Endoscopic minimally invasive treatment of congenital muscular torticollis in children.

BACKGROUND: This study aimed to investigate the clinical efficacy of minimally invasive endoscopic treatment of children with congenital muscular torticollis (CMT). METHODS: In total, 72 children (41 male, 31 female) with CMT who underwent endoscopic surgery at the Department of Orthopedics, Xi'an Children's Hospital, between January 2021 and January 2023 were included. Their mean age was 54 ± 36.1 (range, 12-141) months. Of these, 29 (40.3%) cases involved the left side while 43 (59.7%) involved the right side. Preoperative preparation involved precise body surface markings of the sternocleidomastoid muscle(SCM), clavicle, and important nerve and blood vessels, followed by the establishment of surgical channels through passive separation techniques. An arthroscope and a low-temperature plasma knife were utilized for accurate localization and surgical release of the clavicular and sternal heads of the SCM. The duration of surgery, blood loss, postoperative hospital stay, neck range of motion measurements, and any intraoperative or postoperative complications were analyzed using the rank sum test. Cervical and thoracic braces were applied for three months postoperatively, with follow-up assessments conducted using Cheng's scoring system. RESULTS: All patients successfully underwent endoscopic surgery, without the need for conversion to open surgery. No intra- or postoperative complications were observed. The average surgical duration was 56.4 ± 15.7 min, with minimal intraoperative bleeding (1-5 mL) and no need for blood transfusion. The mean postoperative hospital stay was 2.7 ± 0.8 days. Over a mean follow-up period of 22.2 ± 5.5 (range, 14-32) months, significant improvements were observed in neck rotation (from 20.2° [17.7° to 25°] to only 3.6° [2° to 6.7°]) and lateral flexion (from 19° [17° to 22.6°] to only 3° [2° to 7.8°]) restrictions (p < 0.05). According to Cheng's scoring system, 70 (97.2%) patients achieved excellent or good clinical outcomes, while 2 (2.8%) had average outcomes. The torticollis deformity was corrected during the follow-up period, and all surgical incisions healed without noticeable scarring. CONCLUSION: Endoscopic release is a safe, effective, and minimally invasive treatment option for CMT in children.

Posterior-only approach cervical hemivertebrectomy and short fusion with pedicle screws in young children with cervical scoliosis: case report and technical note.

PURPOSE: Cervical hemivertebrae (C3-6) causing significant osseous torticollis, head tilt and facial asymmetry are rare and complicated. Cervical hemivertebrectomy (CHVE) by a posterior-only approach was never reported because it is highly risky and its efficacy remains controversial. This study is to evaluate the feasibility and preliminary clinical outcomes of posterior-only approach for CHVE and torticollis correction in young children. METHODS: Four young children aged 5-9 years old with significant torticollis caused by cervical hemivertebrae underwent deformity correction consisting of cervical pedicle screw (CPS) placement with O-arm-based intraoperative navigation, CHVE using ultrasonic bone scalpel and short-segmental posterior instrumentation and fusion. Details of this novel technique were presented. The preliminary short-term clinical and radiographic outcomes were assessed. RESULTS: On average, the operative time was 312.5 ± 49.9 min, and the surgical blood loss was 375.0 ± 150.0 ml. The structural cervical scoliosis was corrected from 31.5 ± 7.3° to 11.0 ± 4.1°, and the average correction rate was 64.9%. Head tilt was favorably corrected from 11.0 ± 4.2° to 3.5 ± 2.6°. The shoulder balance improved from 6.3 ± 1.3° to 1.5 ± 1.9°. One case with C6 CHVE had convex side radiating nerve root pain but no sign of muscle power weakness. Full recovery was achieved one month after surgery. No other complication occurred. CONCLUSIONS: CHVE by a posterior-only approach was a feasible alternative option for the treatment of congenital cervical scoliosis. It could resect the CHV effectively and achieve satisfactory torticollis correction without additional anterior access surgery. Successful CPS placement in this child population was essentially important to enable reliable osteotomy closure and firm posterior instrumentation.

The effect of combined surgery and physiotherapy on the facial asymmetry in patients with congenital muscular torticollis: a retrospective cohort study.

The aim of this study was to assess the influence of surgical therapy, intraoperative evaluation, and immediate physiotherapy on the facial asymmetry of patients with congenital muscular torticollis (CMT). Patients who underwent a combination of unipolar sternocleidomastoid muscle release with perioperative physiotherapy between 2014 and 2020 in the Department of Oral and Maxillofacial Surgery, Radboud University Medical Center, Nijmegen were enrolled. Three-dimensional photographs of the face acquired 2 months preoperatively and 1.5-2 years postoperatively were assessed. Based on 43 patients, there was a significant improvement in the asymmetry indices (angles between bilateral exocanthion, bilateral cheilion, and nasion-gnathion lines): mean ± standard deviation reductions in indices (Ex-Ex)-(Ch-Ch), (Ex-Ex)-(Na-Gn), and (Ch-Ch)-(Na-Gn) of 0.88 ± 1.08° (P < 0.001), 1.04 ± 1.26° (P < 0.001), and 0.21 ± 1.06° (P = 0.024), respectively. Analysis of covariance (ANCOVA) showed that intervention at an early age (P = 0.017) and left-sided torticollis (P = 0.030) were associated with a significantly greater improvement in the facial asymmetry. This study found that the use of combined surgery and physiotherapy reduced the facial asymmetry of patients with CMT at 2 years postoperatively. Early intervention and left-sided torticollis were associated with a greater improvement in the facial asymmetry. This indicates that attention should be given to early intervention and right-sided CMT cases postoperatively.

Unipolar myomectomy for congenital muscular torticollis: A retrospective study.

In this study, unipolar myomectomy was used to address limited neck movement and tight muscles in pediatric, adolescent, and adult patients. A retrospective chart review was performed for patients from January 2006 to February 2023, who were diagnosed with congenital muscular torticollis and underwent a unipolar myomectomy. Outcome evaluation, adapted from the Cheng and Tang system - cervicomandibular angle (CMA), facial asymmetry, cranial asymmetry, tilting limitation (TL), rotation limitation (RL), subjective assessment, and residual contracture - included various parameters scored from 0 to 3 points and categorized as poor, fair, good, or excellent. In total, the data for 36 patients (21 males and 15 females) were analyzed. Participants were aged 0.8-38 years. Surgery improved CMA, RL, and TL, with no complications (12.2°-1.2°, 18.6°-5.2°, and 17.6°-6.5° for CMA, RL, and TL, respectively; p < 0.001). The mean overall score was comparable among different age groups (2.8 ± 0.5, 2.2 ± 0.62, and 2.1 ± 0.37 for the pediatric, adolescent, and adult groups, respectively). Within the limitations of the study it seems that unipolar myomectomy is a promising, effective surgical option for individuals of multiple age groups.

Transaxillary endoscopic subfascial operation for persistent muscular torticollis in pediatric patients: A 13-year retrospective study in Taiwan.

BACKGROUND: The endoscopic surgery for persistent muscular torticollis has been well-described and most are subcutaneous working caverns. As the sternocleidomastoid muscle is located beneath the deep cervical fascia that corresponds to the pectoral fascia, this study aimed to review our results of the transaxillary approach under the pectoral fascia and the deep cervical fascia. METHODS: Between November 2009 and January 2022, pediatric patients with persistent muscular torticollis receiving transaxillary endoscopic subfascial operation were retrospectively reviewed and analyzed. RESULTS: There were thirty-three consecutive patients with median age of 6.5 years (range, 5.5 months-15.7 years). The median operating time was 90.0 min. With a median follow-up of 14.8 months (range, 5.0-127.7), the final outcomes showed excellent-to-good results in 90.9%, fair results in 6.1%, and poor results in 3.0%. Univariate analysis revealed that the long-term outcomes of the operation were independent of gender, age, involved side and previously open myotomy (p = 0.662, 0.818, 0.740 and 0.596, respectively). CONCLUSIONS: The subfascial working cavern would be technically achievable for the transaxillary endoscopic approach with good functional and cosmetic outcomes.

The application of electrophysiology in the correction of spastic torticollis by triple surgery-report of 96 cases.

OBJECTIVE: To investigate the effect and value of electrophysiology in the 'triple operation' (selective excision of spastic muscles in the neck, selective resection of the posterior branch of the cervical nerve and accessory neurotomy) of spastic torticollis. METHODS: Preoperative electromyography (EMG) examination was performed on 96 patients with spastic torticollis treated in our hospital from January 2015 to December 2019. The results were used to assess the responsible muscles' primary or secondary position and the function of antagonistic muscles and to formulate a personalised surgical plan. A Cascade PRO 16-channel electrophysiological diagnostic system (produced by Cadwell, USA) was used to record the evoked EMG. Target muscles were denervated under intraoperative electrophysiological monitoring and re-examined by EMG six months later to evaluate the efficacy. RESULTS: The satisfactory rate of target muscle denervation was 95%, and the overall good rate was 79.1%. CONCLUSION: Electrophysiological examination and intraoperative application may have a positive value in the selection of the operative method, improving the rate of denervation and evaluating the prognosis of the 'triple operation'.

[Surgical treatment of congenital muscular torticollis]. / Operative Behandlung des Torticollis muscularis congenitus.

OBJECTIVE: Surgical treatment of congenital muscular torticollis with tripolar release of the sternocleidomastoid muscle, followed by modified postoperative treatment with a special orthosis. INDICATIONS: Muscular torticollis due to contracture of the sternocleidomastoid muscle; failure of conservative therapy. CONTRAINDICATIONS: Torticollis due to bony anomaly or other muscular contractures. SURGICAL TECHNIQUE: Tenotomy of the sternocleidomastoid muscle occipitally and resection of at least 1 cm of the tendon at the sternal and clavicular origin. POSTOPERATIVE MANAGEMENT: Orthosis must be worn for 6 weeks 24 h/day, then for another 6 weeks 12 h/day. RESULTS: A total of 13 patients were treated with tripolar release of the sternocleidomastoid muscle and modified postoperative management. Average follow-up time was 25.7 months. One patient presented with recurrence after 3 years. No intra- or postoperative complications were observed.

Improvement of obsessive-compulsive disorder after pallidothalamic tractotomy for cervical dystonia.

A 30-year-old woman with tardive dystonia in the cervical region from long-term antipsychotic meds was treated with radiofrequency ablation of the right pallidothalamic tract in the fields of Forel. The patient showed improvement in both cervical dystonia and obsessive-compulsive disorder after the procedure, with 77.4% improvement in cervical dystonia and 86.7% improvement in obsessive-compulsive disorder. Although the treatment site in this case was intended to treat cervical dystonia, the lesion was located in the optimal stimulation network for both obsessive-compulsive disorder and cervical dystonia, suggesting that neuromodulation of this region could potentially treat both simultaneously.

Multipoint fixation with vascularised fibular bone graft and myotomy for atlanto-axial instability in cervical dystonia: a case report.

Spinal instability is a challenging condition to manage in patients with cervical dystonia. Standard surgical stabilisation approaches may fail to cope with additional stress forces created by spasmodic muscles leading to construct failure either in the immediate or late post-operative period. Long-term stabilisation relies on the management of dystonic symptoms and adjunctive strategies to increase fusion success rate. We discuss the management of a challenging patient with translational C1/2 instability who had three metalwork failures with standard occipito-cervical fixation techniques within a 12 month period. A combined surgical approach using multipoint fixation, sternocleidomastoid myotomy and a vascularised fibular occiput-C2 bone graft successfully prevented further metalwork failure at over 2 years follow up.

Factors influencing and long-term effects of manual myotomy phenomenon during physiotherapy for congenital muscular torticollis.

PURPOSE: To investigate the factors influencing and long-term effects of manual myotomy (MM) occurring during physiotherapy for congenital muscular torticollis (CMT). METHODS: We retrospectively collected the clinical data of children with CMT receiving physiotherapy between 2008 and 2018. The children were divided into manual myotomy (MM) and non-manual myotomy (NMM) groups according to whether MM occurred during treatment. We assessed physiotherapy outcomes in children with CMT using craniofacial asymmetry parameters and the Cheng-Tang rating score. By measuring the ear-eye distance, ear-nose distance, eye-mouth distance, ear-mouth distance, half-head circumference, and half-head top at two sides to evaluate craniofacial asymmetry. Based on the Cheng-Tang assessment criteria, we recorded the range of rotation, range of lateral flexion, the status of the contracted muscle, the hardness of the mass, the extent of head tilting during activities and sleeping, the status of daily activities, face size, type of head shape, cranial changes, and subjective head tilting to assess the effectiveness of treatment. Clinical data and outcome indicators (craniofacial asymmetry parameters and Cheng-Tang rating score) were compared. RESULTS: The MM group had a significantly higher total Cheng-Tang rating score than the NMM group (P < 0.05). Age at initial physiotherapy session was the risk factor for MM during physiotherapy. CONCLUSION: Children with CMT developing MM during physiotherapy generally have a good outcome, although we do not recommend MM as a goal of treatment. Physiotherapists should understand this phenomenon, assess relevant factors to predict risk, and carefully observe treatment to prevent possible complications.

Posterior Surgery in the Treatment of Craniovertebral Junction Deformity with Torticollis.

OBJECTIVE: To investigate the clinical effect of posterior surgery in the treatment of craniovertebral junction (CVJ) deformities with torticollis and methods for preventing and treating complications in order to obtain a reasonable treatment strategy. METHODS: From January 2007 to December 2017, 78 patients who suffered from CVJ deformities with torticollis treated by posterior surgery were analyzed. The surgical techniques were all posterior correction and fusion to restore the anatomical alignment of the craniovertebral junction. The visual analog score (VAS) and Short Form-36 (SF-36) health survey questionnaire were utilized to evaluate preoperative and postoperative neck pain, and changes in the torticollis angle and atlas-dens interval (ADI) were evaluated through anteroposterior X-ray and computed tomography. Intra- and postoperative complications were all recorded. One-way ANOVA, LSD-t test, and χ2 test were performed to evaluate the difference between the preoperative and postoperative data. RESULTS: The mean follow-up time was 37.4 ± 15.7 months, the average operation time was 115.6 ± 12.8 min, and the average blood loss was 170.8 ± 26.3 mL. According to the deformity site, the range of posterior correction and fusion was as follows: 38 cases of C1 -C2 , 33 cases of C0 -C2 , and seven cases of C0 -C3 . The preoperative SF-36, VAS, torticollis angle, and ADI were 42.6 ± 8.8, 4.8 ± 1.1, 37.2 ± 11.2°, and 4.9 ± 2.3 mm, respectively. The difference was significant at 3 months post operation (p < 0.05), and there was no significant difference at the final follow-up compared with 3 months post operation (p > 0.05). CONCLUSION: It can objectively achieve favorable correction and satisfactory clinical effects under posterior correction and fixation for CVJ deformities with torticollis. Intra- and postoperative complications can be settled by proper management.

A rare case of atlantoaxial rotatory fixation after posterior calvarial vault expansion surgery in a Crouzon patient.

INTRODUCTION: Atlantoaxial rotatory fixation (AARF) is a rare condition that occurs most commonly in children. The torticollis caused by AARF usually presents as abnormal posturing of the head and neck, with rotation of the chin to the opposite side. AARF in children could occur due to congenital bony malformation, minor trauma, upper respiratory tract infections (Grisel's syndrome), postoperatively after head and neck (ENT) surgery, and unknown reasons. AARF in the postoperative patient is a rare and poorly understood entity. METHODS: The authors present a case report of a 2-year-old boy with Crouzon Syndrome undergoing posterior calvarial vault expansion (PVE) surgery that developed AARF as a complication. RESULTS: The authors believe that cranial vault surgery should be considered a potential risk procedure for AARF, especially if it is done in susceptible populations (syndromic craniosynostosis patients) with other underlying sequelae (tonsillar ectopia or syringomyelia). During surgery, careful attention should be paid to maintaining a neutral alignment of the patient's cervical spine as rotatory movements under anaesthesia and muscle relaxation may be contributory factors. CONCLUSION: AARF should be suspected and investigated in children with painful torticollis after craniofacial surgery.

Torticollis, Facial Asymmetry, Local Pain, and Barré-Liéou Syndrome in Connection with One-Sided Ponticulus Posticus: A Case Report and Review of the Literature.

BACKGROUND: Ponticulus posticus (PP) occurs frequently and may cause symptom series, including vertebrobasilar insufficiency, migraine, hearing loss, and Barré-Liéou syndrome. However, few studies to date have described surgical treatment of PP. We report a rare case of a patient who suffered from torticollis, facial asymmetry, localized pain, and Barré-Liéou syndrome in connection with PP. We also review the pertinent literature, focusing on surgical treatment for symptoms due to PP. CASE PRESENTATION: A 23-year-old male presented with the chief complaint of continuous significant dizziness to the point of losing consciousness while rotating his head to the right. Plain radiographs and computed tomography (CT) scans of the cervical spine showed a С1 anomaly with the formation of complete PP on the left (dominant) side, with acute-angled, С-shaped kinking of the vertebral artery. Resection of PP via the posterior midline was performed successfully. The patient had satisfactory postoperative relief from localized pain and Barré-Liéou syndrome, but there were no obvious changes in the torticollis and facial asymmetry observed during the 3-month follow-up period. CONCLUSIONS: This case is a rare presentation of torticollis, facial asymmetry, localized pain, and Barré-Liéou syndrome in connection with one-sided complete PP. This tetrad indicates that PP may affect the patient earlier than expected. In such situations, early diagnosis and timely surgical treatment may significantly improve patients' quality of life and avoid the development of torticollis and face asymmetry.

Unilateral pallidothalamic tractotomy at Forel's field H1 for cervical dystonia.

BACKGROUND: Neurosurgical ablation of Forel's field H1 for cervical dystonia, which is currently abandoned, was formerly used in the 1960s-1970s. Regardless of the lack of neuroimaging modalities and objective evaluation scales, the reported efficacy was significant. Although recent studies have reappraised the ablation of the pallidothalamic tract at Forel's field H1 for Parkinson's disease, the efficacy for cervical dystonia has not been investigated well. METHODS: Data of 35 patients with cervical dystonia who underwent unilateral pallidothalamic tractotomy at Forel's field H1 were retrospectively analyzed. The Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) scores, the neck score of the Burke-Fahn-Marsden Dystonia Rating Scale (BFMDRS), and adverse events were evaluated preoperatively and at the last available follow-up period. RESULTS: The mean clinical follow-up period was 13.9 ± 6.5 months. The mean TWSTRS total scores were 34.3 ± 14.0 preoperatively and 18.4 ± 16.5 at the last available follow-up period (46.4% improvement, p < 0.0001). The BFMDRS neck score also improved significantly from 6.2 ± 2.9 preoperatively to 2.8 ± 2.8 at the last available follow-up period (55.0% improvement on the neck score, p < 0.0001). Reduced hand dexterity in seven patients, hypophonia in five patients, dysarthria in four patients, and executive dysfunction in one patient were confirmed as adverse events at the last available follow-up evaluation. One patient had postoperative hemorrhage. CONCLUSION: The current study confirmed significant improvement in TWSTRS total scores and BFMDRS neck scores at the 13.9-month follow-up after unilateral pallidothalamic tractotomy. The pallidothalamic tract in Forel's field H1 is expected to be an alternative treatment target for cervical dystonia.

Application of Ultrasonography During Sternocleidomastoid Muscle Release for Congenital Muscular Torticollis: A Case Report.

CASE: We report a 4-year-old girl with congenital muscular torticollis (CMT) who was treated with sternocleidomastoid muscle (SCM) tenotomy using ultrasonography (US). Prior to the surgery, US was utilized to identify the clavicle and sternum branches of the SCM, sternohyoid muscles, internal jugular vein, and common carotid artery. Then, local anesthesia was injected into the layer between the fascial sheath of the SCM and carotid sheath to reduce bleeding and avoid vascular injury. During surgery, the SCM dissection was carefully conducted under US guidance to avoid vascular injury. No residual of SCM dissection and improvement of neck motion were confirmed before the skin closure. Postoperative course was good with no obvious complications in this patient. CONCLUSION: The intraoperative US investigation during SCM tenotomy is a useful procedure that provides vital information about dissection area of SCM and orientation of internal jugular vein that reduces the risk of insufficient tenotomy and vascular injury.

Improvements in Nerve Dissection Surgery Methodology for Spasmodic Torticollis Treatment.

Spasmodic torticollis is the most common focal dystonia and is characterized by aberrant involuntary contraction of muscles of the neck and shoulders, which greatly affects patients' quality of life. Consequently, patients with this condition often desire treatment to alleviate their symptoms. The common clinical treatments for spasmodic torticollis include interventions such as drug therapy, botulinum toxin injections, and surgery. Surgical treatment is feasible for patients who do not respond well to other treatments or who are resistant to drugs. The gradual improvement of surgeons' understanding of anatomy and the ongoing developments in surgical techniques since their advent in the 1640s have resulted in many innovative surgical approaches that have led to improvements in the treatment of spasmodic torticollis. Previously used surgical treatments that result in uncertain outcomes, various postoperative complications, and serious damage to motor functions of the head and neck have gradually been discontinued. Nerve dissection surgery is the most common surgical treatment for spasmodic torticollis. This article reviews existing research on nerve dissection surgery for the treatment of spasmodic torticollis and the history of its development, along with the advantages and disadvantages of various surgical improvements. This article aims to provide clinicians with practical advice.

Embedded adaptive deep brain stimulation for cervical dystonia controlled by motor cortex theta oscillations.

Dystonia is a disabling movement disorder characterized by excessive muscle contraction for which the underlying pathophysiology is incompletely understood and treatment interventions limited in efficacy. Here we utilize a novel, sensing-enabled, deep brain stimulator device, implanted in a patient with cervical dystonia, to record local field potentials from chronically implanted electrodes in the sensorimotor cortex and subthalamic nuclei bilaterally. This rechargeable device was able to record large volumes of neural data at home, in the naturalistic environment, during unconstrained activity. We confirmed the presence of theta (3-7 Hz) oscillatory activity, which was coherent throughout the cortico-subthalamic circuit and specifically suppressed by high-frequency stimulation. Stimulation also reduced the duration, rate and height of theta bursts. These findings motivated a proof-of-principle trial of a new form of adaptive deep brain stimulation - triggered by theta-burst activity recorded from the motor cortex. This facilitated increased peak stimulation amplitudes without induction of dyskinesias and demonstrated improved blinded clinical ratings compared to continuous DBS, despite reduced total electrical energy delivered. These results further strengthen the pathophysiological role of low frequency (theta) oscillations in dystonia and demonstrate the potential for novel adaptive stimulation strategies linked to cortico-basal theta bursts.