What is the appropriate evaluation and management for torticollis in a 64-year-old patient?

Torticollis in a 64-Year-Old: Evaluation and Management

In a 64-year-old with torticollis, you must first determine if this is congenital muscular torticollis (CMT) that was never treated or acquired torticollis from a new pathologic process—this distinction fundamentally changes your approach, with acquired causes requiring urgent evaluation for red flag conditions (infection, tumor, cervical spine pathology, dystonia) while neglected CMT can proceed directly to conservative or surgical management.

Initial Evaluation Strategy

Critical First Step: Distinguish Congenital vs. Acquired

• Congenital muscular torticollis in adults: Patient will report lifelong oblique neck positioning since infancy, typically with visible/palpable sternocleidomastoid (SCM) muscle contracture and compensatory craniofacial asymmetry 1, 2, 3
• Acquired torticollis: New-onset presentation requires immediate investigation for underlying pathology

Red Flag Assessment for Acquired Cases

If torticollis is new or progressive, you must evaluate for:

• Neurological deficits (myelopathy, radiculopathy)
• Fever, weight loss, night pain (infection, malignancy)
• Trauma history
• Medication-induced dystonia
• Cervical spine structural pathology

Imaging Approach for Acquired Torticollis

Plain radiographs of the cervical spine are the appropriate first-line imaging for screening spondylosis, degenerative disc disease, and malalignment 4.

• Do NOT order MRI or CT as initial imaging unless red flags are present 4
• MRI without contrast is indicated only when red flags exist (radiculopathy, myelopathy, concern for infection/tumor) 4
• CT is not recommended as first-line examination for chronic neck pain without red flags or neurological symptoms 4

Management of Neglected Congenital Muscular Torticollis

Understanding Patient Goals

In adults with long-standing CMT, primary treatment goals vary by age and presentation 3:

• Cosmetic concerns: Most common (46% of patients), typically younger adults
• Pain: More common in older patients (30%), from chronic muscle imbalance
• Functional limitation: Restricted range of motion (24%)

Treatment Algorithm

Step 1: Conservative Management

Physical therapy remains first-line even in adults with neglected CMT, though evidence is primarily from pediatric populations 5, 6. However, in a 64-year-old with lifelong untreated torticollis, the likelihood of significant improvement from PT alone is low given decades of established contracture.

Step 2: Botulinum Toxin Injection

• Consider for patients who fail PT or have contraindications to surgery
• Limited evidence in adults with CMT, but used successfully in stepwise protocols 5, 6
• May provide temporary improvement but unlikely to achieve definitive correction in long-standing cases

Step 3: Surgical Release

Bipolar release of the sternocleidomastoid muscle is the definitive treatment for neglected CMT in adults and should be strongly considered in a 64-year-old with symptomatic disease 2, 3.

Surgical Outcomes in Adults

The evidence for surgical intervention in adults with neglected CMT is compelling:

• Excellent safety profile: No significant permanent complications reported in multiple series 2, 3
• High success rates: 71-89% achieve excellent or good results 2, 3
• Functional improvement: Statistically significant improvements in neck rotation, lateral flexion, and head tilt 2, 3
• Pain relief: Effective for pain originating from chronic muscle imbalance 3
• Cosmetic improvement: Reduces cervicomandibular angle and craniofacial asymmetry 2, 3
• Patient satisfaction: 93.7% satisfaction rate reported 2

Surgical Technique Considerations

• Bipolar release (both sternal and clavicular heads of SCM) is the standard approach 2, 3
• Transient sensory deficits of the ipsilateral lower ear lobe may occur but resolve 2
• Mean follow-up data shows sustained improvement at 12-30 months 2

Clinical Pitfalls to Avoid

1. Do not assume all torticollis in adults is benign: Always rule out acquired causes first
2. Do not order MRI reflexively: This violates appropriateness criteria and leads to false-positive findings in asymptomatic degenerative changes 4
3. Do not delay surgical referral in symptomatic neglected CMT: Decades of conservative management failure suggests surgery is the appropriate next step
4. Do not overlook the SCM muscle flap option: In patients requiring concurrent procedures (e.g., parotid surgery), the contracted SCM can be utilized as a reconstructive flap 1

Specific Recommendation for This Case

For a 64-year-old with lifelong torticollis consistent with neglected CMT who is now symptomatic, refer directly to a surgeon experienced in SCM bipolar release rather than pursuing prolonged conservative management. The patient's age and duration of deformity make spontaneous improvement or PT success highly unlikely, while surgical outcomes remain excellent even in older adults 2, 3.

If the torticollis is new-onset or the history is unclear, obtain cervical spine radiographs first and conduct thorough neurological examination before proceeding with any treatment plan 4.