9.02 Torticollis (Wry Neck)

agk’s Library of Common Simple Emergencies

Presentation

The patient complains of neck pain and is unable to turn his head, usually holding it twisted to one side, with some spasm of the neck muscles, with the chin pointing to the other side. These symptoms may have developed gradually, after minor turning of the head, after vigorous movement or injury, or during sleep The pain may be in the neck muscles or down the spine, from the occiput to between the scapulae. Spasm in the occipitalis, sternocleidomastoid, trapezius, splenius cervicis, or levator scapulae muscles can be the primary cause of the torticollis, or it can be secondary to a slipped facette, herniated disc, or viral or bacterial infection.

What to do:

Ask the patient about precipitating factors, and perform a thorough physical examination, looking for muscle spasm, point tenderness, and signs of injury, nerve root compression, masses or infection. Include a careful nasopharyngeal examination, as well as a basic neurologic exam.
When forceful trauma is was involved and fracture, dislocation or subluxation are possible, then obtain lateral, anteoposterior and odontoid roentgenographic views of the cervical spine. If there are neurologic deficits, computed tomography or magnetic resonance imaging may be better to visualize nerve involvement (as well as herniated disks, hematomatas or epidural abscesses).
When there is no suspicion of a serious illness or injury, apply heat (e.g., a Hydrocolator pack wrapped in several thicknesses of towel); give anti inflammatory analgesics (e.g., aspirin, ibuprofen, naproxen), and perhaps oral cyclobenzaprine (Flexeril) or diazepam (Valium). Alternating heat with ice massages may also be helpful as well as gentle range of motion exercises.
If the onset was gradual, muscle tenderness and spasm are pronounced, neck motion seems constrained only by muscle stretching, and the symptoms are most severe when certain muscles are stretched, myalgias are probably the cause, and the routine above constitutes the treatment.
If there is point tenderness posterior to the sternocleidomastoid muscle (over the vertebral facets) and the head cannot turn toward the side of the point tenderness, suspect a facet syndrome, obtain x rays, and gently test neck motion again after a few minutes of manual tractiton along a longitudinal axis (sometimes this provides some relief).
If there is any arm weakness or paresthesia corresponding to a cervical dermatome, suspect nerve root compression as the underlying cause, and arrange for x rays and neurosurgical or orthopedic consultation.
With signs and symptoms of infection (e.g., fever, toxic appearance, lymphadenopathy, tonsillar swelling, trismus, pharyngitis or dysphagia) take soft tissue lateral neck films and consider complete a blood count and erythrocyte sedimentation rate to help rule out early abscess formation. Arrange for specialty consultation.
For minor causes, discharge the patient with a soft cervical collar for further relief, and arrangements for x rays and followup if the torticollis has not fully resolved in 1 or 2 days.

What not to do:

Do not overlook infectious etiologies presenting as torticollis, especially the pharyngiotonsillitis of young children, which can soften the atlantoaxial ligaments and allow subluxation.
Do not undertake violent spinal manipulations in the ED, which can make an acute torticollis worse.
Do not confuse torticollis with a dystonic drug reaction from phenothiazines or butyrophenones.

Discussion

Although torticollis may signal some underlying pathology, usually it is a local musculoskeletal problem – only more frightening and noticeable for being in the neck – and need not always be worked up comprehensively when it first presents in the ED.

Illustration

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