From the Guidelines
Torticollis, or wry neck, is most effectively treated with a combination of botulinum toxin injections, prism, or strabismus surgery, which can help reduce both vertical and torsional diplopia, improve the perceived tilting of the visual field, and in select cases, resolve head tilt 1.
Treatment Approach
The treatment of torticollis should prioritize addressing the underlying cause and severity of the condition.
- For patients with torticollis associated with strabismus, the primary goal is to improve the vertical and torsional deviation, improve the head posture, and enhance the area of single binocular vision.
- A variety of surgical choices exist, including inferior oblique weakening, inferior rectus weakening, superior oblique strengthening, and superior rectus weakening, which can be used alone or in combination to achieve the desired outcome 1.
Non-Surgical Interventions
Before considering surgical intervention, non-surgical treatments such as:
- Prism therapy to reduce diplopia and torticollis
- Botulinum toxin injections to reduce muscle spasms and improve head posture
- Physical therapy focusing on stretching and strengthening exercises to improve range of motion and prevent recurrence may be beneficial in managing symptoms and improving quality of life 1.
Surgical Intervention
Surgical intervention is often necessary for patients with larger and incomitant deviations, and the decision for which muscle(s) to operate on depends on the magnitude of deviation in primary gaze, the degree of torsion, and the field of gaze with greatest deviation 1.
- The most common procedures used include inferior oblique weakening, inferior rectus weakening, superior oblique strengthening, and superior rectus weakening.
- In patients with a small vertical deviation, vertical rectus pole recessions may be preferable to minimize the risk of overcorrections 1.
From the Research
Treatment Options for Torticollis
- Botulinum toxin injections have been shown to be an effective treatment for spasmodic torticollis, with 95% of patients reporting considerable benefit from at least one treatment 2.
- The use of botulinum toxin therapy in combination with other treatments, such as massage, physiotherapy, and medication, is common, with patients undergoing a mean of 14.3 different treatments 3.
- For patients with botulinum toxin resistant torticollis, selective ramisectomy denervation may be an effective treatment option, with 37.5% of patients experiencing moderate or complete return of normal neck function 4.
Treatment of Congenital Muscular Torticollis
- The use of combined botulinum toxin and physical therapy has been shown to be effective in treating congenital muscular torticollis, with significant improvements in head tilt and range of neck rotation 5.
- An evidence-based algorithm for the conservative management of congenital muscular torticollis has been proposed, taking into account prognostic factors such as sternocleidomastoid fibrotic mass, passive range of motion rotation deficit, and age at initiation of treatment 6.
- Preliminary treatment parameter recommendations for clinic and home programming have been suggested to accompany the algorithm, with the goal of improving consistency of care and outcomes for infants with congenital muscular torticollis 6.
Adverse Effects and Considerations
- Dysphagia is a common adverse effect of botulinum toxin injections, occurring after 44% of all treatments, but is severe in only 2% of cases 2.
- The development of antibodies to botulinum toxin is a consideration, with 3 out of 5 patients experiencing loss of treatment efficacy due to antibody formation 2.
- Patients with emotional disorders prior to onset of dystonia may require additional support and treatment, with a higher rate of medical and non-medical treatments in addition to botulinum toxin therapy 3.