What is the recommended treatment for torticollis?

Treatment of Torticollis

For acute torticollis, initiate multimodal analgesia with NSAIDs as first-line therapy, combined with heat application and gentle stretching exercises, while screening for red flags that require urgent neurological evaluation. 1, 2

Immediate Management for Acute Torticollis

Pharmacological Approach

• NSAIDs (ibuprofen or naproxen) are the first-line agents for pain control and inflammation reduction 1, 2
• Add acetaminophen for additional pain relief during the first 24-48 hours if NSAIDs alone are insufficient 1, 2
• Avoid benzodiazepines as they are conditionally recommended against for musculoskeletal pain conditions 1, 2
• For severe pain with significant muscle spasm, consider a short course of oral corticosteroids to rapidly reduce inflammation 1, 2

Non-Pharmacological Interventions

• Apply heat therapy to the affected neck area for 15-20 minutes, 3-4 times daily to relax tense muscles and improve circulation 1, 2
• Implement gentle stretching exercises to gradually restore normal range of motion 1
• Ensure proper positioning during rest and sleep to prevent symptom worsening 1, 2
• Limit screen time and activities requiring prolonged neck positioning 2

Physical Therapy for Persistent Cases

Supervised physical therapy should be initiated if symptoms persist beyond initial conservative management. 1

• Gentle manual therapy techniques including mobilization and trigger point therapy reduce muscle tension 1
• Supervised postural exercises and stretching with or without manual trigger point therapy have demonstrated benefit 1
• Home exercise programs focusing on gentle stretching and strengthening of neck muscles should be implemented 1

Management of Congenital Muscular Torticollis

Conservative Management (First-Line)

• Observation and physical therapy, with or without bracing, is effective in most cases, especially if instituted within the first year of life 3
• Physical therapy with forceful stretching of the restricting neck band should be attempted before considering surgery 4
• Botulinum toxin has been shown to be an effective intermediate treatment for more resistant cases of congenital muscular torticollis 3

Surgical Intervention

Surgery is indicated for classical congenital muscular torticollis that does not respond to physiotherapy and stretching. 4

• Timing: Operation may be delayed until age 1 year, but should be completed prior to school age to maximize reversal of craniofacial asymmetry 4
• Most reliable procedure: Inferior open tenotomy of the sternal and clavicular heads of the sternocleidomastoid muscle 4
• Place incisions low in the neck along skin lines (not over the clavicle) to avoid hypertrophic scarring 4
• Surgical principles include: (1) identification and release of all restricting bands involving the sternocleidomastoid and other neck structures, (2) moving the head through full range of motion before completing the procedure, and (3) resuming physical therapy within 2 weeks post-operatively to prevent recurrent scar contracture 4
• For patients presenting after age 1 year, there is an increased rate of requiring sternocleidomastoid muscle lengthening 3
• In neglected adult cases, bipolar release of the sternocleidomastoid muscle followed by post-surgical physical therapy can be effective 5

Red Flags Requiring Urgent Evaluation

Immediately evaluate for serious underlying pathology if any of the following are present:

• Progressive neurological symptoms including weakness, numbness, or tingling in arms or legs 1, 2
• Signs suggesting spinal cord compression 1, 2
• Worsening pain despite appropriate medication 2
• Associated neurological findings such as nystagmus, internuclear ophthalmoplegia, hemiparesis, sensory loss, or ataxia 6

Special Diagnostic Considerations

• Rule out ocular causes such as eye muscle weakness, which can present as torticollis 1, 2
• Consider imaging studies if no improvement is seen with initial management or if neurological symptoms develop 1, 2
• Obtain cervical spine radiographs as part of the systematic work-up 3
• Magnetic resonance imaging of the brain and neck is no longer considered cost-effective or necessary in congenital muscular torticollis 3
• Differentiate muscular from non-muscular torticollis, as missing non-muscular causes could be life-threatening 3

Management of Spasmodic Torticollis (Cervical Dystonia)

• Botulinum toxin A injection is safe and efficacious with minimal adverse effects, though expensive and short-lasting 7
• Anticholinergics, benzodiazepines, dopaminergics, and dopamine antagonists have been used with variable clinical improvement 7
• Neurosurgical procedures should only be considered when symptoms are refractory to combined medical treatment and botulinum toxin injections 7

Common Pitfalls to Avoid

• Do not assume all torticollis is benign muscular torticollis; underlying central nervous system or infectious disorders must be considered 4, 3
• Avoid delaying surgery in congenital cases beyond school age, as reversal of craniofacial asymmetry is best achieved at an early age with maximum growth potential 4
• Only modest results should be anticipated in older children or adults with long-standing disease or advanced craniofacial asymmetry 4
• Provide written discharge instructions, as patients rarely remember verbal instructions alone 2