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Imaging in Acute Torticollis NXPowerLite
Imaging in Acute Torticollis NXPowerLite
Torticollis
Division of Neuroradiology
Department of Radiology
University of North Carolina at Chapel Hill
Overview of This Presentation
I. Introduction
II. Imaging algorithm for acute torticollis
III. Causes of torticollis
A. Trauma
B. Infection/Inflammation
C. Neoplasm
D. Other/Idiopathic
IV. Atlantoaxial rotatory fixation
V. Selected references
At the Conclusion of this Exhibit
One Should Be Able To:
• Define torticollis
• Describe an algorithm for imaging patients
presenting with torticollis
• List several potential causes of torticollis
and describe their typical imaging features
• Discuss the concept of atlanto-axial
rotatory fixation and its diagnosis
Introduction: What is Torticollis?
• Derived from the
Latin tortus (twisted)
+ collis (neck or
collar)
• Torticollis is defined
as abnormal
twisting of the neck
which causes the
head to be held in a
rotated or tilted
position.
Introduction: Clinical Aspects of
Acute Torticollis
• Torticollis refers to a symptom rather than a
distinct disease process
• It can be caused by a wide variety of conditions
(over 80 causes have been described) which
range from relatively innocuous to life-
threatening
• May be congenital or acquired
• Occurs more frequently in children than in adults
• The right side is affected in 75% of patients
Introduction: Chronic Sequelae of
Torticollis
• Physical
– Positional plagiocephaly
– Facial deformities
– Cervical spine degeneration
– Radiculopathies and myelopathies
• Psychiatric
– Major depression
– Agoraphobia
– Substance abuse
– OCD
Imaging of Patients with Torticollis
• Choice of imaging studies depends on age and if
history of trauma is present.
• In newborn infants with congenital muscular torticollis,
ultrasound is preferred and often diagnostic.
• In older children and adults with post trauma torticollis,
CT of neck/cervical spine is needed to exclude
fracture or malalignment. If CT is positive, MRI and
MRA of the neck should be considered to evaluate for
associated cord, ligamentous, or arterial injuries.
• In older children and adults presenting with torticollis
without trauma, neck/cervical spine CT is the initial
imaging study; if negative, then brain and cervical
spine MRI is performed to exclude a CNS cause of
torticollis.
Imaging Algorithm for Acute Torticollis
Patient with
torticollis
Older child or
Newborn infant
adult
CT or MRI of
Stop Negative Positive Positive Negative
neck
T2 T1 post-Gd
Inflammatory Causes of Torticollis:
Rheumatoid Arthritis
Unenhanced
sagittal T1 MR in a
patient with
rheumatoid arthritis
and torticollis.
There is pannus
destroying the dens
and compressing
the lower brainstem
and medulla.
Neoplastic Causes of Torticollis
• CNS tumors
– Spinal cord or brainstem tumors
– Posterior fossa tumors and cysts
– Vestibular schwannoma
– Metastases
• Bone tumors
– Vertebral eosinophilic granuloma
– Osteoid osteoma/osteoblastoma
– Metastases (spine or skull base)
Neoplastic Causes of Torticollis:
Spinal Cord Tumor
Sagittal enhanced T1
MRI of the cervical
spine demonstrates an
enhancing, expansile
ganglioglioma in a 10-
year-old female
presenting with acute
torticollis.
Neoplastic Causes of Torticollis:
Skull Base Tumor
Lateral radiograph of
the cervical spine
shows hypoplasia and
fusion of lower cervical
vertebrae in a patient
with Klippel-Feil
syndrome and
torticollis
Klippel-Feil Syndrome
• Heterogeneous group of conditions unified by presence
of congenital synostosis of some or all cervical vertebrae
• Classic triad described by Klippel and Feil consisting of
short neck, low posterior hairline, and limited range of
motion of neck (seen in <50% of patients)
• Commonly associated abnormalities include congenital
scoliosis, rib abnormalities, deafness, genitourinary
abnormalities, Sprengel’s deformity, and cardiac
abnormalities
• Along with congenital scoliosis, accounts for nearly 1/3
of nonmuscular causes of torticollis in children
• Cervical anomalies are well characterized by CT
Idiopathic Spasmodic Torticollis
(IST)
• Also referred to as cervical dystonia
• Nontraumatic, acquired form of torticollis
presenting as spasms or jerks of SCMs
• Females more commonly affected by 4.5:1
• Typically occurs in adults over age 30
• Diagnosis requires exclusion of other potential
causes of torticollis and that symptoms be present
for at least 6 months
• Conventional neuroimaging studies usually
negative
Idiopathic Spasmodic Torticollis
(IST)
• Although pathophysiology of IST is not
understood, the interstitial nucleus in the
brainstem has been implicated as a probable
site of abnormality
• IST may be due to abnormalities of the basal
ganglia, vestibular systems, or spinal accessory
nerves
• Proton MR spectroscopy in IST patients may
demonstrate diminished n-acetyl-aspartate
(NAA) levels in basal ganglia when compared
with normal controls
Proton MR Spectroscopy in
Idiopathic Spasmodic Torticollis
From Lustrin ES, Karakas SP, Ortiz AO, et al. Pediatric cervical spine: Normal anatomy,
variants, and trauma. Radiographics 2003; 23:539-60. (Used with permission)
Radiographic Diagnosis of Atlanto-
axial Rotatory Fixation
• CT is essential for imaging of AARF
• When rotation is accompanied by anterior or
posterior displacement (Fielding types 2-4), CT
is diagnostic
• Type 1 rotatory fixation appears identical to
other causes of torticollis when patients are
imaged at rest
– Thus, patients with suspected type 1 AARF should be
scanned at rest and with maximal voluntary
contralateral head rotatation
– CT in patients with AARF shows little or no change in
position of atlas with respect to axis
Type 1 Atlanto-axial Rotatory
Fixation