The influence of age on the results of open sternomastoid tenotomy in muscular torticollis.

The ideal age for surgery for muscular torticollis, the complications and results of open sternomastoid tenotomy were investigated in 60 patients operated on at different age-groups. Under the age of 1, tethering of the scar to the deeper structures was common and was mainly responsible for the lower percentage of good results (42.1 per cent). In the age-group 1 to 4 years, satisfactory correction of facial asymmetry, head and tilt and limitation of neck movements, was achieved with overall 66.7 per cent good results. However, in patients above the age of 5, not only was the correction of the secondary deformities uncertain but the late complications like loss of sternomastoid column, disfiguring scar and presence of lateral bands were more common. Only 33.3 per cent had good results in the 5 to 8 year age-group and none in the above 9 years age-group. The best time for surgery in muscular torticollis is in the patient between 1 and 4 years of age.     

Clinical determinants of the outcome of manual stretching in the treatment of congenital muscular torticollis in infants. A prospective study of eight hundred and twenty-one cases

BACKGROUND: The natural history of congenital muscular torticollis and the outcome of different treatment modalities have been poorly investigated, and the results of treatment have varied considerably. METHODS: The main objective of this prospective study was to evaluate the outcomes of 821 consecutive patients with congenital muscular torticollis who were first seen when they were less than one year old, were treated with a standardized program of manual stretching, and were followed for a mean of 4.5 years. Before treatment, the patients were classified into one of three clinical groups: (1) palpable sternomastoid tumor, (2) muscular torticollis (thickening and tightness of the sternocleidomastoid muscle), and (3) postural torticollis (torticollis but no tightness or tumor). RESULTS: Of the 821 patients, 452 (55%) had a sternomastoid tumor; 276 (34%), muscular torticollis; and ninety-three (11%), postural torticollis. Multivariate analysis of the outcomes showed that (1) the duration of treatment was significantly associated with the clinical group (p < 0.0001), a passive rotation deficit of the neck (p < 0.0001), involvement of the right side (p < 0.0001), difficulties with the birth (p < 0.009), and age at presentation (p < 0.0001); (2) the overall final assessment score was associated with the rotation deficit (p = 0.02), age at presentation (p = 0.014), and duration of treatment (p < 0.0001); and (3) subsequent surgical treatment was required by 8% (thirty-four) of the 452 patients in the sternomastoid tumor group compared with 3% (eight) of the 276 patients in the muscular torticollis group and 0% (none) of the ninety-three patients in the postural torticollis group. CONCLUSIONS: This large prospective study demonstrated that controlled manual stretching is safe and effective in the treatment of congenital muscular torticollis when a patient is seen before the age of one year. The most important factors that predict the outcome of manual stretching are the clinical group, the initial deficit in rotation of the neck, and the age of the patient at presentation. Surgical treatment is indicated when a patient has undergone at least six months of controlled manual stretching and has residual head tilt, deficits of passive rotation and lateral bending of the neck of >15 degrees, a tight muscular band or tumor, and a poor outcome according to our special assessment chart.     

胸锁乳突肌下端切断术治疗肌性斜颈

目的：本文报告54例肌性斜颈手术治疗经验。方法：对54例肌性斜颈行胸锁乳突肌下端切断术治疗。结果：疗效优者达85．2％,无一例并发症。结论：胸锁乳突肌下端切断术,操作简单、安全,是一种值得信赖的治疗方法。     

Outcome of treatment for congenital muscular torticollis: a study on ages for treatment, treatment methods, and postoperative therapy

The objective of this study is to review the clinical course after surgical treatment of congenital muscular torticollis and investigate the problems. Based on the treatment strategy of our institution for patients with congenital muscular torticollis, we treated young children with unipolar tenotomy of the sternocleidomastoid muscle, with postoperative use of our original brace, and school age or older children with bipolar tenotomy of the sternocleidomastoid muscle and postoperative use of a simple immobilizing brace, mainly a Philadelphia collar. This study included nine patients who underwent unipolar or bipolar tenotomy of the sternocleidomastoid muscle in our department between November 1990 and April 2006. Of these, four were boys and five were girls. Seven had right and two had left torticollis. The age at surgery ranged from 1 year 6 months to 24 years. Five underwent unipolar tenotomy and four underwent bipolar tenotomy. The study period from the first visit to the present ranged from 1 year 6 months to 18 years 9 months. The evaluation was based on the presence of recurrence and the assessment criteria described by Tanabe (Arch Orthop Trauma Surg 122:489–493, 2002). Three of five patients treated with unipolar tenotomy had a second surgery due to recurrence. None of those treated with bipolar tenotomy experienced recurrence. According to Tanabe’s criteria, among the five patients treated with unipolar tenotomy, two were graded as excellent, two fair, and one poor. And among the four treated with bipolar tenotomy, three were graded as excellent and one fair. Although this study included only nine patients treated and followed-up, more than half of those treated with unipolar tenotomy of the sternocleidomastoid muscle experienced recurrence requiring further surgery. Among those treated with bipolar tenotomy, the outcomes were generally good, and no recurrence was observed. Unipolar tenotomy of the sternocleidomastoid muscle in young children requires special attention with regard to recurrence. We decided to conduct bipolar tenotomy in young children and investigate future outcomes.     

Tenotomy and postoperative brace treatment for muscular torticollis

A postoperative corrective brace for congenital muscular torticollis is introduced and the results and indications for its use are presented. Thirty-three of 55 patients who underwent open tenotomy of the sternocleidomastoid muscle with application of the brace following surgery were evaluated in follow-up. Tenotomy was performed at the sternoclavicular origin of the muscle. The mean age at operation was six years; the mean follow-up period was seven years. The results were good in 21 patients (64%), fair in seven (21%), and poor in five (15%). Facial asymmetry remained in all patients over the age of ten who underwent operation. Alopecia, one of the complications of the brace, was found only in patients under age five. This combined treatment with tenotomy and postoperative brace is considered best indicated for patients between six and ten years of age.     

Surgical correction of muscular torticollis in the older child

Thirty-three children between 6 and 16 years of age who were treated for muscular torticollis were followed up from 2 to 10.5 years after surgery. All patients had a distal open release of the sternocleidomastoid muscle. Preoperative and postoperative assessment by a rigid scoring system showed that all patients improved in terms of function as well as cosmesis. Children less than 12 years of age showed the most improvement, with 71% excellent and good results. Late release of the sternomastoid in muscular torticollis can, therefore, give acceptable results.     

The clinical presentation and outcome of treatment of congenital muscular torticollis in infants--a study of 1,086 cases

BACKGROUND/PURPOSE: The main objectives of this study were to define the clinical patterns and characteristics of congenital muscular torticollis (CMT) presented in the first year of life and to study the outcome of different treatment methods. METHODS: This is a prospective study of all CMT patients seen in 1 center over a 12-year period with uniform recording system, assessment methods, and treatment protocol. RESULTS: From a total of 1,086 CMT infants, 3 clinical subgroups of sternomastoid tumor (SMT; 42.7%), muscular torticollis (MT; 30.6%), and postural torticollis (POST; 22.1%) were identified. The SMT group was found to present earlier within the first 3 months and was associated with higher incidence of breech presentation (19.5%), difficult labor (56%), and hip dysplasia (6.81%). Severity of limitation of passive neck rotation range (ROTGp) was found to correlate significantly with the presence of SMT, bigger tumor size, hip dysplasia, degree of head tilt, and craniofacial asymmetry. CONCLUSIONS: A total of 24.5% of the patients with initial deficits of passive rotation of less than 10 degrees showed excellent and good outcome with active home positioning and stimulation program. The remaining cases with rotation deficits of over 10 degrees and treated with manual stretching program showed an overall excellent to good results in 91.1% with 5.1% requiring subsequent surgical treatment. The most important prognostic factors for the necessity of surgical treatment were the clinical subgroup, the ROTGp, and the age at presentation (P < .001).     

Use of a rugby helmet brace for postoperative treatment of muscular torticollis

Prior to 1992, our postoperative management for congenital muscular torticollis consisted of either plaster cast immobilization or no immobilization, depending on the patient's age and the degree of contracture. However, some patients required further surgery and developed complications. In 1992, we produced rugby helmet braces for postoperative management. The purpose of this study was to compare the clinical results of the previous postoperative management with the results achieved using rugby helmet braces. Twenty-five children aged younger than 6 years underwent caudal partial resection of the sternocleidomastoid muscle. Twelve children aged 6 years and older underwent cranial tenotomy. These 37 patients were divided into 2 groups: no immobilization or plaster immobilization (group A; n=19) and rugby helmet braces (group B; n=18). Canale's method was used for evaluation of clinical results. In group A, the results were good in 12 patients, fair in 4, and poor in 3, whereas all 18 patients in group B had good results. Two patients in group A required further surgery, and complications were observed in 5 patients. In group B, alopecia areata was observed in 1 patient.The rugby helmet brace is easy to put on and remove, providing good retention and allowing for physiotherapy. It provides a useful method of postoperative management for congenital muscular torticollis.     

Outcome of surgical treatment of congenital muscular torticollis.

Eighty-four patients with congenital muscular torticollis were treated surgically in a 10-year period with a mean followup of 5 years (range, 2-13 years). All patients were classified into subgroups according to the type of congenital torticollis, the limitation of passive rotation of the neck, and other parameters, including head tilt and craniofacial asymmetry. Twenty-two (26.2%) patients underwent surgery before they were 1 year of age, 22.6% were between 1 and 3 years of age, 38.1% were between 3 and 10 years, and 13.1% were older than 10 years. Postoperative management included physiotherapy for 3 to 4 months and the application of a multiply adjustable torticollis brace for 10 weeks in children older than 2 years of age. Loss of the sternomastoid column was found in 82.6%, poor scar in 2.4%, lateral band in 47.2% and 1.2% required a second operation. The final overall score showed excellent results in 88.1%, good results in 8.3%, and fair to poor results in 3.6%. The most important factor affecting the overall result and outcome was found to be the age of the patient at the time of operation. However, this series also showed that for patients who were 10 years or older at the time of surgery, 63.6% had excellent results and 81.8% had good to excellent results, indicating the benefit of surgery even in the late cases.     

Congenital muscular torticollis and sternomastoid tumor: results of nonoperative treatment

BACKGROUND: Congenital muscular torticollis (CMT) and sternocleidomastoid tumor of infancy remains to be one of the mysteries of pediatric surgery. Its cause is still debated and its management is controversial. METHODS: Fifty-seven infants and children treated consecutively for sternomastoid tumors and CMT over a 5-year period (1992 to 1997) at the Pediatric Surgery Clinic of Social Security Council Ankara Children's Hospital are reviewed. The obstetric history was recorded in 48 patients. A lump in the neck, head tilt, plagiocephaly, and facial asymmetry were reasons for refferal correlating with the age of admission. Under 18 months of age passive and active stretching exercises (PSE and ASE) were initiated in all of the cases. RESULTS: In 28 children under the age of 3 months the outcome was excellent with none needing surgery. Successively 25% of the 3- to 6-month-old infants, 70% of the 6- to 18-month-old children, and 100% of all the older children required surgery. Spontaneous normal vaginal delivery was recorded in 23 of 48 (48%) cases, whereas vaginal vacuum extraction in four cases, vaginal forceps in six, vaginal as breech in two, and caesarean section in 11 was noted. CONCLUSIONS: It was concluded that PSE and ASE are highly effective for the treatment of congenital muscular torticollis. The success rate of conservative treatment is primarily dependent on the patients' age at the initiation of exercises. The hypothesis of injury through the birth canal and intrauterine malposition are valid only in 12 (25%) and 13 (27%) of cases, respectively. Therefore, it is difficult to attribute as an etiologic factor.     

舒筋散结膏辅助治疗早期小儿肌性斜颈113例临床观察

目的研究中药外敷佐治早期小儿肌性斜颈的疗效。方法将113例先天性肌性斜颈患儿随机分成治疗组76例和对照组37例,对照组应用标准化牵伸手法及磁疗,治疗组在对照组基础上,结合舒筋散结膏外敷。结果治疗组总有效率为93.2%,对照组总有效率为75.7%,两组疗效差异有统计学意义（P〈0.05）。结论应用活血化瘀中药外敷可提高小儿先天性肌性斜颈的治疗效果。     

Snapping during manual stretching in congenital muscular torticollis

Manual stretching frequently is used in the treatment of congenital muscular torticollis in infants. During manipulation, it is not uncommon for the sternocleidomastoid muscle to snap or suddenly give way. The main objective of this study was to evaluate the predisposing causes and clinical significance of such snapping. Four hundred fifty-five patients younger than 1 year of age with congenital muscular torticollis treated with a standardized gentle manual stretching program during a 13-year period were studied. Using prospective standardized assessment parameters, the pretreatment, treatment, and followup results of a group of 41 patients with snapping detected during treatment were compared with the results of a group of 404 patients without snapping during treatment. The group with snapping was associated with a more severe sternomastoid tumor, higher incidence of hip dysplasia, earlier clinical presentation, and shorter duration of treatment. With a mean followup of 3.5 years, the group with snapping was not different from the group that had no snapping in the final assessment score and percentage requiring surgery. From this study, unintentional snapping during the gentle manipulation treatment of congenital muscular torticollis has clinical and ultrasonographic evidence of partial or complete rupture of the sternocleidomastoid muscle. No long-term deleterious effect on the outcome was observed after the snapping.     

年龄大于5岁儿童先天性肌性斜颈的手术治疗

目的观察大年龄儿童（年龄大于5岁）先天性肌性斜颈的手术治疗效果。方法手术治疗大年龄肌性斜颈患儿37例,切断胸锁乳突肌锁骨头、胸骨头,于乳突处切断胸锁乳突肌止点腱,并充分松解挛缩组织,术后均作枕颌牵引。结果所有病例均获随访,随访时间2～5年,平均随访2．6年,所有患儿的功能和外观均有改善,其中优28例（75．7％）,良9例（24．3％）。结论胸锁乳突肌上、下端切断术加术后牵引是治疗大龄儿童先天性肌性斜颈的首选手术治疗方式。     

Long-term results of open sternocleidomastoid tenotomy for idiopathic muscular torticollis

At the end of their skeletal growth, we evaluated the cases of sixty-seven patients who had had an open tenotomy of the sternal and clavicular origins of the sternocleidomastoid muscle for idiopathic muscular torticollis. The average length of follow-up was 15.4 years, and the average age at the last follow-up was 23.9 years. The patients were divided into three groups according to their age at the time of operation. Group I consisted of patients who were operated on between the ages of five months and six years; Group II, of patients who were operated on between the ages of seven and eleven years; and Group III, of patients who were operated on when they were twelve years old or older. According to our method of evaluation, 37 per cent of the patients had a good, 45 per cent had a fair, and 18 per cent had a poor result. The patients in Group I had the best results and those in Group III, the worst. In general, the patient's age at operation, the duration of the disease, and the severity of the deformity before the operation had the major effects on both cosmetic and functional results.     

Cap brace: a new treatment for newborn and infant congenital muscular torticollis]

Herein is reported a new treatment, using a cap brace, for congenital muscular torticollis (CMT) in newborn and infant. The subjects consisted of 72 cases undergoing cap brace treatment (CB-group), and 197 cases undergoing ordinary treatment (O-group) for CMT. In children of the O-group, the rolling-over developmental stage was later than in normal infants, while in those of the CB-group this stage was not delayed. The good prognostic factors for lessening cranial and facial asymmetry, evaluated by chi-square test, were as follows: partus praematurus, a high APGAR score, breast-feeding, an early start to rolling-over, early vanishing of the sternomastoid tumor, and early vanishing of limitation of neck movement. For discriminant analysis of the factors related to cranial and facial asymmetry, the quantification method of the second type was used. In the O-group, discrimination between asymmetry and no asymmetry was achieved (R = 0.832), but in the CB-group the factors involved could not be discriminated. Moreover, ultratomosonography was very useful for examining the sternomastoid muscle. The internal echogenicity changed from low to high with aging, and was the echo pattern was classified as types I to IV accordingly. Patients with an early change from type I to type II tended to show good results in cranial and facial asymmetry. This brace was developed with an improvement of the other similar braces. But unlike other devices our brace did not fix the infant's head in one position for correction. And as a result of this virtue, the sternomastoid muscle of the affected side was relaxed and the vanishing periods of asymmetrical tonic neck reflex are hastened. Use of this brace improved the cure rate and was especially effective in decreasing cranial and facial asymmetry.     

学龄期儿童先天性肌性斜颈的治疗

目的探讨学龄期儿童先天性肌性斜颈的治疗方法。方法采用胸锁乳突肌单极切断术加术后胸颈联合斜颈矫形支具固定4~6个月,治疗学龄期儿童先天性肌性斜颈65例,男23例,女42例;手术平均年龄8岁(6~14岁)。结果本组65例,随访时间1~4年,平均2.7年。参考Cheng的疗效分级法,其中优42例(64.6%),良15例(23.1%),可5例(7.7%),差3例(4.6%)。结论胸锁乳突肌单极切断术加术后胸颈联合斜颈矫形支具,创伤小、疗效好、并发症少,是学龄期儿童先天性肌性斜颈首选的治疗方式。     

Torticollis due to a combination of sternomastoid contracture and congenital vertebral anomalies

We report four children with sternomastoid contracture combined with torticolis secondary to congenital vertebral anomalies. Two had features of Klippel-Feil syndrome and a proximal release of the contracted sternomastoid produced good cosmetic correction initially. Progression of the deformity occurred subsequently without recurrence of sternomastoid contracture. One child had such mild deformity that it was merely observed. The fourth child was born with torticollis without sternomastoid tightness and a vertebral anomaly was later recognised. He slowly developed a sternomastoid contracture and his condition was considerably improved by sternomastoid release. This combination of causes of torticollis has not, as far as we know, been previously reported. The clinician should be aware of it and should also realise that radiographs of the very immature spine may not disclose the bony anomalies.     

Idiopathic muscular torticollis in adults. Results of open sternocleidomastoid tenotomy

Eight adult patients who underwent open tenotomy for idiopathic muscular torticollis were evaluated with an average follow-up of 14 years. The age of the patients at operation ranged from 20 to 37 years, with an average of 26 years. The sternal head of the sternocleidomastoid muscle was divided in two patients, both the sternal and the clavicular heads were divided in five patients, and in one patient all three heads were divided. After the operation a Minerva plaster cast was applied with the head hyperextended, bent away from the deformity, and rotated towards the deformity. Neurovascular complications were not observed. Facial asymmetry did not improve after surgery, but at follow-up all the patients had a satisfactory range of motion of the neck, although the radiographic alterations of the cervical spine present before the operation had not improved.     

内镜下胸锁乳突肌切断治疗肌性斜颈的疗效观察

目的探讨内镜下离断胸锁乳突肌治疗肌性斜颈的效果。方法23例肌性斜颈患儿,年龄1个月～12岁,中位数2岁6个月。右侧腋窝皮纹线内置入5mm trocar,手持镜头将胸锁乳突肌下端胸骨头和锁骨头表面的肌膜钝性分离,充入CO2气体加压至6mmHg,形成皮下空间。在外侧颈下横纹内和前胸横纹处切开3mm分别置入3mm弯钳和电刀尖。电凝或电切横断胸锁乳突肌纤维束,松解胸锁乳突肌周围的纤维组织。结果23例均在内镜下完成手术。平均手术时间51．2min（35～135min）,术中出血量均〈1ml。无损伤周围大血管和神经。1例颈部切口处皮肤轻微电灼伤,2周后自愈。术后行颈部舒展活动训练,术后第1天出院。23例随访3个月～4年,中位时间6个月,斜颈均矫正,疗效优18例,良5例,切口瘢痕不明显,皮肤弹性好,随表情无异常活动现象,无复发。结论内镜下胸锁乳突肌切断治疗肌性斜颈具有微创、恢复快、效果好的优点,瘢痕不明显,美观且不损伤颈阔肌,对表情活动无影响。