What are the treatment options for cervical torticollis?

Treatment of Cervical Torticollis

Immediate Treatment Recommendation

For cervical dystonia (spasmodic torticollis), botulinum neurotoxin injections should be offered as first-line treatment, with all FDA-approved formulations demonstrating efficacy despite varying evidence levels. 1

Treatment Algorithm by Type

Cervical Dystonia (Spasmodic Torticollis) in Adults

Botulinum Neurotoxin Therapy:

• AboBoNT-A and rimaBoNT-B are similarly effective and should be offered as primary treatment options 1
• OnaBoNT-A and incoBoNT-A have similar efficacy and should be considered for treatment 1
• All FDA-approved formulations are commonly used despite differing evidence levels 1
• Botulinum toxin may help reduce secondary contracture and severity of compensatory head position 1

Surgical Intervention:

• Reserved for patients who fail 1-2 years of conservative therapy including botulinum toxin 2
• Selective denervation and resection of cervical muscles achieves total or marked relief in 87.9% of cases with long-term follow-up (2-29 years) 2
• Surgery should only be considered after exhausting conservative options 2

Congenital Muscular Torticollis in Infants and Children

Conservative Management (First-Line):

• Physical therapy with manual cervical stretching exercises should be initiated within the first year of life for optimal outcomes 3, 4
• Approximately 95% of patients achieve acceptable range of motion with early passive stretching exercises and active strengthening of contralateral muscles 5
• Observation and physical therapy, with or without bracing, is effective in most cases when started early 3

Intermediate Treatment:

• Botulinum toxin (Botox) has been shown effective for resistant cases of congenital muscular torticollis that fail initial physical therapy 3

Surgical Management:

• Indicated for patients presenting after age 1 year or those failing conservative therapy 3
• Sternocleidomastoid muscle lengthening may improve range of motion but not necessarily plagiocephaly, facial asymmetry, or cranial molding 3
• Subperiosteal lengthening at the mastoid insertion combined with division of lower fibrotic bands provides stable lengthening with minimal postoperative fibrosis 5

Critical Diagnostic Considerations

Rule Out Non-Muscular Causes:

• Complete physical and neurologic examination with cervical spine radiographs is mandatory 3
• Congenital anomalies of occipital condyles and upper cervical spine must be excluded before surgical release 4
• MRI of brain and neck is no longer considered cost-effective or necessary in congenital muscular torticollis 3

Differential Diagnosis Varies by Age:

• Infants: Congenital muscular torticollis is most common; also consider ocular torticollis, Sandifer's syndrome (gastroesophageal reflux), neural axis abnormalities, benign paroxysmal torticollis 4
• Older children: Atlantoaxial rotatory displacement from trauma or oropharyngeal inflammation (Grisel's syndrome), retropharyngeal abscess, pyogenic cervical spondylitis 4
• Adolescents: Posterior fossa tumors (if intermittent with headaches/vomiting), cervical spine neoplasms, cervical dystonia 4

Common Pitfalls to Avoid

• Missing nonmuscular torticollis could be life-threatening - always perform systematic workup to differentiate muscular from nonmuscular causes 3
• Proceeding with sternocleidomastoid release without ruling out congenital cervical spine anomalies risks catastrophic complications 4
• Delaying physical therapy beyond the first year of life increases the likelihood of requiring surgical intervention 3, 5
• In cervical dystonia, premature surgical intervention before adequate trial of botulinum toxin (1-2 years) may expose patients to unnecessary surgical risks 2

Special Considerations

Temporomandibular Joint Dysfunction:

• Growing clinical evidence suggests TMJ dysfunction may be a coexisting factor in spasmodic torticollis 6
• Dental appliances with varying occlusal heights to increase vertical dimension have shown benefit in select cases 6
• This represents an adjunctive consideration when TMJ dysfunction coexists 6