Introduction

What is post traumatic torticollis?

The appearance of abnormal neck or shoulder alignment after localized trauma is an indication of posttraumatic cervical dystonia (PTCD).¹ Torticollis is defined as abnormal rotation and tilting of the head and neck due to a contracted sternocleidomastoid muscle, leading to the tilting of the head toward the involved muscle and rotation of the chin in the opposite direction. This condition can occur in anyone in all age groups, from infants to adults. Torticollis can be divided into two different types: congenital and acquired after birth.²

Clinical manifestations

A characteristic, painful, fixed head tilt and shoulder elevation,  painful contralateral shoulder depression, as well as non dermatomal sensory loss, dystonic posturing in a limb, jaw, limb tremor, limb weakness.¹

Risk factors

Major causes of this condition include abnormal movements, trauma, infection/inflammation, congenital abnormalities, ophthalmologic, gastrointestinal, neuromuscular diseases, and tumors.³

Mechanism

Peripheral trauma 

Direct injury to the neck muscles or soft tissues may cause abnormal muscle contractions. A study documented cases of torticollis that occurred shortly after neck trauma, thus implying a direct association between peripheral injury and the development of dystonia.⁴

Central nervous system involvement

Trauma may disrupt central motor pathways, which leads to dystonic movements. Psychological factors and central mechanisms have been found to be involved in the development and persistence of abnormal posturing and pain in these patients.¹ 

Psychological factors 

Stress and psychological conflict may be expressed somatically, thereby contributing to the perpetuation of torticollis. In one study, psychological assessments indicated that psychological factors were being expressed through somatic channels in patients with post-traumatic torticollis.¹

Clinical presentation and diagnosis

A comprehensive assessment of the patient with torticollis includes a careful history, physical examination, and in some cases, radiographic examination. A history of trauma-even seemingly minor trauma-is important Trauma may result in acute muscle spasm, the most common cause of trauma-associated torticollis. It may also produce a C1-C2 subluxation, which can lead to serious neurologic deficit.⁵

Physical examination

The nasopharynx should be inspected carefully: retropharyngeal and retrotonsillar abscesses are commonly identified in acute torticollis. Cervical lymph nodes and the thyroid gland should be palpated Lymphadenitis and hyperthyroidism have been identified as causes.

Palpation of the neck should include assessment of the size and texture of the sternocleidomastoid muscles and assessment for any cervical masses.

Ocular or vestibular signs should be documented, and a full neurologic examination is required.

X-RAY EXAMINATION-Cervical spine roentgenography is always required when trauma is suspected or when cervical fracture is suspected and must include odontoid, anteroposterior, lateral, and oblique views. Cervical spine films may also be ordered if the patient's symptoms do not quickly respond to conservative management. X-ray films are usually negative but when positive in acute traumatic torticollis, the most common findings include C2-C3 subluxation or Cl-C2 rotary subluxation.

Excludes the possibility of rotary subluxation or fracture. He draws attention to the fact that any delay in immobilization may result in injury to cervical nerve roots, the cervical spinal cord, or the cervicomedullary junction. If neurologic deficits are noted, computed tomography (CT), magnetic resonance imaging (MRI), or myelography may be indicated. Vertebral angiography may be needed for identification of vascular compression.^5,6,7

Treatment and management

Treatment of torticollis is aimed at correcting the underlying disease process. Conservative therapy is advocated by most authors. Surgical measures are only very rarely needed in resistant cases and in some rare situations such as tumor-caused muscle contracture. The nuchal pain that results from chronic head torsion often requires special physiotherapy, nerve or facet blocks, and psychotherapy, If bacterial infection exists it must be treated. For acute pain: A muscle relaxant intramuscularly and then prescribe oral tablets. I request that the neck be massaged with ice at bedtime. Therapy begins with assessment of active cervical range of motion (voluntary movement by the patient) palpating the cervical muscles, noting temperature as well as the presence of moisture, firmness, bogginess, or thickening. Passive range of motion of the cervical spine is assessed to determine resistance. Soft tissue stretching is done, Manual traction is applied in a longitudinal axis to the fibers of the sternocleidomastoid After these therapeutic measures are completed, ultrasound may be applied to the cervical musculature for 15 minutes. The patient is then given instruction in home therapy, including active cervical range-of-motion exercises and muscle-resistance techniques. In cases where muscle spasms are severe or persistent, botulinum toxin injections may be considered. These injections can help relax the affected muscles by blocking nerve signals that cause muscle contractions.^4,8

Prognosis

Early Intervention: Treatment should be initiated as soon as symptoms arise. Early intervention has been shown to have a positive outcome and reduce the period of rehabilitation. Several studies have shown that a considerable percentage of patients achieve complete recovery if treatment is instituted promptly and appropriately.⁹

Summary

Post-traumatic torticollis is a complex condition that results from trauma-induced disruptions in musculoskeletal, neurological, and psychological systems. It manifests as abnormal head positioning, muscle spasms, and pain, significantly impacting a patient’s quality of life. Early and accurate diagnosis through clinical evaluation and imaging is essential to rule out serious complications like cervical subluxation or vascular compression.

Treatment primarily focuses on conservative management, including physical therapy, pain relief, and muscle relaxation techniques. In severe cases, botulinum toxin injections may provide symptom relief, while surgical interventions are reserved for resistant or structurally compromised cases. Rehabilitation plays a crucial role in restoring neck mobility, preventing long-term complications, and improving overall prognosis.

The prognosis is generally favorable with early intervention, as timely physiotherapy and medical treatment can lead to full recovery in many cases. However, delayed diagnosis or inadequate rehabilitation can prolong symptoms and lead to chronic complications. Moving forward, a multidisciplinary approach that integrates neurological, musculoskeletal, and psychological care is essential for optimal management. Future research should focus on improving treatment modalities and identifying early biomarkers for better patient outcomes.

FAQ’s

What is post-traumatic torticollis?

Post-traumatic torticollis is a condition where abnormal head and neck positioning occurs after an injury. It results from muscle spasms, nerve involvement, or structural damage in the cervical spine.

What causes post-traumatic torticollis?

It is primarily caused by direct trauma to the neck muscles, ligaments, or vertebrae. Other contributing factors include whiplash injuries, neurological disturbances, and psychological stress.

What are the symptoms of post-traumatic torticollis?

• Painful head tilt and restricted neck movement
• Muscle stiffness and spasms
• Shoulder elevation or misalignment
• Neurological symptoms like tremors or sensory loss in severe cases

How is post-traumatic torticollis diagnosed?

A diagnosis is made through: 

• Physical examination (assessing muscle tightness and posture)
• X-rays and MRI scans (to check for fractures or subluxations)
• Neurological tests (if nerve involvement is suspected)

What are the treatment options for post-traumatic torticollis?

• Treatment depends on severity and includes:
• Pain management: NSAIDs, muscle relaxants
• Physical therapy: Stretching, strengthening exercises, manual therapy
• Botulinum toxin injections: For persistent muscle spasms
• Surgical intervention: Only in rare, severe cases