Torticollis (Wry Neck) causes, clinical features, Investigations, Management.

 Torticollis is defined as the rotational deformity of the cervical spine that causes turning and tilting deformity of the head and neck.

Causes:-
  • Congenital 
  • Infective Tuberculosis of the cervical spine, acute respiratory tract infection, etc..,
  • Traumatic Sprain, dislocation and fracture of the cervical spine.
  • Myositis or fibromyositis of sternocleidomastoid, exposure to cold causes myositis.
  • Spasmodic painful, persistent or intermittent sternomastoid muscle contraction.
  • Unilateral muscle paralysis, eg:-polio.
  • Neuritis of spinal accessory nerve.
  • Ocular disturbances Child turns head to one side to compensate for defective vision.
Among the acquired causes of torticollis, spasmodic muscle contraction of the sternocleidomastoid is the most common cause.

Clinical features:-
Head of the patient is tilted towards the affected side while the chin points to the other side. Sternocleidomastoid muscle is prominently seen. In the later stages, the patient may develop facial asymmetry and macular disturbances in the eye.

Radiographs:-
Plain X-ray neck helps to rule out intrinsic causes that can contribute to neck pain. 

Management:-
Conservative  Initially conservative line of treatment is observed. This consists of non-steroidal anti-inflammatory drugs (NSAIDS) muscle, relaxants drugs, etc.,

Physiotherapy measures:-
Like ultrasound, heat, massage is advocated. In acute pain, patient is encouraged to wear a collar. Gradual neck strengthening exercises are advised once the acute symptoms subside. 
Measures aimed at passive correction:- This actually is the mainstay of treatment in early causes of torticollis in infancy.
step 1-> Assess the extent of deformity and the existing ROM
step 2-> To relax the muscles, suitable thermotherapy and gentle massage is carried out.
step 3-> All the movements of the neck are carried out passively by bringing the head of the child beyond the edge of the table in a supine position. With an assistant stabilization both the elbows and with a pillow placed beneath the chest, all the movements of the neck are carried out in a gentle relaxed manner passively.
step 4-. After the above steps, a gentle sustained passive stretch is carried out in he opposite direction of the affected muscle and held for some time in the direction. 
step 5->After doing the above steps, the passive correction is maintained by supporting the neck with appropriate pillows or supports.
Active measures This is a little difficult since the child is still in its infancy and cannot carry out the oral commands. By using a bright colored object which makes noise, the attention of the child can be drawn and its head is made to move in the arc of correction. Cumbersome but is found to be effective.
Home treatment regimen Since the above mentioned methods need repeated manipulation, the mother of the child is taught to carry them out at home at frequent intervals.
Other than the methods already explained two additional measures which the mother needs to carry out are as follows:-
  • In the prone position, with the head of the child turned towards the affected side, the child is encouraged to look back over the shoulder in the opposite direction.
  • During sleep, the head of the child is positioned by pillow support in the opposite side of the deformity. This simultaneously relaxes and maintains the neck corrected position.
Surgical 
Management is advised after the failure of conservative treatment. It consists pf release of sternocleidomastoid muscle from its clavicular attachment as in congenital torticollis and intradural section of both spinal accessory and three cervical roots in cases of torticollis due to spasmodic or neural causes.

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