Slide 082 — Torticollis

Clean FRCS notes with inline figures

•This is a clinical photo showing a paed patient with right sided torticollis

•Evidenced by the head tilting to the right side and rotating to the left side

•There is no plagiocephaly or facial asymmetry noted, over the neck there is no scar, no obvious strabismus noted

•Cock robin posture

History

•Perinatal history (Breech, 1st born, oligohydramios), known congenital conditions (e.g. Klippel Feil syndrome)

•PAIN

Acute painful vs chronic painless

•Onset of symptoms, progression, trauma, previous treatment or H&N

•Any hearing or optical impairment

•Any recently URI sx

•Functional impairment

Examination

•1. Plagiocephaly, low hair line, scapula (KF syndrome)

•2. Facial dysmorphic features or facial asymmetry

•3. SCM spasm, tumour, cervical LN

•4. Rotation and tilt lag 15deg

•5. Squint, hearing

•6. Neuro exam

•If newborn, look for other packaging disorders

Investigations

•Bloods: CBC, inflammatory markers

•Xray look for lateral mass asymmetry in open mouth view, lateral to see ADI, trapezoidal anterior C1 shadow, oval posterior arch sign. Also to exclude fracture or congenital abnormalities

•Dynamic CT is gold standard for AARI (only book it if failed initial conservative management)

•Look for fixed rotation of C1/2 relationship

•+/- contrast to r/o retropharyngeal abscess if raised inflammatory markers

•+/- MRI to exclude underlying infection or tumor

Fielding CT classification:

•Unilateral subluxation with intact transverse ligament (dens is the pivot point)

•Unilateral ant subluxation 3-5mm (opposite facet acts as pivot)

•Bilateral ant subluxation >5mm

•Post subluxation (dens deficiency)

•Dynamic CT (3 sets) to look for fixed relationship between C1 and C2

•Normal C1/2 rotation

•Phase 1-3

Type / group	Definition / note
1	Purely C1 rotate, up to 21deg (SCM pulls skull, OC segment no rotation)
2	C1 C2 rotate together, (C2 pulled by alar ligament)
3	C1 C2 fixed and rotate together

•Mx depends on timing

•<1w: Soft neck collar, analgesics

•1-4w: (“1hr off ,3hr on” cycle) 2-3kg till reduced with reverse Trendelenburg (full rotation over both direction) then SOMI 4wk (if failed after 4w to OT)

•>4w: Halo traction 4w as well, high chance of failure then OT x fuse C1/2 (other indications: irreducible >3 months, neurological deficit, recurrent)

•Grisel’s syndrome: drainage of inflammatory mediators through pharyngovertebral vein to periodontoid plexus → ligamentous laxity

•CMT

•Remember to look for other packaging disorders

•Pathophysiology: local compartment syndrome of SCM avascular fibrous band formation

•Operation

•Presentation >1yo

•>15 deg Head tilt, lag, with tumour

Failed conservative management x 6m

•Unipolar (sternal head <3, sternal + clavicular head 3-10)

•Bipolar in > 10 year

•(alternative is Z plasty)

•Bipolar release in a nutshell

•2cm incision below mastoid, strip attachment from bone

•2cm incision above the sterno-clavicular jx, incise platysma, then cut both heads of SCM together w/ the deep fasica;

Postop:

•Intensive stretching for 3 months

•>2yo → add adjustable torticollis brace for 3 months

Dangers in bipolar release?

•Surface – greater auricular nerve

•Underneath – CNXI

•Anterior - facial nerve

Evidence on CMT:

•Cheng 2001 JBJS

•800 patients < 1yo onset

•95% good response to physiotherapy (address flexion, rotation, tilting), mean FU 4.5 yr

•Poor prognostic factors: >15deg rotation deficit, SCM tumor, late presentation (present >1yo)

Torticollis causes:

Congenital: (usually painless):

•CMT, Klippel Feil

Acquired:

•Osseous – AARI (trauma, tumor, infection, odontoid hypoplasia in Down’s and Achondroplasia, JRA/RA) (usually painful)

•Non Osseous – ENT, eye (Squint), CNS (Arnold chiari), Postural (usually painless), neck burns

Child more likely to have AADI:

•Capsular laxity due to hormonal cause

•Facet more transverse

#	lvl	marL	indent	logical	original note line
1	0	None	None	0	This is a clinical photo showing a paed patient with right sided torticollis
2	0	None	None	0	Evidenced by the head tilting to the right side and rotating to the left side
3	0	None	None	0	There is no plagiocephaly or facial asymmetry noted, over the neck there is no scar, no obvious strabismus noted
4	0	None	None	0	Cock robin posture
5	0	None	None	0	Hx
6	0	None	None	0	Perinatal history (Breech, 1st born, oligohydramios), known congenital conditions (e.g. Klippel Feil syndrome)
7	0	None	None	0	PAIN
8	0	None	None	0	Acute painful vs chronic painless
9	0	None	None	0	Onset of symptoms, progression, trauma, previous treatment or H&N
10	0	None	None	0	Any hearing or optical impairment
11	0	0	0	0	Any recently URI sx
12	0	0	0	0	Functional impairment
13	0	None	None	0	PE
14	0	None	None	0	1. Plagiocephaly, low hair line, scapula (KF syndrome)
15	0	0	0	0	2. Facial dysmorphic features or facial asymmetry
16	0	None	None	0	3. SCM spasm, tumour, cervical LN
17	0	None	None	0	4. Rotation and tilt lag 15deg
18	0	None	None	0	5. Squint, hearing
19	0	None	None	0	6. Neuro exam
20	0	None	None	0	If newborn, look for other packaging disorders
21	0	None	None	0	Ix:
22	0	None	None	0	Bloods: CBC, inflammatory markers
23	0	0	0	0	Xray look for lateral mass asymmetry in open mouth view, lateral to see ADI, trapezoidal anterior C1 shadow, oval posterior arch sign. Also to exclude fracture or congenital abnormalities
24	0	0	0	0	Dynamic CT is gold standard for AARI (only book it if failed initial conservative management)
25	0	0	0	0	Look for fixed rotation of C1/2 relationship
26	0	0	0	0	+/- contrast to r/o retropharyngeal abscess if raised inflammatory markers
27	0	0	0	0	+/- MRI to exclude underlying infection or tumor
28	0	0	0	0	Fielding CT classification:
29	1	685800	-228600	2	Unilateral subluxation with intact transverse ligament (dens is the pivot point)
30	1	685800	-228600	2	Unilateral ant subluxation 3-5mm (opposite facet acts as pivot)
31	1	685800	-228600	2	Bilateral ant subluxation >5mm
32	1	685800	-228600	2	Post subluxation (dens deficiency)
33	0	0	0	0	Dynamic CT (3 sets) to look for fixed relationship between C1 and C2
34	0	0	0	0	Normal C1/2 rotation
35	0	0	0	0	Phase 1-3
36	1	457200	0	1	1: Purely C1 rotate, up to 21deg (SCM pulls skull, OC segment no rotation)
37	1	457200	0	1	2: C1 C2 rotate together, (C2 pulled by alar ligament)
38	1	457200	0	1	3: C1 C2 fixed and rotate together
39	0	0	0	0	Mx depends on timing
40	0	0	0	0	<1w: Soft neck collar, analgesics
41	0	0	0	0	1-4w: (“1hr off ,3hr on” cycle) 2-3kg till reduced with reverse Trendelenburg (full rotation over both direction) then SOMI 4wk (if failed after 4w to OT)
42	1	0	0	1	>4w: Halo traction 4w as well, high chance of failure then OT x fuse C1/2 (other indications: irreducible >3 months, neurological deficit, recurrent)
43	0	0	0	0	Grisel’s syndrome: drainage of inflammatory mediators through pharyngovertebral vein to periodontoid plexus → ligamentous laxity
44	0	0	0	0	===================================
45	0	None	None	0	CMT
46	0	None	None	0	Remember to look for other packaging disorders
47	0	None	None	0	Pathophysiology: local compartment syndrome of SCM avascular fibrous band formation
48	0	None	None	0	OT:
49	0	171450	-171450	1	Presentation >1yo
50	0	171450	-171450	1	>15 deg Head tilt, lag, with tumour
51	0	171450	-171450	1	Failed conservative management x 6m
52	0	0	0	0	Unipolar (sternal head <3, sternal + clavicular head 3-10)
53	0	0	0	0	Bipolar in > 10 year
54	0	0	0	0	(alternative is Z plasty)
55	0	None	None	0	Bipolar release in a nutshell
56	0	None	None	0	2cm incision below mastoid, strip attachment from bone
57	0	None	None	0	2cm incision above the sterno-clavicular jx, incise platysma, then cut both heads of SCM together w/ the deep fasica;
58	0	0	0	0	Postop:
59	0	0	0	0	Intensive stretching for 3 months
60	0	0	0	0	>2yo → add adjustable torticollis brace for 3 months
61	0	0	0	0	Dangers in bipolar release?
62	0	171450	-171450	1	Surface – greater auricular nerve
63	0	171450	-171450	1	Underneath – CNXI
64	0	171450	-171450	1	Anterior - facial nerve
65	0	0	0	0	Evidence on CMT:
66	0	0	0	0	Cheng 2001 JBJS
67	0	0	0	0	800 patients < 1yo onset
68	0	0	0	0	95% good response to physiotherapy (address flexion, rotation, tilting), mean FU 4.5 yr
69	0	0	0	0	Poor prognostic factors: >15deg rotation deficit, SCM tumor, late presentation (present >1yo)
70	0	0	0	0	===================================
71	0	None	None	0	Torticollis causes:
72	0	None	None	0	Congenital: (usually painless):
73	0	171450	-171450	1	CMT, Klippel Feil
74	0	None	None	0	Acquired:
75	0	171450	-171450	1	Osseous – AARI (trauma, tumor, infection, odontoid hypoplasia in Down’s and Achondroplasia, JRA/RA) (usually painful)
76	0	171450	-171450	1	Non Osseous – ENT, eye (Squint), CNS (Arnold chiari), Postural (usually painless), neck burns
77	0	0	0	0	Child more likely to have AADI:
78	0	0	0	0	Capsular laxity due to hormonal cause
79	0	0	0	0	Facet more transverse

#	semantic level	section?	rewritten line
1	0		This is a clinical photo showing a paed patient with right sided torticollis
2	1		Evidenced by the head tilting to the right side and rotating to the left side
3	1		There is no plagiocephaly or facial asymmetry noted, over the neck there is no scar, no obvious strabismus noted
4	1		Cock robin posture
5	0	yes	History
6	1		Perinatal history (Breech, 1st born, oligohydramios), known congenital conditions (e.g. Klippel Feil syndrome)
7	1		PAIN
8	0	yes	Acute painful vs chronic painless
9	1		Onset of symptoms, progression, trauma, previous treatment or H&N
10	1		Any hearing or optical impairment
11	1		Any recently URI sx
12	1		Functional impairment
13	0	yes	Examination
14	1		1. Plagiocephaly, low hair line, scapula (KF syndrome)
15	1		2. Facial dysmorphic features or facial asymmetry
16	1		3. SCM spasm, tumour, cervical LN
17	1		4. Rotation and tilt lag 15deg
18	1		5. Squint, hearing
19	1		6. Neuro exam
20	1		If newborn, look for other packaging disorders
21	0	yes	Investigations
22	1		Bloods: CBC, inflammatory markers
23	1		Xray look for lateral mass asymmetry in open mouth view, lateral to see ADI, trapezoidal anterior C1 shadow, oval posterior arch sign. Also to exclude fracture or congenital abnormalities
24	1		Dynamic CT is gold standard for AARI (only book it if failed initial conservative management)
25	1		Look for fixed rotation of C1/2 relationship
26	1		+/- contrast to r/o retropharyngeal abscess if raised inflammatory markers
27	1		+/- MRI to exclude underlying infection or tumor
28	0	yes	Fielding CT classification:
29	2		Unilateral subluxation with intact transverse ligament (dens is the pivot point)
30	2		Unilateral ant subluxation 3-5mm (opposite facet acts as pivot)
31	2		Bilateral ant subluxation >5mm
32	2		Post subluxation (dens deficiency)
33	1		Dynamic CT (3 sets) to look for fixed relationship between C1 and C2
34	1		Normal C1/2 rotation
35	1		Phase 1-3
36	1		1: Purely C1 rotate, up to 21deg (SCM pulls skull, OC segment no rotation)
37	1		2: C1 C2 rotate together, (C2 pulled by alar ligament)
38	1		3: C1 C2 fixed and rotate together
39	1		Mx depends on timing
40	1		<1w: Soft neck collar, analgesics
41	1		1-4w: (“1hr off ,3hr on” cycle) 2-3kg till reduced with reverse Trendelenburg (full rotation over both direction) then SOMI 4wk (if failed after 4w to OT)
42	1		>4w: Halo traction 4w as well, high chance of failure then OT x fuse C1/2 (other indications: irreducible >3 months, neurological deficit, recurrent)
43	1		Grisel’s syndrome: drainage of inflammatory mediators through pharyngovertebral vein to periodontoid plexus → ligamentous laxity
44	0		——
45	1		CMT
46	1		Remember to look for other packaging disorders
47	1		Pathophysiology: local compartment syndrome of SCM avascular fibrous band formation
48	1		Operation
49	1		Presentation >1yo
50	1		>15 deg Head tilt, lag, with tumour
51	0	yes	Failed conservative management x 6m
52	1		Unipolar (sternal head <3, sternal + clavicular head 3-10)
53	1		Bipolar in > 10 year
54	1		(alternative is Z plasty)
55	1		Bipolar release in a nutshell
56	1		2cm incision below mastoid, strip attachment from bone
57	1		2cm incision above the sterno-clavicular jx, incise platysma, then cut both heads of SCM together w/ the deep fasica;
58	0	yes	Postop:
59	1		Intensive stretching for 3 months
60	1		>2yo → add adjustable torticollis brace for 3 months
61	0	yes	Dangers in bipolar release?
62	1		Surface – greater auricular nerve
63	1		Underneath – CNXI
64	1		Anterior - facial nerve
65	0	yes	Evidence on CMT:
66	1		Cheng 2001 JBJS
67	1		800 patients < 1yo onset
68	1		95% good response to physiotherapy (address flexion, rotation, tilting), mean FU 4.5 yr
69	1		Poor prognostic factors: >15deg rotation deficit, SCM tumor, late presentation (present >1yo)
70	0		——
71	0	yes	Torticollis causes:
72	0	yes	Congenital: (usually painless):
73	1		CMT, Klippel Feil
74	0	yes	Acquired:
75	1		Osseous – AARI (trauma, tumor, infection, odontoid hypoplasia in Down’s and Achondroplasia, JRA/RA) (usually painful)
76	1		Non Osseous – ENT, eye (Squint), CNS (Arnold chiari), Postural (usually painless), neck burns
77	0	yes	Child more likely to have AADI:
78	1		Capsular laxity due to hormonal cause
79	1		Facet more transverse

082. Torticollis

Clean FRCS notes with inline figures

History

Acute painful vs chronic painless

Examination

Investigations

Fielding CT classification:

Failed conservative management x 6m

Postop:

Dangers in bipolar release?

Evidence on CMT:

Torticollis causes:

Congenital: (usually painless):

Acquired:

Child more likely to have AADI:

Direct Q&A

Onset of symptoms, progression, trauma, previous treatment or H&N

Bloods: CBC, inflammatory markers

Mx depends on timing

Surface – greater auricular nerve

Cheng 2001 JBJS

Raw speaker-note hierarchy audit

Improved semantic hierarchy used for the study notes