditions (e.g. Klippel-Feil)
Pain, onset of symptoms, progression, trauma, previous treatment or H&N problems
Hearing or optical impairment, recent URI symptoms, functional impairment

Q9What examination findings should be sought in torticollis?▸

Plagiocephaly, low hairline, scapula (KF syndrome); facial dysmorphism/asymmetry
SCM spasm, tumour, cervical LN
Rotation and tilt lag 15 degrees; squint, hearing; neuro exam
If newborn, look for other packaging disorders

Q10What investigations are used in torticollis?▸

Bloods: CBC, inflammatory markers
Xray: lateral mass asymmetry on open mouth view, lateral for ADI, trapezoidal anterior C1 shadow, oval posterior arch sign; exclude fracture or congenital abnormalities
Dynamic CT is gold standard for AARI (book if failed initial conservative management), 3 sets to look for fixed relationship between C1 and C2
+/- contrast to rule out retropharyngeal abscess if raised inflammatory markers; +/- MRI to exclude infection or tumour

Q11What is Grisel's syndrome?▸

Drainage of inflammatory mediators through the pharyngovertebral vein to the periodontoid plexus
Leads to ligamentous laxity

Q12What is the pathophysiology of congenital muscular torticollis?▸

Q13Describe the bipolar release technique.▸

2cm incision below the mastoid, strip attachment from bone
2cm incision above the sterno-clavicular junction, incise platysma, cut both heads of SCM with the deep fascia
Postop: intensive stretching for 3 months; >2yo add adjustable torticollis brace for 3 months

Q14Why are children more prone to atlantoaxial rotatory instability?▸

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