Torticollis

Related Terms

 Cervical Dystonia
 Head and Neck Dystonia
 Loxia
 Spasmodic Torticollis
 Wry neck
 Wryneck

Differential Diagnoses

 Anterior horn disease

 Cerebral palsy
 Cervical adenitis
 Cervical osteomyelitis
 Conversion disorder (a mental disorder with psychogenic torticollis)
 Epilepsy
 Fractures of the cervical spine
 Labyrinthine disease
 Multiple sclerosis
 Myasthenia gravis
 Parkinson disease
 Radiculopathy
 Retropharyngeal space infection
 Spinal cord neoplasms
 Tetanus

Specialists

 Chiropractor
 Neurologist
 Neurosurgeon
 Orthopedic (Orthopaedic) Surgeon
 Physiatrist
 Physical Therapist

Comorbid Conditions

 Cervical disc disease

 Cervical osteoarthritis

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  Cervical osteomyelitis

Factors Influencing Duration

The individual's age, severity of symptoms, and response to treatment are factors that
may influence length of disability. The presence of an underlying cause such as injury,
degenerative cervical disc disease, cervical osteomyelitis, cervical osteoarthritis, or
infection, may increase duration.

Definition

Spasmodic torticollis (ST) is a neurological movement disorder characterized by

involuntary, intermittent, or prolonged muscle contractions (dystonia) of the neck
muscles that lead to abnormal postures and movement of the head. Torticollis is both a
symptom and a disease with many underlying pathologies. The condition may occur
without a known cause (idiopathic), may be genetic (inherited), or may be acquired
secondary to damage to the nervous system or muscles. Idiopathic torticollis is believed
to develop when circuit abnormalities within the nervous system trigger a biochemical
process that results in neurologic deficit. It may also be psychogenic. Torticollis may be a
symptom of a fracture or dislocation of C1-C2 discs in the upper cervical spine or of
cervical degenerative disc disease. The condition is also called cervical dystonia, referring
to these potential causes. Stress does not cause torticollis directly but is known to
aggravate the condition, increasing pain. ST can occur at any age but occurs most often
in middle-aged women.

Diagnosing torticollis can be difficult because the symptoms resemble other diseases or
conditions, including Parkinson's disease, epilepsy, and muscular dystrophy. Many
physicians are also unfamiliar with the disorder, complicating diagnosis.

Acute torticollis can develop as a result of blunt trauma to the head or neck or even from
falling asleep in an uncomfortable position, involves acute pain and spasm in the neck,
and may resolve by itself in a few days or a couple of weeks. Torticollis due to taking
medications such as dopamine receptor blockers resolves quickly when the medicine is
discontinued. Chronic or persistent torticollis, however, is painful and debilitating and
may interfere with the ability to function. The spasms in the neck that occur with ST
differ from person to person; the head can tilt forward (anterocollis), backward
(retrocollis), or left or right (laterocollis) or can move from side to side (rotational ST). A
"mixed" torticollis involves turning and shaking of the head.

Risk: Age and gender are risk factors: the risk is higher in women than in men, with
onset occurring most often between ages 30 and 50 (Reynolds). An increased risk for

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developing torticollis may be associated with an injury to the head or neck, an infection,
or use of certain medications. There may also be a genetic link, since 5% of individuals
with torticollis report at least one relative with this condition (“Spasmodic
Torticollis/Cervical Dystonia”). However, a family history may also suggest inherited
generalized dystonia (Reynolds). The risk is increased with exposure to heavy metals or
carbon monoxide.

Incidence and Prevalence: The incidence of idiopathic torticollis is estimated to be

about 3 per 10,000 people or about 90,000 individuals (“Spasmodic Torticollis/Cervical
Dystonia”). About 90% of cases are idiopathic, and 10% to 20% are from defined causes
(Reynolds). However, the exact incidence is not known because many individuals go
undiagnosed or their condition has been misdiagnosed. Idiopathic torticollis is more
common in women than men by a 2:1 ratio (Reynolds).

Diagnosis

History: The individual may complain of constant neck pain, stiffness of the neck
muscles, limited range of motion of the neck, and headache. The individual may also
describe various head movements and tremors in the arms. A history of neck or cervical
spine injury or a family history of head tremors may be reported. A thorough history of
illnesses or injuries and medications taken is obtained.

Physical exam: Both head and neck posture (tonic components) and head movements
(phasic components) will be evaluated. Upon examination, enlargement of the neck
muscles and shoulder elevation on the affected side may be observed. A shortening of
the neck muscles may be noted. The individual's head will tilt toward the affected side
while the chin points to the unaffected side. The chin may also point up or down. Head
tremor or spasmodic jerking of the head may be observed. Tremors in the arms may also
be noted. Swallowing difficulty may be observed. The individual may be self-conscious
and show signs of depression.

Tests: X-rays, magnetic resonance imaging (MRI), and computed tomography (CT)
scanning may be done to rule out cervical disc disease, other spinal abnormalities, or
other underlying diseases or conditions. No standard laboratory tests are employed to
diagnose ST. Swallowing tests using imaging and contrast media may be performed. If
genetic torticollis is suspected, DNA testing may be done to identify specific genetic
dystonias. Specialized eye examinations may be performed to rule out ophthalmopathies
as a possible cause.

Treatment
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Treatment for ST is not standardized since symptoms vary from person to person. If an
injury, cervical disc disease, infection, or medication use is determined to be an
underlying cause, it will be corrected first in an attempt to relieve symptoms. In
idiopathic torticollis, oral medications are the mainstay of treatment, including
anticholinergic drugs, glutamate release inhibitors, muscle relaxants, and analgesics such
as nonsteroidal anti-inflammatory drugs (NSAIDS). Injection of botulinum toxin to
paralyze the affected muscle is often the treatment of choice, offering relief for several
months. Heat, cervical spine traction, and massage may be used to treat head and neck
pain. Stretching exercises and neck braces may help alleviate muscle spasms. Neck
spasms and head movements often stop during sleeping hours and resume on waking;
for this reason, some individuals may obtain relief by lying down on their back for
periods during the day. Stress management may be advised to help reduce muscle
tension and pain. If other treatments fail, surgical treatments are sometimes used, such
as selective peripheral denervation (Bertrand procedure) and deep brain stimulation,
which is the controlled delivery of electric pulses to areas of the brain involved with
movement. Combinations of treatments may be required to resolve symptoms.

Prognosis

In most individuals, torticollis progresses gradually over a period of months to years.

Complete remission sometimes occurs. Remission rates of 12% to 21% have been
reported, especially in younger individuals during the first 5 years after onset of the
disease (“Spasmodic Torticollis/Cervical Dystonia”). The majority of remissions are only
temporary. In many cases, torticollis may persist for life and can result in restricted
movement and postural deformity.

After surgery, the mobility of the neck may not return completely to normal, and some
individuals may experience numbness on the back of the head that extends to the top.

Complications

Individuals with prolonged torticollis may develop degenerative osteoarthritis of the

cervical spine, an increase in size (hypertrophy) of the sternocleidomastoid muscle, and
neurological symptoms such as numbness and tingling of the limbs due to compressed
nerve roots in the neck. Prolonged postural changes of the head and neck can also lead
to spinal radiculopathies and/or spinal stenosis or scoliosis. An individual’s
embarrassment because of ST may lead to social isolation and/or depression.

Return to Work (Restrictions / Accommodations)

Work restrictions depend on the severity of the individual's condition (e.g., range of

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motion). Driving, operating heavy machinery, and any other tasks involving neck and
head motions may need to be reduced or eliminated.

Failure to Recover

If an individual fails to recover within the expected maximum duration period, the
reader may wish to consider the following questions to better understand the specifics
of an individual's medical case.

Regarding diagnosis:

 Has diagnosis of torticollis been confirmed?

 Has an underlying cause such as injury, infection, or medication use been
identified?
 How is underlying cause being addressed?
 Have conditions with similar symptoms been ruled out?
 Does individual have symptoms of torticollis such as neck pain, stiffness of the
neck muscles, or limited range of motion of the neck? Does individual have other
symptoms? Does individual have anterocollis, retrocollis, laterocollis, or rotational
torticollis?
 Is individual under significant stress?


Regarding treatment:

 Is underlying cause responding to treatment?

 Have oral medications been prescribed? Is individual responding to treatment?
 Was massage or heat therapy effective?
 Was individual placed in traction? Did traction work?
 Would individual benefit from botulinum toxin injections?
 Have stress management techniques been employed?
 Have surgical procedures been performed?


Regarding prognosis:

 Does individual have restricted movement or postural deformity? Has individual

had a remission?
 What is individual's pain level?
 To what level is function impaired?
 Would a more aggressive form of treatment, such as surgical intervention, be
warranted?
 Has individual experienced any complications?
 Does individual have an underlying condition that may affect recovery, such as
cervical osteomyelitis, cervical osteoarthritis, or cervical disc disease?

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