Surgical Management of Idiopathic Torticollis Secondary to a Fibrotic Band

Introduction

Idiopathic torticollis, or congenital muscular torticollis (CMT), is a congenital condition characterized by involuntary contraction or tightening of neck muscles, resulting in the titling of the head to one side and turning to the opposite side. While the exact etiology of idiopathic torticollis remains unclear, fibrotic bands (excessive growth of fibrous tissue) and muscle imbalance have been implicated as potential causative factors in some patients. When conservative treatments such as physical therapy fail to improve symptoms or when there is evidence of a fibrotic band causing the torticollis, surgical intervention may be considered necessary. Surgical release of such fibrotic bands offers a promising avenue for symptom relief and restoration of normal head positioning. The article further highlights the indications, surgical procedures, complications, and clinical outcomes associated with idiopathic torticollis surgery.

When Is Surgery Indicated for Idiopathic Torticollis?

The surgical management of idiopathic torticollis is indicated if:

• Failure of Conservative Approach: Conservative treatment strategies such as physiotherapy, botulinum toxin injections, and pharmacotherapy fail to resolve the condition.

• Evident Fibrotic Bands: In cases where the formation of taut fibrotic bands in the neck is evident in diagnostic imaging studies such as ultrasound, magnetic resonance imaging (MRI), and computed tomography (CT) scans indicating the necessity of surgical intervention.

• Persistence or Progression of Symptoms: If the torticollis persists or worsens despite conservative management, indicating a need for more aggressive intervention.

• Functional Impairment: When the torticollis significantly impairs the patient's ability to perform daily activities, affects their QoL (quality of life), or hinders functional milestones (e.g., in infants and children).

• Cosmetic Concerns: In cases where the torticollis causes noticeable asymmetry or deformity of the neck or head, leading to cosmetic concerns for the patient or caregivers.

• Patient or Parental Preference: In some cases, patients or parents may prefer surgical intervention over continued conservative management due to dissatisfaction with the progress of non-surgical treatments or the desire for a more definitive solution.

• Surgical Intervention Necessity: When there is evidence that the torticollis is causing secondary complications such as musculoskeletal (muscles and bone) deformities, joint contractures, or developmental delays, surgical intervention may be necessary to prevent further complications and optimize long-term outcomes.

Healthcare specialists must conduct a comprehensive clinical assessment of each patient, considering factors such as their medical history, symptom severity, functional restrictions, and treatment objectives, to determine the need for surgical intervention. Moreover, the decision to undergo surgery should entail a detailed conversation between the healthcare provider and the patient or caregivers, encompassing a thorough exploration of the procedure's potential risks, benefits, and clinical outcomes.

How Is Surgery for Idiopathic Torticollis Performed?

The specific surgical approach depends on factors such as the location and severity of the fibrotic band, as well as the surgeon's preference and expertise. The steps followed during the surgical procedure are:

• Preoperative Assessment: Before initiating the surgical procedure, the surgeon records the detailed medical history of the patient, along with drug history and family history. A thorough clinical assessment with diagnostic imaging tests such as MRI and CT scans might be ordered by the surgeon to rule out the severity and extent of the fibrotic bands.

• Administration of Anesthesia: This procedure is usually performed under general anesthesia to ensure the patient is pain-free throughout the surgery.

• Surgical Incision: During the procedure, the surgeon makes a surgical cut to access the affected muscles and fibrotic band.

• Surgical Dissection: The muscles are exposed layer-by-layer carefully to approach the fibrotic bands.

• Removal or Release of Fibrotic Bands: The fibrotic band is carefully dissected and excised to release the tension on the sternocleidomastoid (SCM) muscle (muscle of the neck) to allow for improved range of motion and alignment of the neck. This can be performed through various surgical approaches, including open surgery or minimally invasive techniques such as endoscopic (a thin tube with an attached camera for improved visibility) release. In a few severe cases, additional procedures may be necessary to treat muscle imbalances or tightness, such as muscle lengthening or transpositioning procedures. This may involve lengthening or transposing certain neck muscles to restore proper alignment and function. Intraoperative (during the operation) electromyography (a device that monitors the electrical activity of muscle) might be performed by the surgeons to monitor muscle activity and ensure adequate release.

• Postoperative Care: After surgery, patients typically undergo a period of rehabilitation and are referred to physiotherapists to optimize outcomes and regain strength and mobility. Pain management and wound care are important aspects of postoperative care.

• Follow-up: Regular follow-up appointments with the surgeon are scheduled to monitor progress and address any concerns or complications associated with surgery.

The surgical management of idiopathic torticollis secondary to a fibrotic band can be an effective option in improving symptoms and restoring neck function, but it requires careful evaluation and consideration of individual patient factors before proceeding with surgery.

Long-Term Clinical Outcomes

The clinical outcomes of surgery for idiopathic torticollis may vary depending on factors such as the underlying cause, the extent of the deformity, and the patient's overall health. In many cases, surgical intervention can significantly improve or resolve symptoms, allowing patients to achieve better neck mobility and alignment.

What Are the Risks and Complications Associated with Idiopathic Torticollis Surgery?

A few risks and complications associated with idiopathic torticollis surgery are:

• Risk of surgical site infection after the surgery.

• Excessive bleeding.

• Damage to the underlying vital structures such as nerves and vessels.

• Recurrence of the symptoms may be there in a few cases.

Conclusion

Surgical management offers a viable solution for addressing idiopathic torticollis secondary to a fibrotic band when conservative measures prove ineffective. Releasing the fibrotic band aims to improve neck mobility and alignment, thus enhancing the patient's QoL. However, careful patient selection and comprehensive preoperative evaluation are crucial to mitigate potential risks and optimize outcomes. Surgeons should tailor their approach based on individual patient factors and preferences. Overall, while surgical intervention presents a promising option for managing this condition, a thorough understanding of its indications, risks, and benefits is essential for informed decision-making and successful treatment.