ICA Pediatrics Council responds to med study on children’s torticollis
In an article published in Pediatrics in December of 2006, authors Snyder and Coley conclude that “The true-positive yield of plain films in non-traumatic infant torticollis was low (4 of 502). There were more false-positive than true-positive results. A common rationale for imaging is to exclude craniocervical or other unstable abnormalities that might contraindicate physical therapy, seen in only 1 of the 502 cases. Close physical examination could safely eliminate most patients sent for radiography.” Acquired torticollis in young children is a common presentation in chiropractic offices. Spasm of the sternocleidomastoid (SCM) muscle will cause the head to tilt to one side while the chin points in the opposite direction. The most common cause of this condition, now well recognized in recent medical texts, is rotary subluxation of the upper two spinal vertebrae. It is important however, especially in the younger child to determine the underlying cause of this condition.
Dr. Peter Fysh, of the ICA Council on Chiropractic Pediatrics board of directors, suggests that congenital torticollis has multiple etiologies which can only be accurately identified by imaging studies. Torticollis in the neonate may be present from birth or may occur in the early weeks of life. Torticollis which is present at birth is well recognized as most commonly due to rotary subluxation of the upper cervical vertebrae, but it can also be associated with spinal anomalies such as hemi-vertebra or spinal cord tumor. Neither of these latter two causes can be identified by physical examination alone. Hemivertebra can only be accurately identified by radiography and while it is possible to identify some cases of spinal cord tumor by the presence of an expanded spinal canal on a cervical radiograph, CT or MRI may be necessary to accurately identify such a tumor. Torticollis that occurs in the early weeks of life is commonly due to fibrous adhesions in the sternocleidomastoid muscle (SCM) resulting from a stretching injury during labor and delivery. This cause, known as pseudotumor, is the only one that can be readily identified on physical examination, and presents as a knot in the SCM on the side of lateral head tilt.
“The fact that the great majority of cases of congenital torticollis are due either to subluxated cervical vertebrae or pseudotumor should not be a cause to overlook a more serious underlying condition,” said Dr. Fysh. He suggests that a newborn infant who presents with torticollis at birth should be evaluated with cervical radiography where any degree of uncertainty exists as to the underlying cause of neonatal torticollis. Once pathology or developmental spinal anomaly have been excluded as the underlying cause, a course of gentle chiropractic spinal adjustments, soft tissue stretching and range of motion exercises will form the basis of an appropriate plan of care. Such a plan should produce change in the infant’s condition within a two to four week program. If change has not occurred in this time, or if new symptomatology, especially neurologic change, is apparent, re-evaluating the need for further imaging studies and co-management with other health care options may be necessary and appropriate.