Treatment for Torticollis

Treatment  for torticollis (We will discuss only for Dystonic torticollis)

Physiotherapy

1. Passive stretching and proper head positioning : It is very helpful in infants and small children. In passive stretching, a strap is used to hold the head in a certain position to release the tension.
2. Tummy time: Laying your baby on the stomach for a short period while awake. It helps strengthen neck and shoulder muscles and prepares the baby for crawling.
3. These modalities often help and bring improvement, but should be started at 3 months of age.
4. Hot fermentation, traction to the neck and massage may help to relieve pain in the head and neck region.
5. Stretching exercises and neck braces help with relieving muscle spasms.

Medical treatment for Dystonic torticollis

1. Anticholinergic drugs are very effective for the treatment of torticollis. Dose is increased gradually to avoid side effects. Trihexyphenidyl is a central muscarinic antagonist and helps in symptomatic treatment of segmental and generalized dystonia. Benztropine, an anticholinergic, blocks presynaptic dopamine uptake. Side effects such as dry mouth and eyes, constipation, dizziness, confusion, urinary retention, hallucinations, increased heart rate.

2. Benzodiazepines, such as clonazepam are effective in decreasing the pain as well as anxiety associated dystonia.
3. Baclofen helps to reduce neck muscle contractions. This is of limited value and can produce drowsiness.
4. Dopaminergic drugs, for example, Levodopa, and dopamine reducing medications such as tetrabenazine, clozapine, quetiapine. These medications have to be supervised by an expert in the field as sometimes they can also worsen the symptoms.
5. Botulinum toxin injection, is injected in the abnormally contracting muscles every 3 months, for symptomatic temporary relief. Injection, has to be done in the affected neck muscles. If blindly injected, it would not provide any relief. The neck muscles can be identified either by EMG or Ultrasound. This is supplemented with the clinical knowledge of the dystonic muscles. Unfortunately, the treatment requires huge dose of botulinum toxin and it is quite expensive. After a few sessions, patients develop resistance (develop antibodies) making it difficult to get the same response.
6.  Anti-depressants, role is limited, but helps with psychogenic causes.

Surgical Treatment for Dystonic torticollis

There are two forms of surgical treatment. One is cervical rhizotomy and the second is deep brain stimulation.

1. Selective peripheral denervation / Cervical Rhizotomy

Indicated in patients with cervical dystonia / torticollis who do not achieve adequate response with medical treatment or repeated botulinum toxin injection. Rhizotomy could be the best option in such patients. About 2/3^rd patients achieve long-term improvement.

Selective peripheral denervation is the best surgical option for these patients. It is not indicated in patients who have symptoms like blepharospasm and laryngeal spasm in addition to cervical dystonia.

he procedure is done under general anaesthesia, to avoid any discomfort to the patient.

First nerves supplying the affected muscles of the neck are selectively resected.

A small incision is given at the back of the neck. Nerves outside the spinal canal, which are supplying the affected muscles, are first identified and stimulated under Neurophysiologic guidance and then only, each nerve is carefully identified and resected under the microscope, this way, affected muscles are denervated without damaging any important structures.

The adequacy of denervation is determined with the help of signals recorded from each muscle before and after the resection of the nerves. Once denervation is over, the patient is turned on his back and the front of the neck is prepared.

One of the muscles which is responsible for torticollis is sternocleidomastoid in the neck. Another small incision is made on the neck and the nerve supplying this muscle is resected. Similarly, the nerve supplying the muscle which is responsible for elevation of shoulder in torticollis is carefully resected.

The complete procedure is done under Neurophysiological monitoring, so results are extremely good. The total duration of stay in the hospital is around 7 days. Procedure is performed only at various Select Centres around the word.

It has been pioneered by Professor Taira from Japan, and we are the only centre in India that performs this surgery. One of the biggest advantage of this surgery is that,  it is a one time procedure and does not involve any implants.

2. Thalamotomy

Thalamotony, ventralis oralis internus (VOI) nucleus is the target for lesioning in Thalamotomy.

Unilateral thalamotomy results in minor improvement in axial and cervical dystonia, whereas bilateral thalamotomy is more effective.

There is a 10%-40% risk of serious complications such as bulbar weakness leading to hypophonia, dysphagia, dysarthria, cognitive impairment and ataxia. Thalamotomy does not give immediate results, but progressive benefit is seen over weeks to months. The surgery is not recommended by most functional neurosurgeons.

3. Deep Brain Stimulation Surgery 

Deep Brain Stimulation of Globus pallidus interna (GPi) for all types of dystonia, especially dystonia associated with Parkinson’s disease and generalized dystonia.

This is the most common surgical procedures performed around the word. The detailed description of deep brain stimulation is given elsewhere on this website. It can be offered for a stand alone focal cervical dystonia or cervical dystonia associated with other disorders like generalised dystonia, secondary dystonia etc.

The success rate of this surgery is pretty high and around 70% to 80% of the Patient’s confirmed adequate suppression of symptoms and resumption of the activities of daily living. This is a relatively safe procedure and has been tried and applied to large number of patients around the world.

Improvement in symptoms is gradual and may take weeks to months post-surgery.

The advantage of DBS is that is has the additional benefit of titrability. We usually recommend DBS for patients having associated symptoms of dystonia in the upper limb or likely to develop dystonia or other body parts. In all other pure cervical dystonia patients, we recommend Cervical Rhizotomy.

For details of the procedure click on – Deep Brain stimulation