Torticollis (Wry Neck)

Torticollis and wry neck are the same condition. "Torticollis" comes from the Latin tortus (twisted) + collum (neck); "wry neck" is simply its English common name. The terms are interchangeable in clinical literature.

A child with torticollis - head tilted to one side with chin pointing to the opposite side

Clinical appearance of torticollis - S Das: A Manual on Clinical Surgery, 13th Ed

Definition

Torticollis is a deformity in which the head is bent (tilted) to one side while the chin points to the opposite side, due to contraction or spasm of the sternocleidomastoid (SCM) muscle and adjacent cervical muscles. In the head, the SCM tilts to its own side and rotates to the contralateral side.

Bailey and Love's Short Practice of Surgery, 28th Ed: "In torticollis the head is tilted towards and rotated away from the tight sternocleidomastoid muscle."

Classification and Types

Type	Key Features
Congenital	Birth/intrauterine origin; SCM fibrosis/tumour; most common
Traumatic	Fracture-dislocation of the cervical spine
Rheumatic	Sudden onset after cold/draught exposure
Inflammatory	Inflamed cervical lymph nodes (e.g., Grisel syndrome)
Spasmodic (Dystonic)	Idiopathic cervical dystonia; adult-onset; neurological
Compensatory	Secondary to scoliosis, ocular problems (ocular torticollis)
Pott's disease	Tuberculosis of the cervical spine
Contracture	Post-burn, post-ulcer scarring
Paroxysmal	Benign paroxysmal torticollis (associated with migraine/BPV in children)

1. Congenital Muscular Torticollis (CMT)

The most common form, presenting in infancy.

Pathogenesis

Fibrosis of the SCM muscle, resulting in a palpable "tumour" (sternomastoid tumour)
Histologically: collagen and fibroblast deposition around atrophied muscle cells (Schwartz's Principles of Surgery)
Proposed causes: malposition/intrauterine constraint, birth trauma (tearing of SCM fibers with haematoma formation), intrauterine compartment syndrome, vascular injury, primary SCM myopathy
Also occurs in C-section deliveries, confirming intrauterine factors

Clinical Features

Head tilted toward the affected (tight) SCM, chin rotated away
Palpable firm/rigid mass in the muscle in ~2/3 of cases
In long-standing cases: facial hemiatrophy on the affected side (smaller eye-to-mouth distance, flattened nose, less arched eyebrow, less full cheek - due to impaired vascular supply from restricted mobility)

Investigations

Diagnosis usually clinical (characteristic fibrotic nodule)
USS: evaluates SCM thickness and predicts need for surgery; useful in management
Cervical spine X-ray: if congenital vertebral anomaly suspected
MRI: if neurological findings present

Treatment

Non-operative (first-line):

Stretching exercises during infancy
Early intervention (before 3-4 months) achieves 92-100% full passive neck rotation; only ~1% need surgery
For every month treatment is delayed, surgical risk increases
Established facial asymmetry or >30° motion restriction at start of treatment predicts a poor outcome
If CMT persists beyond 1 year, non-operative treatment is rarely successful

Surgical:

Release of SCM origin and/or insertion
Indicated when non-operative treatment fails or if significant restriction persists
Campbell's Operative Orthopaedics (2026): surgery for neglected cases improves health-related quality of life; botulinum toxin combined with PT may help resistant cases

2. Spasmodic Torticollis (Idiopathic Cervical Dystonia)

A neurological form, distinct from congenital/mechanical types.

Features

Most frequent form of focal (restricted) dystonia
Onset: early to middle adult life; slightly more common in women (peak 5th decade)
Usually idiopathic; rare DYT1 gene abnormality in some patients
Quality of movement: intermittent turning/tilting, smooth or jerky, or sustained deviation to one side
Often accompanied by irregular high-frequency tremor
Gestes antagonistes ("sensory tricks"): placing a hand on the chin/neck, counterpressure, or resting occiput on a high-backed chair reduces spasms (becomes less effective over time)
Spasms worse on standing/walking; reduced when lying down
Chronic cases: muscle hypertrophy and pain
Muscles affected: SCM, levator scapulae, trapezius, posterior cervical muscles bilaterally
~15% also have oral/mandibular/hand dystonia; ~10% have blepharospasm

Treatment (Adams and Victor's Principles of Neurology, 12th Ed)

Modality	Notes
Botulinum toxin	Injection every 3-6 months into affected muscles (guided by palpation + EMG); ~90% response rate; first-line
Anticholinergics	Trihexyphenidyl/benztropine - partial relief; poorly tolerated at effective doses
Deep brain stimulation (DBS)	Globus pallidus interna or subthalamic nucleus; for refractory cases; some adverse effects (dysarthria, dyskinesia)
Surgical denervation	Combined sectioning of spinal accessory nerve + first 3 cervical motor roots (bilateral); reserved for severe refractory cases; 1/3 to 1/2 long-term relief
Spontaneous remission	Occurs in 10-20% (usually early-onset cases); nearly all relapse within 5 years

Key Comparison: Congenital vs Spasmodic Torticollis

Feature	Congenital Muscular	Spasmodic (Dystonic)
Age of onset	Birth/infancy	Adult (peak 5th decade)
Cause	SCM fibrosis/trauma	Idiopathic cervical dystonia
SCM finding	Firm palpable mass	Muscle hypertrophy (late)
Movement quality	Fixed positional deformity	Intermittent, jerky, or sustained
Sensory trick	Absent	Present (geste antagoniste)
Facial asymmetry	Yes (long-standing)	No
First-line treatment	Physiotherapy/stretching	Botulinum toxin
Surgery	SCM release	DBS / nerve sectioning (refractory)

Sources:

S Das: A Manual on Clinical Surgery, 13th Ed, pp. 377-378
Bailey and Love's Short Practice of Surgery, 28th Ed
Schwartz's Principles of Surgery, 11th Ed
Campbell's Operative Orthopaedics, 15th Ed (2026)
Adams and Victor's Principles of Neurology, 12th Ed, pp. 109-111
The Developing Human - Clinically Oriented Embryology

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