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The authors made a meta-analysis of the results of botulinum toxin injection for the treatment of spasmodic torticollis. They concluded that botulinum toxin is effective for the treatment of cervical dystonia.
Dystonia is a rare consequence of head trauma. We describe one case of post-traumatic spasmodic torticollis and review thirty-one cases reported in the literature. The time course among the head injury and the onset of dystonia ranged from two hours to nine years. Eleven cases had mild head injury and twenty had severe. On CT studies, the most frequent lesion was extradural, subdural and thalamic hemorrhagies; on MRI there were lesions in contralateral basal ganglia or thalamus. In our case, initial CT findings were bilateral hygroma and generalized brain edema. A follow-up CT sixt days after head injury showed cerebral atrophy and MRI scan (one year later) showed cerebral atrophy either. The pathophysiologic mechanisms related to the appearence of dystonia are poorly understood. However, there are evidences suggesting that some dysfunction of lenticulothalamic neuronal circuits plays an important role. The period of time between the head injury and the appearance of post-traumatic dystonia, seems to be related to aberrant central neurons.
OBJECTIVE: The purpose of this study was to investigate the existence of sternocleidomastoid (SCM) imbalance in a plagiocephalic population and further clinically describe its difference, if any, from congenital muscular torticollis (CMT). If SCM imbalance is different from CMT, then the development of terminology and a differential diagnosis may allow early recognition and intervention and possible prevention of positional plagiocephaly in the first place. DESIGN: This was a retrospective, random review of 100 patients referred for orthotic correction of their positional plagiocephaly. SETTING: The data was collected in a private orthotic clinic and was directed by a physical therapist. The patients were seen on a weekly or biweekly basis. PATIENTS: Eighty-three patients diagnosed with positional plagiocephaly that were referred for Dynamic Orthotic Cranioplasty during 1996 were studied. RESULTS: Sixty-four percent of the sample was identified as having SCM imbalance and 12% was diagnosed with CMT. There were no statistically significant differences between the characteristics of these two groups in relation to the etiological factors of positional plagiocephaly. The only observed difference was related to symptoms of the neck itself. CONCLUSIONS: Seventy-six percent of the sample was found to have some degree of SCM dysfunction, whether it be SCM imbalance or CMT. The finding that over three quarters of our population suffers from some form of SCM dysfunction, either SCM imbalance or CMT, suggests that any degree of SCM dysfunction may act as a precursor to positional plagiocephaly and therefore should be recognized and treated at the earliest opportunity.
BACKGROUND: Benign paroxysmal torticollis (BPT) is an episodic functional disorder of unknown etiology, characterized by the periods of torticollic posturing of the head, that occurs in the early months of life in healthy children. CASE REPORT: We reported two patients with BPT. In the first patient the symptoms were observed at the age of day 20, and disappeared at the age of 3 years. There were 10 episodes, of which 2 were followed by vomiting, pallor, irritability and the abnormal trunk posture. In the second patient, a 12-month-old girl, BPT started from day 15. She had 4 episodes followed by vomiting in the first year. Both girls had the normal psychomotor development. All diagnostical tests were normal. CONCLUSION: The recognition of BPT, as well as its clinical course may help to avoid not only unnecessary tests and the treatment, but also the anxiety of the parents.
Visuospatial functions were studied in 18 patients with spasmodic torticollis and 18 matched controls. Subjects were examined with respect to their judgement of the subjective vertical, personal and extrapersonal orientation, the discrimination of left and right, the ability to judge angles and distances, and a drawing task. Patients showed marked deficits in extrapersonal orientation and atypical displacement errors to the right when requested to set the subjective vertical. Results were largely independent of the clinical characteristics of the disease. The pattern of results was attributed to a subtle attention deficit underlying complex measures of visuospatial functions. This may reflect a discrete dysfunction of the striatal-frontal circuits at least in a subgroup of patients.
Nineteen patients were operated on for congenital muscular torticollis after the age of 1 year. Tenotomy gave good results below 5 years of age and resection of the sternocleidomastoid muscle was satisfactory in most of the older children.
OBJECT: Botulinum toxin injections are the best therapeutic option in patients with spasmodic torticollis. Although a small number of patients do not benefit from such therapy, the majority respond well but may develop antibodies to the toxin after repeated applications. In those termed primary nonresponders, no improvement related to botulinum toxin has been shown. In patients in whom no response was shown and those in whom resistance to the therapy developed, selective peripheral denervation is a neurosurgical option. METHODS: Between June 1988 and August 2001, 155 patients underwent selective peripheral denervation. Surgery was performed at a mean of 8.5 years after the onset of symptoms (range 0.5-37 years). The mean age of the patients at the onset of dystonia was 39.7 years (range 17-77 years). For evaluation of results, patients' responses were assessed. Results were obtained in 140 patients in whom the follow-up period ranged from 3 to 124 months (mean 32.8 months): 18 reported complete relief of their symptoms, 50 significant relief, and 34 moderate relief; 19 noted only minor relief and the remaining 19 no improvement. The results differ substantially when compared with those previously demonstrated in patients who received botulinum toxin injections. Although 80% of the secondary nonresponders were satisfied with the result of surgery, only 62% of the primary nonresponders considered the operation helpful. There were no major side effects. The recurrence rate was 11%. CONCLUSIONS: The injection of botulinum toxin should be the first-choice treatment. If surgery is required, selective peripheral denervation provides the best results and has the fewest side effects compared with all surgical options.
To help determine whether ocular torticollis causes facial asymmetry, we analyzed photographs of patients with long-standing head tilts for amounts of tilt and facial asymmetry. Significant facial asymmetry that correlated with the side of the head tilt was found in patients with congenital superior oblique muscle paresis, but not in patients with traumatic superior oblique muscle paresis nor in patients with dissociated vertical deviation. The mechanism explaining the development of facial asymmetry in these patients may be deformational molding of the face and skull from the infant's sleeping with its head turned predominantly to one side during the first 6 to 12 months of life. Early strabismus surgery to correct the head tilt may help prevent facial asymmetry, but ensuring that the infant sleeps with alternating head positions may be more important.
Torticollis in childhood may be a presenting symptom of many different disorders. The various etiologies of head tilt are briefly reviewed. Further investigations will depend on the patient's history as well as the local and neurological findings. Therapeutic problems are not discussed.
A postoperative corrective brace for congenital muscular torticollis is introduced and the results and indications for its use are presented. Thirty-three of 55 patients who underwent open tenotomy of the sternocleidomastoid muscle with application of the brace following surgery were evaluated in follow-up. Tenotomy was performed at the sternoclavicular origin of the muscle. The mean age at operation was six years; the mean follow-up period was seven years. The results were good in 21 patients (64%), fair in seven (21%), and poor in five (15%). Facial asymmetry remained in all patients over the age of ten who underwent operation. Alopecia, one of the complications of the brace, was found only in patients under age five. This combined treatment with tenotomy and postoperative brace is considered best indicated for patients between six and ten years of age.
Among the different etiological factors of spastic torticollis the authors attribute the main role to the gamma-motor system. They have elaborated a treatment method which blocks the neuromotor points of the gamma-motor system in the sternocleidomastoid and Musculus trapesius muscle by alcoholnovocain or phenolglycerine. Treatment was administered to 44 patients from 17-67 years with etiologically different diseases. A significant improvement was marked in 11 patients, improvement in 28. The absence of a positive effect was seen in patients with torsion dystonia. Clinico-EMG data demonstrated that influence on the peripheral segment of the reflectory are which is involved in the phasic-tonic muscle reactions, by a differentiated focal disengagement of gamma-motor mechanism facilitates a removal of spasticity and a restitution of a normal tonic and motor activity in the muscles of the neck.
64 cases with spasmodic torticollis were observed during 5 years and treated with botulinum toxin (BTX). BTX was injected into dystonic muscles mostly into sternocleidomastoid then--trapezius, and splenius capitis muscle. Improvement (excellent, good and fair) was achieved in 40 patients (62%). Lack of information about 6 patient (9%). Injections were repeated every 3-4 months and in several cases even 1-2 during the year. After several injections atrophy and denervation potentials in EMG were observed in the majority of injected muscles. Neurotic syndromes coexisting with dystonia had worsening influence on therapeutic effects. Adverse events were observed in 5 cases. Treatment with BTX is very simple, easy, harmless and can be administered in outpatients.
UNLABELLED: The differential diagnosis of acquired torticollis in infants and children comprises a large variety of disorders, including inflammation, neurologic disease or trauma. CONCLUSION: Spinal cord tumours in patients with ALL are a rarely reported entity and secondary spinal involvement in leukaemia presenting as head tilt is even more uncommon.
Familial transmission of congenital muscular torticollis (CMT) has been reported in the literature, and postaxial polydactyly has been frequently reported in familial cases, but, to our knowledge, familial CMT with postaxial polydactyly has not been described. In this article, we report a rare case of CMT with postaxial polydactyly in 3 generations of a family and suggest an autosomal-dominant pattern of inheritance in these cases.
An extremely rare vascular complication, carotid artery aneurysm, developed 60 years after a torticollis operation. The patient's internal jugular vein was completely obstructed proximal to the subclavian vein. There was an associated incomplete obstruction of the ipsilateral common carotid artery on the right aspect of the neck--the site where resection of the whole sternocleidomastoid muscle had been performed when she was one year old. The patient had audible bruits over the right common carotid at the base of her neck but no signs of occlusive cerebrovascular disease. The diagnosis was made mainly with use of technetium radionuclide angiography. To the authors' knowledge, this is the first such report in the English or German literature.
The authors describe the clinical picture and treatment of neurovascular spastic torticollis (NVST) with special reference to 20 patients with ST, who underwent microvascular decompression of the accessory nerves. Postural attenuation of ST served as a criterion for the screening of the patients. The authors describe the results of clinico-anatomic correlations, attesting to the diverse neurological picture of NVST and to the presence of correlations between the nystagmus in ST and compression of nerve XI of the posterior connective artery as well as between facial hyperkineses in ST patients and compression of the accessory nerves by the pathologically involuted vertebral and posteroinferior cerebellar arteries.
Myotomy was performed in 40 patients under 10 years of age with typical congenital muscular torticollis. Follow-up studies were carried out on 29 out of 40 cases. The patients without muscle relief of the affected sternomastoid muscle after myotomy had good range of motion of the neck. On the other hand, the patients who had undergone muscle release had, to grater or lesser extent, disturbances of the range of movement. For complete release of contracture, total excision may be the only operation in younger cases.
Herein is reported a new treatment, using a cap brace, for congenital muscular torticollis (CMT) in newborn and infant. The subjects consisted of 72 cases undergoing cap brace treatment (CB-group), and 197 cases undergoing ordinary treatment (O-group) for CMT. In children of the O-group, the rolling-over developmental stage was later than in normal infants, while in those of the CB-group this stage was not delayed. The good prognostic factors for lessening cranial and facial asymmetry, evaluated by chi-square test, were as follows: partus praematurus, a high APGAR score, breast-feeding, an early start to rolling-over, early vanishing of the sternomastoid tumor, and early vanishing of limitation of neck movement. For discriminant analysis of the factors related to cranial and facial asymmetry, the quantification method of the second type was used. In the O-group, discrimination between asymmetry and no asymmetry was achieved (R = 0.832), but in the CB-group the factors involved could not be discriminated. Moreover, ultratomosonography was very useful for examining the sternomastoid muscle. The internal echogenicity changed from low to high with aging, and was the echo pattern was classified as types I to IV accordingly. Patients with an early change from type I to type II tended to show good results in cranial and facial asymmetry. This brace was developed with an improvement of the other similar braces. But unlike other devices our brace did not fix the infant's head in one position for correction. And as a result of this virtue, the sternomastoid muscle of the affected side was relaxed and the vanishing periods of asymmetrical tonic neck reflex are hastened. Use of this brace improved the cure rate and was especially effective in decreasing cranial and facial asymmetry.