Epidemiology and causes
Congenital muscular torticollis is one of the most frequent pathologies in pediatric orthopedic practice. In the structure of congenital musculoskeletal diseases, it firmly occupies the 3rd place, accounting for 5 to 12% of cases.
- The disease is more commonly registered in female patients.
- The predominant localization of the deformity is right-sided.
- The leading etiologic theory links the onset of the disease to a primary congenital developmental defect of the sternocleidomastoid muscle itself.
In clinical practice, the erroneous view of a traumatic genesis of the pathology is often encountered. However, it has been proven that cervical spine trauma during labor is not the root cause of the disease; birth trauma acts exclusively as a secondary factor that additionally traumatizes the altered tissue and exacerbates the pre-existing muscular deformity.
Clinical presentation and timeline
A feature of congenital torticollis is the delayed manifestation of the main clinical signs.
- Early neonatal period (first 7–10 days): marked neck deformity and head asymmetry are extremely rare; the pathology may be latent.
- End of the neonatal period (3rd week of life): a characteristic dense formation (induration) forms in the middle part of the affected sternocleidomastoid muscle.
From this moment, a specific head posture of the child begins to clearly trace:
- The head is constantly tilted toward the altered (shortened) muscle.
- The facial skull is rotated in the opposite (healthy) direction.
- There is a persistent restriction of the range of active and passive movements in the cervical spine.
Additional symptoms of the early period: Alongside the forced position, the child gradually develops concomitant trophic and biomechanical disorders: asymmetry of the face and cerebral cranium, distinct differences in the auricles (in their shape, position on the head, and size). In some cases, the natural horizontal skin fold on the neck is visually absent or smoothed out on the side of the affected muscle.
Severity grades and clinical variants
The clinical severity of the condition varies depending on the degree of fibrous changes in the muscle tissue:
- Mild grade (minor changes): mobility is preserved, allowing the physician or parent to passively bring the child's head into the correct midline position.
- Severe grade (significant thickening and rigidity of the muscle): passive manual correction of the head posture is completely impossible.
The further course of the disease has two main vectors of development:
- Self-resolution: a favorable outcome is possible in the early stages if the formed induration in the muscle gradually decreases in size and completely disappears without surgical intervention.
- Progression: the most frequent scenario in the absence of timely treatment. The deformity steadily increases and becomes maximally pronounced by the age of 3–6 years. During this period, gross asymmetry of the neck, as well as the characteristic head tilt and rotation, become striking.
Topographical diagnosis of muscle head involvement
Anatomically, m. sternocleidomastoideus consists of two portions (heads) attaching to the sternum and clavicle. The clinical picture of torticollis directly depends on which particular head is involved in the pathological process to a greater extent.
| Dominant involvement | Leading clinical symptom |
|---|---|
| Sternal head | The pathological rotation of the head toward the healthy side is maximally pronounced. |
| Clavicular head | A sharp tilt of the head toward the shoulder girdle on the affected side dominates. |
Briefly: answers to topical questions
Which congenital and acquired conditions must muscular torticollis be differentiated from?
Muscular torticollis must be differentiated from a number of congenital and acquired pathologies accompanied by a forced head position.
- Cervical vertebrae developmental anomalies — for instance, Klippel-Feil syndrome.
- Atlantoaxial rotatory fixation — often occurs acutely in children and presents with the clinical picture of torticollis (torticollis).
- Intramedullary spinal cord tumors — torticollis acts as an indirect sign of a neoplasm.
- Spasmodic torticollis — focal dystonia (includes torticollis, retrocollis, laterocollis, and anterocollis).
- Sprengel's deformity — congenital high scapula, often accompanying torticollis.
What conservative treatment methods are used for congenital muscular torticollis in children under one year of age?
Conservative treatment of congenital muscular torticollis in infants is used for mild deformity. The main method is head fixation with a tilt in the opposite direction. This therapy is performed in the first and second years of the child's life, and in cases of sharply pronounced muscle changes, it can continue up to three years of age.
What are the indications and optimal timing for surgical treatment of muscular torticollis?
Surgical intervention for muscular torticollis is indicated in severe cases and when conservative therapy is ineffective.
- Main indications: significant underdevelopment of the sternocleidomastoid muscle (m. sternocleidomastoideus) and progressive facial and cranial asymmetry.
- Optimal timing: it is advisable to perform the surgery at the age of 2–3 years, though children over 3 years old are operated on more frequently.
What types of surgical procedures are performed for severe congenital muscular torticollis?
For severe congenital muscular torticollis, several types of surgical interventions on the sternocleidomastoid muscle (m. sternocleidomastoideus) are used.
- Zatsepin's operation — includes transection of the muscle heads at the clavicle, dissection of the superficial cervical fascia, and resection of the lower segments of the heads by 1.5–2.0 cm to prevent recurrence.
- Tendon lengthening — an alternative option for correcting muscle length.
- Muscle extirpation with plastics — complete removal of the affected muscle followed by defect replacement with a Dacron mesh or preserved tendon.
After surgery, a plaster thoraco-cranial bandage is applied in a hypercorrection position.
What instrumental diagnostic methods are used to confirm the diagnosis of muscular torticollis?
To confirm the diagnosis and perform differential diagnosis of muscular torticollis, medical imaging is used. The main instrumental method is radiography of the cervical spine. This study is performed to clarify the cause of the forced head position, as well as to rule out concomitant bone pathology and cervical spine anomalies.
Rule of opposites: the head is TILTED toward the diseased muscle, and the face is ROTATED away from it (toward the healthy side).
Class and exam questions
At what age do the first reliable signs of muscular torticollis appear?
During the first 7–10 days of life, symptoms are virtually absent. Reliable signs (muscle induration and restricted movement) manifest by the 3rd week of life.
Can birth trauma be considered the main cause of torticollis development?
No. According to the leading theory, the cause is a congenital developmental defect of the muscle itself. Birth trauma acts only as a factor that exacerbates the existing pathology.
Is spontaneous recovery from the disease possible?
Yes, self-resolution is possible if the primary induration in the muscle resolves on its own over time. However, the deformity more often progresses and peaks by 3–6 years of age.
How to clinically determine which head of the muscle is more affected?
If the child has a predominant head rotation, the sternal head is more severely affected. If head tilt to the side dominates, the clavicular head is more involved in the process.
What else to study on this topic
- Methods of conservative treatment for torticollis in the first year of life (redression, physical therapy).
- Indications and optimal timing for surgical intervention on the m. sternocleidomastoideus.
- Differential diagnosis of muscular torticollis from osseous forms (Klippel-Feil syndrome).
- Secondary spinal deformities in long-standing untreated muscular torticollis.
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