Treatment of congenital muscular torticollis in patients older than 8 years

The authors treated congenital muscular torticollis by sternocleidomastoid muscle release in 32 patients over 8 years of age who had not received any prior medical treatment or in whom torticollis had recurred since initial treatment. The results were analyzed to compare clinical results after an average of 39 months (range 24-74 months) by dividing the patients into two groups: patients who were still in the growing period (group 1, n=19) and patients who had finished growth (group 2, n = 13) at surgery. According to the total score table by Cheng et al (which includes motion deficits, craniofacial asymmetry, scar, band, head tilt, and subjective assessment), there were 13 excellent and 6 good results in group 1 and 2 excellent, 8 good, and 3 fair results in group 2. The clinical results were statistically less successful in group 2 than in group 1 by Cheng's score table (P <0.05). However, most patients showed marked improvement in neck motion and head tilt, with satisfactory functional and cosmetic results. Thus, in patients older than school age, even for those who have finished growth, sufficient unipolar or bipolar release of the sternocleidomastoid muscle and intensive postoperative care are expected to yield satisfactory treatment 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).     

Surgical treatment of muscular torticollis for patients above 6 years of age

Eighteen patients with congenital muscular torticollis, aged 6-22 (average 11) years, underwent surgical releases of the contractive bands. There were 8 boys and 10 girls. Preoperative open mouth radiograph of the odontoid process in 16 patients showed asymmetry of articular facets of the axis and tilt of the odontoid process to the side of the torticollis. Sixteen patients received bipolar releases, the others received distal releases. After the operation, a neck collar was applied and an exercise program was started. At an average follow-up of 5 years and 7 months, there were excellent or good results in 10 patients. All of the patients except 2 showed improvement of the facial asymmetry and all except 1 had a satisfactory range of motion of the neck. One patient underwent a second operation due to recurrence. The follow-up radiographs showed improvement of the tilt of the odontoid process, but the asymmetry of the articular facets of the axis persisted. We suggest that bipolar release is the treatment of choice for congenital muscular torticollis in patients of more than 6 years of age. To determine the influence of a bipolar release on the functions of the cervical spine, longer follow-up intervals are needed.     

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。     

先天性肌性斜颈影像学表现的研究进展

先天性肌性斜颈(CMT)是小儿最常见的肌肉畸形,患侧胸锁乳突肌纤维化收缩导致患儿头向患侧偏斜,早期诊断治疗,纤维化则可逆,若斜颈持续存在,可导致患儿头、面、颈部发育畸形。弹性成像技术能快速、准确、无创、可重复地评价CMT患儿胸锁乳突肌纤维化程度,提高CMT患儿诊断准确率。本文对CMT的影像学表现进行综述。     

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.     

Efficacy of bipolar release in neglected congenital muscular torticollis patients

Surgical correction of the congenital muscular torticollis (CMT) is recommended for patients with unsuccessful conservative treatment. The aim of this study is to evaluate the efficacy of surgical release of congenital muscular torticollis in neglected cases. We retrospectively evaluated the data of our patients in terms of age, sex, clinical presentation, localization of the lesion, diagnostic tests, and additional abnormalities. The age at operation ranged from 6 to 23 years. Complete muscular release as determined by pre-operative and postoperative range of motion measurements was achieved in all of the patients by bipolar release. In this study, neck motion and head tilt showed marked improvement with surgical treatment in cases with CMT who were admitted to the hospital lately. Congenital muscular torticollis patients can benefit from surgical intervention above the age of 5. Bipolar release is an adequate and complication-free method.     

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.     

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.     

Frontal cephalometric analysis in the evaluation of facial asymmetry in torticollis,and outcomes of bipolar release in patients over 6 years of age

BACKGROUND: The aim of this study was to investigate the mid-term results of bipolar release in congenital muscular torticollis patients over 6 years of age, and the efficacy of frontal cephalometric analysis in the determination and follow-up of facial asymmetry. METHODS: Twelve patients (9 boys, 3 girls) from 7 to 12 years of age were included in the study. Bipolar release was performed, followed by 5-7 days of traction and 3 months of physiotherapy. Posteroanterior cephalometric radiography was performed at the beginning of and after therapy. The postural symmetry angle (PSA) was used to determine the presence and severity of facial asymmetry. A modified version of Lee et al.'s system was used in evaluating the results. RESULTS: The average follow-up period was 3 years and 5 months. According to the congenital muscular torticollis evaluation system, the outcome was excellent in 2 of the patients, good in 6, fair in 2 and poor in 2. Asymmetry was not severe in all patients at the beginning of therapy according to PSA values, being insignificant in 2, mild in 6, and severe in 4. The PSA results of the last examination indicated that severe facial asymmetry persisted in 3 patients. In 2 of them, PSA values remained within the limits of severe asymmetry despite a slight angular correction. DISCUSSION: Congenital muscular torticollis patients can benefit from surgical treatment over the age of 6 years. Bipolar release is an adequate and complication-free method. Moreover, PSA may be used as an objective method in the determination and follow-up of facial asymmetry in torticollis patients.     

The coconut condyle: occipital condylar dysplasia causing torticollis and leading to c1 fracture

In this report we discuss the case of a child who was initially diagnosed at 1 month of age with congenital muscular torticollis. After falling off a slide at 22 months of age, the patient had onset of pain and an abrupt worsening of his torticollis. After a full workup, it was found that the patient had a C1 fracture and a disproportionately large ipsilateral occipital "coconut" condyle. We believe this congenital anomaly to be the cause of his original head tilt and also predisposed him to C1 fracture and worsening head tilt.     

Perioperative celecoxib administration for pain management after total knee arthroplasty – A randomized, controlled study

Background

Congenital muscular torticollis is the third most common congenital musculoskeletal anomaly after dislocation of the hip and clubfoot. When diagnosed early, it is obvious that it can be managed with good or excellent results. The aim of this prospective study was to determine the efficacy of surgery in neglected adult cases.

Methods

From January 2003 to June 2007, 18 adult skeletally matured patients were surgically treated for neglected congenital muscular torticollis and prospectively followed (at least one year). Bipolar release was performed in all patients. Radiography and the modified Lee's scoring system which included function and cosmesis, were used to measure the surgical results. Complications were also recorded.

Results

Four cases were lost during follow-up. Of the remaining 14 patients, 10 cases were males and 4 females. The age at operation ranged from 18 to 32 (average 21.9) years. The mean follow-up period was 2.5 years (range 1–5 years). Excellent results were noted in 7 patients, good in 5, and poor in 2 patients. Significant improvement (>10°) of the cervico-thoracic scoliosis was noted only in 3 of 10 patients.

Conclusion

Patients with congenital muscular torticollis can benefit from surgical treatment even in adulthood. Surgical bipolar sectioning of the sternocleidomastoid muscle should be considered even in adults with irreversible facial and skeletal deformities. The surgery restores the range of neck motion and resolves the head tilt; therefore it can improve the quality of life. This procedure is an effective and relatively complication-free method.     

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.     

Common rotational variations in children

Most rotational variations in young children, such as in-toeing, out-toeing, and torticollis, are benign and resolve spontaneously. Understanding the normal variations in otherwise healthy children is vital to identifying true structural abnormalities that require intervention. A deliberate assessment of the rotational profile is necessary when evaluating children who in-toe or out-toe. In-toeing is usually attributable to metatarsus adductus in the infant, internal tibial torsion in the toddler, and femoral anteversion in children younger than 10 years. Out-toeing patterns largely result from external rotation hip contracture, external tibial torsion, and external femoral torsion. Although congenital muscular torticollis is the most common explanation for the atypical head posture in children, more serious disorders, including osseous malformations, inflammation, and neurogenic disorders, should be excluded.     

胸锁乳突肌多头切断术治疗成人先天性肌性斜颈

目的探讨胸锁乳突肌多头切断术治疗成人先天性肌性斜颈的方法及效果。方法 2009年3月—2011年2月,收治19例成人先天性肌性斜颈患者。男13例,女6例;年龄16～32岁,平均23.5岁。X线片检查示,12例伴不同程度颈椎侧弯及楔形改变。10例伴患侧面部发育迟缓。4例既往曾行胸锁乳突肌单侧头切断术。患者均采用胸锁乳突肌多头切断术,联合术后石膏托及颈托外固定3～6个月。结果术后患者切口均Ⅰ期愈合,无感染及血肿发生。16例患者获随访,随访时间5个月～2年,平均8个月。患者头颈部畸形均较术前明显改善。术后2周疗效评定:7例无颈椎畸形患者为优;12例伴颈椎畸形患者优1例,良7例,一般4例。术后2周测量患侧胸锁乳突肌乳突尖至胸锁关节距离,无颈椎畸形患者较术前延长(1.88±0.30)cm,手术前后差异有统计学意义(t=6.24,P=0.00),且术后测量值与正常值比较差异无统计学意义(t=1.87,P=0.11);伴颈椎畸形患者术后较术前延长(3.38±0.30)cm,差异有统计学意义(t=11.37,P=0.00),但术后测量值仍低于正常值(t=12.19,P=0.00)。结论采用胸锁乳突肌多头切断术治疗成人先天性肌性斜颈,能明显改善症状,恢复颈部活动功能。     

Subcutaneous tenotomy of the sternocleidomastoid muscle as therapy in muscular torticollis

This study reviews the cases of 49 patients with congenital muscular torticollis after an average follow-up of seven years, who were treated with subcutaneous sternomastoid tenotomy. An excellent result was found in 18 patients (37%), a good result in another 18 patients (37%), while the result of 13 patients (26%) must be regarded as unsatisfactory. There were no severe complications to be seen. These results are compared with other operative technics of treatment of muscular torticollis and the poor results are analyzed. We believe that subcutaneous sternomastoid tenotomy is a good method for treatment of muscular torticollis, with the advantage of avoiding any ugly scar.     

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。     

Adult presentation of congenital muscular torticollis: a series of 12 patients treated with a bipolar release of sternocleidomastoid and Z-lengthening

Adult presentation of neglected congenital muscular torticollis is rare. We report 12 patients with this condition who underwent a modified Ferkel's release comprising a bipolar release of sternocleidomastoid with Z-lengthening. They had a mean age of 24 years (17 to 31) and were followed up for a minimum of two years. Post-operatively a cervical collar was applied for three weeks with intermittent supervised active assisted exercises for six weeks. Outcome was assessed using a modified Lee score and a Cheng and Tang score. The mean pre-operative rotational deficit was 8.25° (0° to 15°) and mean lateral flexion deficit was 20.42° (15° to 30°), which improved after treatment to a mean of 1.67° (0° to 5°) and 7.0° (4° to 14°) after treatment, respectively. According to the modified Lee scoring system, six patients had excellent results, two had good results and four had fair results, and using the Cheng and Tang score, eight patients had excellent results and four had good results. Surgical management of adult patients with neglected congenital muscular torticollis using a modified Ferkel's bipolar release gives excellent results. The range of neck movement and head tilt improved in all 12 patients and cosmesis improved in 11, despite the long-standing nature of the deformity.     

Magnetic resonance imaging in the evaluation of infantile torticollis

This retrospective study assessed the use of magnetic resonance imaging (MRI) in 58 infants with infantile torticollis. Eighteen patients had nonmuscular causes of torticollis (group 1); MRI identified lesions in 16 patients. Of 40 patients with a diagnosis of congenital muscular torticollis (group 2), 28 had a normal MRI. Five patients had asymmetry of the sternocleidomastoid without noticeable signal changes. Seven patients showd evidence of fibromatosis colli. Asymmetry of the posterolateral skull consistent with plagiocephaly was common. Magnetic resonance imaging did not alter treatment of group 2. Findings of compartment syndrome of sternocleidomastoid were inconsistent. Magnetic resonance imaging is not recommended for asymptomatic patients with infantile torticollis.