Overview 

Torticollis occurs when the head and neck tilt to one side, creating a twisted posture. It can occur while in the womb or develop later on. The positioning can result from muscular or neurological contributions.

Torticollis can be divided into many categories; however, in this article, we will focus on two: congenital torticollis and acquired torticollis. We will discuss the pathophysiology of both types of torticollis. This means exploring the disruptions in the processes associated with the condition.

Classification of torticollis 

• Congenital torticollis (CT): commonly found in infants. It develops in the womb due to prenatal trauma or during prenatal development
• Acquired torticollis (AT) develops later in childhood or adulthood. This is generally caused by neurological factors combined with infection or trauma. It can be characterised by involuntary contractions in the neck

Pathophysiological interactions in congenital torticollis 

In CT, the main muscle – the sternocleidomastoid muscle (SCM) – is affected. The SCM is found on either side of the neck. The muscle binds the back of the skull to the front of the collarbones, making it vital in the correct positioning of the head. SCM also serves as a protective shield for nerves and soft tissues against external damage.¹

In the case of CT,  low amniotic fluid levels in the womb or pressure on the uterine wall from external factors can impact the position of the foetus’ head or neck. Depending on the orientation, it can cause compression or oxygen deprivation of the SCM, thereby damaging it. 

Another source of damage to the SCM is during birth, specifically breech births or a significant size difference between the fetus and the birth canal. This results in excessive twisting of the SCM muscle and the damage previously mentioned.² 

When the baby suffers these injuries, a fibrous band forms around the SCM. This band causes the SCM to shorten or contract. The shortening of the muscle on one side can be seen visibly as the tilting of the head on one side.³

The level of damage has corresponding consequences. There are varying degrees of intensity (from lowest to highest):³

• Postural – the child will prefer one side of the body, but retain normal muscle movement
• Muscular – associated with the tightening of the SCM and a decrease in the range of motion 
• Sternocleidomastoid mass – the ability for passive movement is completely gone due to the increased thickening of the fibrous band around the SCM

Postural CT can be identified in the early stages of development. Hence, its treatment reflects its mild manner. Out of the three types of CT discussed, postural has the shortest treatment time.

On the contrary, children with sternocleidomastoid masses require a more invasive approach. Generally, it is identified around three to six months post-birth and follows a long-term intervention plan.³

Pathophysiological interactions in acquired torticollis

While the SCM is the primary muscle affected in AT, other cervical muscles, such as the splenius capitis or trapezius, may also become involved secondarily.

To explain, the muscles in the neck attempt to compensate for the damage to the SCM. Consequently, this damage to SCM strains the cervical muscles – trapezius, scapula, splenius, scalenes, and platysma – at the top of the spine, along with eight pairs of cervical nerves. This form of AT is called cervical dystonia or spasmodic torticollis.⁴

Cervical dystonia

Continuous tension can misalign the muscles and harm muscle health. Cervical dystonia can be further divided into two categories: primary and secondary.

Primary cervical dystonia

Primary cervical dystonia can be identified by the absence of basal ganglia. These are a collection of nuclei in the brain that are responsible for voluntary movement. This gap in the brain could be due to genetics or stroke.

Secondary cervical dystonias

Secondary cervical dystonias arise from more external factors, such as trauma or drug use.

AT is further subcategorised based on its causes. For example, AT is subcategorised as spasmodic torticollis or cervical dystonia that causes a rigid neck from increased muscle tone due to various triggers, including emotional stress, physical overload, or sudden movements.

The factors causing muscle ill-health can trigger unwanted signalling, which leads to involuntary neck muscle spasms.⁵ 

Diagnostics 

Torticollis is primarily diagnosed with a physical exam and medical history. However, each type of torticollis has its defining features. 

Congenital torticollis can be diagnosed through imaging using ultrasound, MRI (magnetic resonance imaging), or CT (computed tomography) scan. This can allow doctors to assess muscle and neural structures. Highlighting features include:

• Reduced neck range of motion 
• Significant SCM mass
• Head position preference 

For young infants, newborns - 2 months, ultrasonography is used. Using this technique, doctors assess neck masses and monitor the child post-treatment. The MRI scan is used to rule out the non-muscular causes. 

For this condition, the pathophysiological lens is crucial to look through, as there are several similar diseases that torticollis could be mistaken for. For example, Parkinson's disease or multiple sclerosis.³

Treatments based on pathophysiology 

Treatment for torticollis is dependent on the specific type of torticollis the individual is experiencing. However, time is of the essence. The sooner the child receives treatment, the greater the chances for recovery. It is said that ‘if treatment begins before six months, 97% of infants will improve’.³ For the most effective results, several personalised approaches can be taken:

• Physiotherapy 
• Neurology 
• Orthopaedic surgery 
• Neurosurgery

It is important to further note that recovery rates of torticollis vary between categories, and recurrences are a common factor in all of them. It would be beneficial to pair a patient with a nurse or therapist to help navigate what could be a frustrating journey to recovery.

In torticollis treatment, a team of specialists, involving physicians, nurses, physical therapists, and chiropractors, assemble. This is all to ensure the well-being of the individual with torticollis.

Physiotherapies can be combined with medicine in most cases of torticollis.⁵ The main medicines used include:⁵

• Muscle relaxants 
• Anxiety/spasms treatments 
• Botulinum toxin injection (Botox)

For infants, a more aggressive approach can be taken as a first-line treatment:

• ‘Helmet therapy’ is commonly used where there is moderate to severe asymmetry
• Consistent neck rotations on the affected side to avoid stiffness
• Lateral rotations and flexing can also help in treating torticollis

These at-home treatments have to be handled with care. Parents and carers must be very educated on how to safely move the neck.³ 

FAQs

Is torticollis hereditary?

Torticollis is not known to be hereditary. However, congenital torticollis may have some genetic links involved. Currently, research is being done on the matter. 

Can torticollis resolve on its own?

This depends on the severity of the case. Mild cases of torticollis in early infants can be settled if the proper therapies are carried out. 

How is torticollis linked to neurological dysfunction?

The damage to the basal ganglia is what causes various types of torticollis. The nerves can be disrupted through stroke, multiple sclerosis, or cranial nerve damage. 

What are the risk factors for torticollis?

Each kind of torticollis can be caused by various causes. This ranges from prolonged poor posture to trauma at birth and neurological factors. 

Summary  

• Torticollis can be identified by the abnormal twisting of the neck and head due to muscular/neurological causes
• Congenital and acquired torticollis are the two most common types
• Congenital torticollis occurs at birth and involves the shortening of the sternocleidomastoid muscle (SCM) linked to birth trauma 
• Acquired torticollis develops due to later traumas in childhood or adulthood 
• Neurological contributions involve the dysfunction of the basal ganglia, which is crucial in motor movement and damage to peripheral nerves 
• Muscular contribution rides on the function of the SCM, which plays a central role. This causes muscle imbalances in the neck and spine, causing deterioration in muscle health 
• The muscles and neural signals create a feedback loop where one impacts the other and vice versa
• Treatments involve a combination of physiotherapy and a medicinal approach