TORTICOLLIS/Wry neck/ContractureSCM.pptx

Here's presentation of Torticollis by Dr Jainam Salot , Pediatric Orthopaedics Resident at CNBC , Delhi. Suggestion welcomed at [email protected]. Extensive Description In ppt.

1. TORTICOLLIS DR JAINAM SALOT CNBC

2. INTRODUCTION Also known as wry neck/ Fibromatosis coli It is a cervical spine abnormality in which SCM is shortened on involved side , leading to Ipsilateral tilt of head C/L rotation of face and chin Producing Cock-Robin appearance M:F – 3:2 Right side mostly involved

3. Associated conditions Metatarsus Adductus DDH CTEV Torticollis is almost certainly a packaging problem , presents due to intra-uterine crowding , leading to series of events.

4. Etiology Birth trauma and difficult delivery has been eliminated as possible cause. Hereditary- 10% cases Vascular/Neuropathic insult during embryogenesis Intrauterine or Perinatal Compartment syndrome leading to Muscle ischaemia and contracture of SCM OTHER CAUSES Its classified based on Congenital/ Acquared Painful/ NonPainful

5. Causes of Torticollis Congenital CMT Ocular Torticollis Vertebral Anomalies Acquired Traumatic – C1 Fracture - Atlantoaxial rotatory Instability 2. Inflammatory torticollis 3. Tumors like Eosinophilic Granuloma

6. Clinical presentation Postural – mildest form with no tightness of SCM or mass felt Muscular – Muscle tightness+ - passive ROM restriction Mass – SCM tumor/ pseudotumor - Significant restriction in ROM - Mass usually grows for 1-2 months , then gradually reduces in size and disappears by 1-2 years Neglected cases present with Plagiocephaly (Oblique head with asymmetric cranio-facial features) In neglected cases , visual dysfunction is seen impacting quality of life in child

7. Secondary Cervicothoracic Scoliosis starts developing in these patients. Its seen as early as from 8 months Severity increases with age and SCM tightness Asymmetry of trunk and limb occurs gradually Asymmetry of Shoulder levels All these leads to secondary Pelvic Malalignment Syndrome To know which head of SCM is mainly involved , we do following test by which, the surgeon is aware of the more severe attachment and can plan surgical incisions and dissection accordingly

8. In supine position with both the shoulders stabilized and head and neck supported by the examiner over the edge of the examination couch in such a way that the head and neck region is free to rotate. The examiner now rotates the head and neck laterally and extends it such that the patient’s head hangs over the edge of the examination couch. The SCM head which is mainly involved becomes more prominent

9. Classification

10. Investigations Xrays – Cervical Spine Xray To see any vertebral anomalies 2. Cobbs Angle – to see for secondary scoliosis

11. USG- Gives diagnosis and severity of torticollis Shows SCM thickness and changes in echo signal Early stage shows Local thickness with uneven echoes Late stage shows diffuse increase in echo signals/ Cord like hyperechoic signal MRI – rule out secondary causes Opthal evaluation

12. Treatment Options Massage OTPT Orthosis Surgery

13. MASSAGE Increases temperature of local tissues Dilates capillaries and accelerates circulation of blood Promotes absorption of local tissue metabolites Promotes growth and development of tissues Done in early stages only

14. OTPT To be started at earliest , as it correlates with cervical ROM AGE <1 month – 98% patient recover within 1-2 months 1-3 months – 89% within 6 months 3-6 months- 62% within 7 months >6 months -<20% within 10 months Neck passive ROM Neck and trunk Active ROM Development of symmetric movement Parental education To be continued till the movements- both rotation and tilt are almost comparable B/L

15. Orthosis Soft Collar Pinless Halo Differential Collar

16. Surgery – Ideal age is between 2-5 yrs <2 years Problem in Postop wound management Easy formation of hematoma Easy infection Brace fitting difficult due to short neck Poor compliance to Post-Op Rehab protocol >5 years Residual Craniofacial Asymmetry Increased complication risk

17. Indications for surgery Neck tilt persisting even after 2 years of age Progressing deformity despite conservative treatment Gaze deviation>30* Rotational restriction>30*

18. Unipolar Release Bipolar release Modified Ferkel’s release Resection Endoscopic

19. Proximal release done at level of mastoid process as close to bone as possible to prevent injury to Spinal accessory nerve.

20. Neglected Torticollis Usually severe as due to increase vertebral height during growth spurt, head tilt worsen Squint worsen Surgical Management of adults with neglected CMT using Bipolar release with Z lengthening gives excellent clincal and functional results - Patwardhan et al in JBJS 2011 However , facial asymmetry may take upto 1 year to correct and persist in some cases

21. Halo Fixation Simultaneous correction of Skull and cervical spine abnormality, Provides external immobilization to protect spinal decompression and achieve spinal fusion Early mobilization can be done Anterior pins- Frontal area 1 cm above Supraorbital rim Posterior pin – Parietooccipital region below equator of skull Multiple pin construct used to enhance pin-skull fixation Atleast 6 pins in child younger then 6 years C/I Skull anomalies Metabolic bone diseases

22. Endoscopic Resection better view of the operating field, ensuring a complete and precise release protection of the muscle from denervation by damage of the spinal nerve. One of the endoscopic techniques described is the so-called Wry neck technique , which is based on simultaneous subperiosteal lengthening of the sternocleidomastoid muscle at its mastoid insertion, and division of the inferior fibrotic bands. Given that the sternomastoid muscle is fixed at a lower level on the mastoid apophysis, the lengthening of the muscle is maintained, as the fibrosing and shortening tendency is minimal, which allows to maintain postoperative cervical mobility

23. Post-Op protocol Consist of Orthosis Full time for 3 months Night time for 1 year OR head halter traction employed for initial 3 weeks to provide rest to the part, reduce neck spasm and muscle stretching. Physiotherapy After 7 days once the pain subsides Strenghtening of Para-cervical muscles Active and passive assisted exercises Mirror therapy- visualization and posture correction

24. Complications Injury to spinal accessory nerve Injury to carotid sheath scar Residual deformity may persist Craniofacial asymmetry

25. Assessment of Result MODIFIED LEE’S SCORE Excellent- 14-15 Good – 12-13 Fair- 10-11 Poor- <9

26. Modified Cheng and Tang score

27. THANK YOU