Congenital torticollis or wry neck is a condition which is found in infants and can be detected at birth or shortly after.
It is characterized by rotational deformity of the cervical spine with a secondary tilting of the head. There is a lateral head tilt to one side and contralateral rotation.
Congenital torticollis is most commonly the result of unilateral shortening and thickening or excessive contraction of the sternocleidomastoid muscle.
The basic abnormality is known as endomysial fibrosis with deposition of collagen and migration of fibroblasts around individual muscle fibers.
Congenital torticollis leads to a limitation of the head mobility in both rotation and lateral flexion and progressive degrees of neck contracture.
Anatomy of Sternomastoid Tenotomy
The sternocleidomastoid muscle has a sternal and clavicular head. The sternal head is directed from the manubrium sterni superiorly, laterally and posteriorly and the clavicular from the medial third of the clavicle vertically upward.
It runs to the mastoid process. It enables an ipsilateral lateral flexion and a contralateral rotation. The muscle extends the upper part of the cervical spine and flexes the lower part.
Congenital muscular torticollis is characterized by a unilateral contraction of the sternocleidomastoid muscle that forces the infant to hold the head tilted toward the affected side with a slight rotation of the chin to the contralateral side.
The affected side seems to be excessively stronger than the contralateral side. This causes an imbalance in the neck muscles. In some cases, the shoulder is elevated on the affected side.
When congenital muscular torticollis is left untreated, it can cause fibrosis of the cervical musculature with progressive limitation of head movement, craniofacial asymmetry, and compensatory scoliosis that worsens with age.
Diagnosis of Sternomastoid Tenotomy
Ultrasonography can clearly differentiate postural torticollis from sternomastoid tumor patients. Normally the sternocleidomastoid muscle (SCM) can be seen as a hypoechoic structure with short echogenic lines that represent normal perimysium.
In sternomastoid tumor patients, there is an enlargement of the sternocleidomastoid muscle, asymmetry of the sternocleidomastoid muscle, a heterogeneous internal pattern of echogenicity and overall echogenicity with surrounding tissue.
In congenital muscular torticollis patients, there is a visible alteration in the size and echogenicity of the SCM.
MRI is recommended when either the clinical symptoms do not resolve within 12 months or when there are typical features of CMT. MRI can demonstrate changes in muscle shape and signal intensity.
Medical Management related with Sternomastoid Tenotomy
Treatment of congenital torticollis includes observation, the use of braces, exercise programs, traction, and various operations.
These include subcutaneous tenotomy, open tenotomy, bipolar tenotomy, and radical resection of a sternomastoid tumor or the sternocleidomastoid muscle.
Traditionally, the operative treatment of congenital muscular torticollis has been largely determined by the age of the patient.
Although some experts have suggested that operations should be performed within a few weeks of birth, later reports have shown spontaneous resolution of symptoms within a year of birth, or there were satisfactory results with conservative treatment, such as bracing, exercise and massage.
An operation performed too early particularly before one year of age creates problems in post-operative wound management owing to the easier formation of hematomas and increased prevalence of infection.
Therefore, some authors have reported that the optimal time for the operation is between one and four years of age.
Latest studies suggest that age is not the most important factor when determining the optimal time for operation, and that compliance with a post-operative rehabilitation program is the most important consideration.
They suggest that operative treatment of congenital muscular torticollis should be delayed until such compliance is possible.