Torticollis refers to abnormal cervical procedures, which are characterized by tonic or intermittent spasms of neck muscles that cause involuntary deviation of head from the normal position.

Torticollis (wry neck, or loxia) is a type of movement disorder that show extension, flexion, or twisting of muscles of the neck beyond their normal position. The Latin definition of torticollis means “twisted neck”. (Fig. 1) Torticollis results in a dynamic or fixed posturing of the head and neck in tilt, rotation, and flexion. Spasms of the neck muscles are usually more prominent on one side than the other causing tilting of the head.

Torticollis is most commonly observed, in mid-adult life with an incidence being between 30 to 40 years of age. Initially torticollis begins with a feel of tension in the neck muscles for months before the manifestation of dystonia. This is followed by intermittent posturing of the neck with head turning. Over a period of time this becomes constant and fixed, only abating during sleep. Symptoms may progress rapidly over several weeks or gradually over several years until a plateau is typically reached 3 to 5 years after the initial manifestation. Though temporary, spontaneous remission of torticollis have been known. Permanent remission is almost unusual.

Spasmodic torticollis is an adult onset focal or segmental dystonia with a variable combination of neck flexion, extension, rotation and tilting. Each patient has a characteristic dystonic posturing. This dystonic posture is present at rest, worsen with action or stress, and improve or resolve completely during sleep.

Types of torticollis

Rotational torticollis– is a rotation of the chin around the longitudinal axis towards the shoulder.
Laterocollis– It is a lateral tilt of the head in the coronal plane with the ear moving toward the shoulder.
Anterocollis– It is a forward deviation of the head in the sagittal plane with the chin moving towards the chest.
Retrocollis– It is the backward deviation of the head in the sagittal plane thereby elevating the chin and moving the occiput towards the upper back.

Primary or Idiopathic torticollis
Idiopathic spasmodic torticollis (IST) is a chronic, progressive form of torticollis classified as a focal dystonia. Abnormalities of basal ganglia (deep seated nuclei of the brain) have been implicated in its pathogenesis, though the exact cause is not known. This torticollis starts with mild posturing but later on becomes severe. It affects the day to day activities of a person. It typically worsens during the first 5 years of onset and then eventually plateaus. It manifests as either fixed form or intermittent jerky form or a combination of both. Spontaneous remission is seen in 20% of patients but it is usually not complete or prolonged. Also, nearly all patients relapse within 5 years.

Secondary torticollis
Secondary torticollis is not commonly seen.
It can be caused by

  • Focal brain lesions of various origins,
  • Neurodegenerative disorders,
  • Metabolic disorders, and
  • Drugs and chemicals that affect the basal ganglia, thalamus, and brainstem
  • Following peripheral injury [79–81].

Non- dystonic or Pseudodystonia are the disorders that are associated with sustained muscle contractions probably due to reflex mechanisms or reaction to some other disturbance
e.g. Tilting of the head to improve vision in 4th nerve palsy or in hemianopia.
Non-dystonic torticollis can be divided into:

  • Congenital Torticollis
  • Acquired Torticollis

Congenital Torticollis-

  • In utero malposition or birth trauma
  • Malformations of cervical spine
  • Hypertrophy of cervical muscles
  • Arnold-chairi malformation

Acquired Torticollis
– CNS mass lesions, abnormalities of the cervical spine, and local head and neck infections are more likely. Psychiatric causes may occur during adolescence.

  • Cervical musculoskeletal abnormalities like AAD, fracture clavicle, scapula
  • Infections like cervical spine osteomyelitis
  • Neurological causes like syringomyelia, tumours
  • Other causes like psychogenic, benign paroxysmal torticollis