What is the appropriate evaluation and management of torticollis in a child?

Evaluation and Management of Torticollis in Children

Torticollis in children requires immediate systematic evaluation to differentiate benign congenital muscular torticollis from potentially life-threatening conditions including posterior fossa tumors, cervical spine injuries, and infections—with imaging mandatory when red flags are present.

Initial Clinical Assessment

Critical Red Flags Requiring Urgent Imaging

The following findings mandate immediate diagnostic workup 1, 2:

• Altered mental status 1
• Focal neurologic deficits 1
• Neck pain (particularly post-trauma) 1
• Resistance to head/neck motion 1
• Progressive neurological symptoms 3
• Recent trauma (especially diving, high-risk motor vehicle crash, substantial torso injury) 1
• Conditions predisposing to cervical spine injury 1

Key Historical and Physical Examination Elements

Age of onset determines differential diagnosis 4, 5:

• Birth to 3 months: Consider congenital muscular torticollis or benign paroxysmal torticollis 3, 4
• After 3 months: Higher suspicion for acquired pathology (tumors, infections, trauma) 2

Associated symptoms to evaluate 1, 2:

• Pupillary abnormalities (suggest drug/toxin ingestion or cranial nerve compression) 1
• Fever, skin erythema (suggest infection) 6
• Ataxia, nystagmus, gait abnormalities (suggest posterior fossa pathology) 1
• Palpable neck mass (requires ultrasound evaluation) 6

Diagnostic Imaging Algorithm

When Imaging is Mandatory

Obtain cervical spine imaging if ANY of the following are present 1:

• Torticollis following trauma 1
• Neck pain with torticollis 1
• Neurological symptoms 1, 2
• Age >1 year with new-onset torticollis 2
• No improvement with initial conservative management 3

Imaging Modality Selection

For trauma-related torticollis 1:

• First-line: Cervical spine radiographs (2+ views have 90% sensitivity) 1
• CT cervical spine: Use for abnormal/ambiguous radiograph findings 1
• MRI cervical spine: Indicated for abnormal neurological examination or suspected soft-tissue/ligamentous injury 1

For non-traumatic torticollis with concerning features 6, 2:

• Ultrasound with Doppler: First-line for suspected neck mass or congenital anomaly 6
• MRI brain and cervical spine: Essential when neurological symptoms present to rule out posterior fossa tumors, brainstem pathology, or spinal cord lesions 2

Important caveat: MRI is no longer considered cost-effective for uncomplicated congenital muscular torticollis without neurological symptoms 4.

Management Based on Etiology

Congenital Muscular Torticollis (Benign)

Conservative management (first-line for age <1 year) 4, 5:

• Physical therapy with stretching exercises 3, 4
• Heat therapy to affected sternocleidomastoid muscle 3
• Proper positioning during sleep 3
• Success rate highest when initiated within first year of life 4, 5

Pharmacological adjuncts 3:

• Acetaminophen or ibuprofen for pain relief in first 24-48 hours 3
• NSAIDs as first-line for pain control 3
• Avoid benzodiazepines (conditionally recommended against) 3

Escalation for resistant cases 4:

• Botulinum toxin injection for cases resistant to physical therapy 4
• Surgical sternocleidomastoid lengthening if presenting after age 1 year or failing conservative therapy 4, 7, 5

Acute Traumatic Torticollis

Atlantoaxial rotary subluxation management 8:

• Mild/acute cases: Soft cervical collar, rest, analgesics 8
• Moderate cases: Head halter traction 8
• Severe/chronic cases: Halo traction or surgical intervention 8

Post-trampoline neck injury 1:

• Any neck pain or torticollis after trampoline use requires prompt medical evaluation 1
• High risk for vertebral artery dissection (presents 12-24 hours post-injury) 1
• Risk for atlanto-axial subluxation even in previously normal children 1

Pathologic Torticollis Requiring Specialist Referral

Immediate neurosurgical consultation for 2:

• Posterior fossa tumors (cerebellar tumors, brainstem gliomas) 2
• Spinal cord lesions (neuroenteric cysts, Chiari malformations) 2
• Cervical spine pathology (eosinophilic granuloma, vertebral anomalies) 2

Ophthalmology referral 3, 2:

• Rule out ocular causes (eye muscle weakness, congenital cataract, microphthalmia) 3, 2

Pediatric surgery/ENT referral 6:

• Congenital neck masses requiring definitive surgical excision 6

Critical Safety Warnings

Spinal manipulation is contraindicated 3:

• Case report documented quadriplegia in infant after spinal manipulation for torticollis 3
• Manual therapies require meticulous patient selection and technique 3

Do not miss life-threatening causes 4, 2:

• Craniospinal tumors, CNS infections, and cervical spine injuries can present as torticollis 2
• Missing nonmuscular torticollis can be life-threatening 4
• Always obtain imaging when clinical features suggest acquired pathology 2

Common Pitfalls to Avoid

• Assuming all torticollis is benign muscular tightness: 40% of cases in one series had serious underlying pathology including tumors 2
• Delaying imaging in trauma patients: Torticollis is a high-risk criterion in PECARN guidelines requiring imaging 1
• Performing flexion-extension radiographs acutely: These are unlikely to yield additional results and pose injury risk 1
• Using MRI routinely for uncomplicated congenital muscular torticollis: Not cost-effective without neurological symptoms 4