Is torticollis associated with neck pain and stiffness?

Torticollis: Definition and Clinical Presentation

Yes, torticollis is characterized by neck pain and stiffness, along with an abnormal head position where the head is tilted to one side with the chin rotated to the opposite side. This condition involves sustained involuntary muscle contractions, particularly of the sternocleidomastoid muscle, resulting in the characteristic wry neck appearance 1.

Types of Torticollis

Torticollis can be classified into several categories:

1. Congenital Muscular Torticollis:

   • Most common pediatric form
   • Presents with tight sternocleidomastoid muscle causing head tilt
   • Usually painless in infants
   • May include a palpable tumor within the muscle 2, 3

2. Acquired Torticollis:

   • Posttraumatic: Develops 1-4 days after neck trauma with marked limitation of range of motion, pain, and muscle spasms 4
   • Cervical Dystonia: Adult-onset form with sustained involuntary muscle contractions 1
   • Secondary: Can result from underlying conditions including:
     • Atlanto-axial subluxation
     • Vertebral artery dissection
     • Neurological disorders 5

Clinical Features

The clinical presentation of torticollis typically includes:

• Head tilted to the affected side (with the sternocleidomastoid muscle contracted)
• Chin rotated to the opposite side
• Limited range of neck motion
• Neck pain and stiffness (particularly in acquired forms)
• Muscle spasms in the neck 1, 4

In cervical dystonia specifically, patients may present with:

• Combination of neck rotation (rotatory torticollis)
• Flexion (anterocollis)
• Extension (retrocollis)
• Head tilt (laterocollis)
• Lateral or sagittal shift 1

Some patients may demonstrate "sensory tricks" (geste antagonistique) that temporarily improve symptoms, such as touching the chin or back of the head 1.

Diagnostic Considerations

Torticollis requires careful evaluation as it can be a symptom of serious underlying conditions:

• Neck pain and stiffness with torticollis after trauma requires prompt medical evaluation for potential atlanto-axial subluxation 5
• Persistent torticollis may indicate vertebral artery dissection, which can lead to devastating neurological complications 5
• In adults with acute onset, imaging may be necessary to rule out serious pathology 5

Treatment Approaches

Treatment depends on the type and cause of torticollis:

1. Congenital Muscular Torticollis:

   • Physical therapy with stretching exercises (>90% success rate)
   • Observation and bracing in mild cases
   • Surgical muscle lengthening for resistant cases, especially if presenting after age 1 2, 3

2. Cervical Dystonia/Spasmodic Torticollis:

   • Botulinum toxin injections (75% success rate)
   • Pharmacotherapy (anticholinergics, dopaminergic agents)
   • Physical therapy
   • Surgery for refractory cases 1, 6

3. Posttraumatic Torticollis:

   • Pain management
   • Physical therapy
   • Botulinum toxin injections may provide some improvement
   • Anticholinergic therapy is generally ineffective 4

Clinical Implications

It's crucial to differentiate between muscular and non-muscular causes of torticollis, as missing a non-muscular cause could be potentially life-threatening 2. Torticollis with meningeal signs (stiff neck with headache) may indicate increased intracranial pressure requiring immediate evaluation 5.

For patients with persistent torticollis after trauma, imaging studies should be considered to rule out serious pathology such as fractures or vascular injuries 5.

Key Takeaways

• Torticollis presents with neck pain, stiffness, and characteristic head positioning
• The condition can be congenital or acquired
• Treatment approaches vary based on etiology but often include physical therapy and, in some cases, botulinum toxin injections
• Prompt evaluation is essential to rule out serious underlying conditions, especially in cases of acute onset or following trauma