9.02 Torticollis (Wry Neck)
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agk's Library of Common Simple Emergencies

Presentation
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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, sterno- 
cleidomastoid, 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:
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- Ask the patient about precipitating factors, 
    and perform a thorough physical examinat- 
    ion, 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, anteropost- 
    erior and odontoid roentgenographic views 
    of the cervical spine. If there are neurol- 
    ogic 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 consult- 
    ation.
- 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:
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- 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 torti- 
    collis worse.
- Do not confuse torticollis with a [dystonic 
    drug reaction] from phenothiazines or 
    butyrophenones.

Discussion
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Although torticollis may signal some underlying 
pathology, usually it is a local musculoskel- 
etal problem--only more frightening and notice- 
able 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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img/cse0902.gif

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 from Buttaravoli & Stair: COMMON SIMPLE EMERGENCIES
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