What are the recommended treatment steps for torticollis, including acute muscular spasm, congenital muscular torticollis, and cervical dystonia?

Treatment of Torticollis

Acute Muscular Torticollis (Wry Neck)

For acute torticollis, initiate NSAIDs as first-line therapy combined with heat application and gentle stretching exercises, adding muscle relaxants if spasm is significant. 1

First-Line Management

• Start NSAIDs immediately for pain control and inflammation reduction 1
• Apply heat therapy directly to tense cervical muscles to improve blood circulation 1
• Begin gentle stretching exercises to restore normal range of motion 1
• Add muscle relaxants (such as cyclobenzaprine or methocarbamol) to the NSAID regimen when muscle spasm is prominent 1
• Avoid benzodiazepines as they are conditionally recommended against for musculoskeletal pain 1

Second-Line Management

• Consider a short course of oral corticosteroids (e.g., prednisone 40-60mg daily for 5-7 days) for severe pain with significant inflammation 1
• Implement supervised postural exercises and manual trigger point therapy 1
• Ensure proper head positioning during rest and sleep to prevent prolonged abnormal posture 1

Red Flags Requiring Immediate Imaging

• Progressive neurological symptoms suggesting spinal cord compression (weakness, numbness, gait disturbance) 1
• Scalp tenderness with jaw claudication in elderly patients, suggesting giant cell arteritis requiring urgent evaluation 1

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Congenital Muscular Torticollis (CMT)

For congenital muscular torticollis in infants, manual cervical stretching exercises should be initiated as early as possible, ideally within the first year of life, as this maximizes outcomes and reduces the need for surgery. 2, 3

Initial Assessment

• Perform thorough physical and neurologic examination to identify the characteristic cord-like sternocleidomastoid muscle, ipsilateral cervical lateral flexion, and contralateral chin rotation 4, 2, 3
• Obtain cervical spine radiographs to rule out congenital anomalies of the occipital condyles and upper cervical spine before proceeding with treatment 4, 2
• Rule out ocular causes such as eye muscle weakness that may present as compensatory head tilt 1, 4
• Consider Sandifer's syndrome (gastroesophageal reflux causing torticollis) in infants with feeding-related symptoms 4, 5

Conservative Management (First-Line)

• Initiate manual cervical stretching exercises as soon as CMT is diagnosed, preferably within the first few months of life 4, 2, 3
• Physical therapy with or without bracing is usually effective in most cases, especially when instituted within the first year of life 2
• Continue stretching program for several months with regular monitoring of range of motion 2, 3

Intermediate Management

• Botulinum toxin injections have been shown effective for more resistant cases of CMT that fail to respond adequately to physical therapy 2, 6
• Consider botulinum toxin before proceeding to surgical release in persistent cases 6

Surgical Management

• Sternocleidomastoid muscle lengthening is indicated for patients presenting after age 1 year or those who fail conservative management 4, 2
• Rule out congenital cervical spine anomalies with imaging before performing surgical release to avoid catastrophic complications 4
• Counsel families that surgery may improve range of motion but not necessarily plagiocephaly, facial asymmetry, or cranial molding 2

Important Caveats

• Magnetic resonance imaging of the brain and neck is no longer considered cost-effective or necessary in straightforward CMT cases 2
• Consider imaging only if no improvement occurs with initial management or if neurological symptoms develop 1, 5
• Missing nonmuscular torticollis (tumors, infections, vertebral anomalies) could be life-threatening, so maintain high index of suspicion 2, 5

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Cervical Dystonia (Spasmodic Torticollis)

For cervical dystonia causing involuntary neck muscle contractions and abnormal head postures, botulinum toxin injections should be offered as first-line treatment. 7

Botulinum Toxin Treatment

• AboBoNT-A and rimaBoNT-B are similarly effective and should be offered for cervical dystonia 7
• OnaBoNT-A and incoBoNT-A have similar efficacy and should be considered for treatment 7
• All FDA-approved formulations of botulinum neurotoxin are commonly used despite differing evidence levels 7

Adjunctive Management

• Refer to rehabilitation specialist for comprehensive neuromusculoskeletal management if cervical dystonia is found 7
• Prescribe nerve-stabilizing agents such as pregabalin, gabapentin, or duloxetine for pain management and spasm control 7
• Consider botulinum toxin type A injections into affected muscles for both pain management and spasm control 7

Distinguishing CMT from Cervical Dystonia in Adults

• CMT in adults is differentiated by frequent facial asymmetry, cord-like SCM, absence of head tremor, lack of sensory trick, and head tilt since infancy 6
• Persistent adult CMT can be successfully treated with botulinum toxin injections with long-lasting benefit 6

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Pediatric Torticollis: Life-Threatening Causes

In children with acquired torticollis, particularly with neurological symptoms, imaging must be performed urgently to rule out craniospinal tumors, infections, and vertebral anomalies. 5

High-Risk Presentations Requiring Imaging

• Craniospinal pathologies including cerebellar tumors, brainstem gliomas, Chiari malformations, and arachnoid cysts causing brainstem compression 5
• Osseous abnormalities including eosinophilic granuloma, congenital vertebral anomalies (hemivertebrae, blocked vertebra) 5
• Infections such as retropharyngeal abscess, pyogenic cervical spondylitis, and cerebellar empyema 4, 5
• Atlantoaxial rotatory displacement from trauma or oropharyngeal inflammation (Grisel's syndrome) 4
• Posterior fossa tumors when intermittent torticollis is associated with headaches, vomiting, or neurologic symptoms 4

Pediatric Pain Management

• Acetaminophen or ibuprofen for pain relief during the first 24-48 hours in appropriate weight-based doses 1

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Ocular-Related Torticollis

For ocular-related torticollis presenting with vertical diplopia and head tilt, prism glasses should be prescribed for small deviations, while larger incomitant deviations require surgical intervention. 1

Treatment Targets

• Improved binocular vision, diplopia control, and reduced tilt of subjective visual vertical 1
• Prism glasses for small vertical deviations (1-6 prism diopters) 1
• Surgical intervention for larger and incomitant deviations that cannot be managed with prisms 1