Torticollis y (from the Latin torti, meaning twisted and collis, meaning neck) y Torticollis, or wryneck, is a stiff neck

associated with muscle spasm, classically causing lateral flexion contracture of the cervical spine musculature (a condition in which the head is tilted to one side). The muscles affected are principally those supplied by the spinal accessory nerve. y Is one of a broader category of disorders that exhibit flexion, extension, or twisting of muscles of the neck beyond their normal position. In torticollis your neck tends to twist to one side. Classification y Congenital muscular torticollis o Etiology is unclear. o Birth trauma or intrauterine malposition is also considered to cause damage to the sternocleidomastoid muscle in the neck. o This results in a shortening or excessive contraction of the sternocleidomastoid muscle, often with limited range of motion in both rotation and lateral bending. The head is typically tilted in lateral bending toward the affected muscle and rotated toward the opposite side. o The condition may be caused by scars, disease of cervical vertebrae, adenitis, tonsillitis, rheumatism, enlarged cervical glands, retropharyngeal abscess, or cerebellar tumors. It may be spasmodic (clonic) or permanent (tonic). The latter type may be due to Pott's Disease (tuberculosis of the spine). o The reported incidence of congenital torticollis is 0.3-2.0 %. Sometimes a mass (a sternocleidomastoid tumor) in the affected muscle may be noted, this appears at the age of two to four weeks, it disappears gradually, but sometimes the muscle becomes fibrotic. It is likely to disappear within the first five to eight months of life. o The condition is treated initially with physical therapy, with stretching to correct the tightness, strengthening exercises to achieve muscular balance, handling to stimulate symmetry. A TOT Collar is sometimes used. About 5 10% requires "surgical release" of the muscle if stretching fails. o Infants with torticollis have a higher risk for plagiocephaly. Altering the head position and using a pillow when supine helps as does giving a lot of tummy time when awake. o If torticollis is not corrected, facial asymmetry can develop. Head position should be corrected before adulthood (to about the age of 18 there can be improvement). o Common treatments might involve a multi-phase process: 1) Low-impact exercise to increase strong form neck stability 2) Manipulation of the neck by a chiropractor, physical therapist or Osteopathic Physician (DO). 3) Extended heat application. 4) Repetitive shiatsu massage.

An Osteopathic Physician may choose to use cranial techniques to properly position the occipital condyles - thereby relieving compression of cranial nerve XI in children with Torticollis. This is an example of Osteopathic Manipulative Treatment.

Acquired Torticollis o Occurs because of another problem and usually presents in previously normal children and adults. o A self-limiting spontaneously occurring form of torticollis with one or more painful neck muscles is by far the most common ('stiff neck') and will pass spontaneously in 1 4 weeks. Usually the sternocleidomastoid muscle or the trapezius muscle is involved. Sometimes draughts, colds or unusual postures are implicated; however in many cases no clear cause is found. o Trauma to the neck can cause atlantoaxial rotatory subluxation, in which the two vertebrae closest to the skull slide with respect to each other, tearing stabilizing ligaments; this condition is treated with traction to reduce the subluxation, followed by bracing or casting until the ligamentous injury heals. o Tumors of the skull base (posterior fossa tumors) can compress the nerve supply to the neck and cause torticollis, and these problems must be treated surgically. o Infections in the posterior pharynx can irritate the nerves supplying the neck muscles and cause torticollis, and these infections may be treated with antibiotics if they are not too severe, but could require surgical debridement in intractable cases. o Ear infections and surgical removal of the adenoids can cause an entity known as Grisel's syndrome, a subluxation of the upper cervical joints, mostly the atlantoaxial joint, due to inflammatory laxity of the ligaments caused by an infection. This bridge must either be broken through manipulation of the neck, or surgically resected. o The use of certain drugs, such as antipsychotics, can cause torticollis. o Antiemetics - Neuroleptic Class - Phenothiazines Spasmodic Torticollis o Is a chronic neurological movement disorder causing the neck to involuntarily turn to the left, right, upwards, and/or downwards. o Torticollis with recurrent but transient contraction of the muscles of the neck and esp. of the sternocleidomastoid. Also known as "intermittent torticollis . "cervical dystonia" o When the disorder occurs in people with a family history, it is referred to as spasmodic torticollis. The characteristic twisting of the neck is initially spasmodic and begins between ages 31-50 years. If you leave the condition untreated, it likely will become permanent. o TREATMENT: Botulinus toxin has been used to inhibit the spastic contractions of the affected muscles.

Signs and Symptoms y Limited range of motion of the head y Headache y Head tremor y Neck pain y Shoulder is higher on one side of the body y Stiffness of neck muscles y Swelling of the neck muscles (possibly present at birth) Clicnical History y Patients with congential muscular torticollis often have a palpable soft tissue mass in the sternocleidomastoid (SCM) muscle shortly after birth. The mass later subsides, leaving a contracted SCM muscle. The head characteristically tilts toward the side of the mass with the chin rotated in the opposite direction. Physical History y Characterization of head and/or neck posture (tonic components) and of dystonic head movements (phasic components) o Tonic head and neck posture (when chronic, may cause scoliosis)  Rotational torticollis: Head is turned around the long axis with nose and chin toward the shoulder; this is the most common head and neck deviation. Tone and bulk increase are appropriate in the sternomastoid contralateral to the direction of turn.  Simple torticollis: No head tilt is present. Document increased tone of neck muscles as symmetric or absent, hypertrophied or normal.  Laterocollis: Head tilts to one side with ear toward shoulder; asymmetric tone and muscle bulk also present.  Anterocollis: Head tilts forward with chin toward the chest, and anterior cervical muscles are increased in tone and bulk.  Retrocollis: Head tilts in hyperextension with increased tone and bulk in the posterior cervical muscles. o Phasic head components  Spasmodic jerks - Rapid irregular clonic jerks with less rapid recovery toward the neutral position  High-frequency oscillations - Horizontal, vertical, mixed, or irregular tremors Diagnostic Procedures y The doctor will take a detailed history emphasizing specific medications that you may be taking. A physical examination will be performed. y When there is a history of trauma, the doctor may take x-rays of your neck to exclude afracture or dislocation of the spinal bones in your neck. y Often, x-rays are sufficient to make this determination. y In a small number of cases, subtle abnormalities or preexisting conditions, for example, degenerative arthritis of the spineof the neck may require a CT scan of the neck.

A electromyogram (EMG) may be done in mild cases to see which muscles are most affected.

Madical and Surgical Management y Application of heat, traction to the cervical spine, and massage may help relieve head and neck pain. Stretching exercises and neck braces may help with muscle spasms. y Prehospital Care o Ensure patent airway. o Perform cervical spine immobilization/precautions for patients with a history of trauma. Medications Benzodiazepines (Muscle relaxant) y By binding to specific receptor sites, these agents appear to potentiate effects of gamma-aminobutyric acid (GABA), facilitate inhibitory GABA neurotransmission, and assist other inhibitory transmitters. Benzodiazepines may act in the spinal cord to induce muscle relaxation. o Diazepam (Valium)  Depresses all levels of CNS, including limbic and reticular formation, possibly by increasing GABA activity Antocholinergic y Anticholinergics are thought to work centrally by suppressing conduction in vestibular cerebellar pathways; these agents may have an inhibitory effect on the parasympathetic nervous system. o Diphenhydramine (Benadryl, Aler-Dryl)  First-generation antihistamine with anticholinergic effects that binds to H1 receptors in the CNS and the body. Competitively blocks histamine from binding to H1 receptors. Has significant antimuscarinic activity and penetrates CNS, which causes pronounced tendency to induce sedation. Approximately half of those treated with conventional doses experience some degree of somnolence. A small percentage of children paradoxically respond to diphenhydramine with agitation. o Benztropine (Cogentin)  By blocking striatal cholinergic receptors, may help in balancing cholinergic and dopaminergic activity in striatum. o Trihexyphenidyl (Artane)  Central cholinergic blockade often effective treatment strategy in dystonias in all categories, not just torticollis. Doses used in nontorticollis dystonias often much higher than those suggested here. Anticholinergics should be tried initially.

Scoliosis y y

y y y

Scoliosis is a sideways curvature of the spine that occurs most often during the growth spurt just before puberty. If the person is less than 3 years old, it is called infantile idiopathic scoliosis. Scoliosis that develops between 3 and 10 years of age is called juvenile idiopathic scoliosis, and people that are over 10 years old have adolescent idiopathic scoliosis. Less than 0.1% has spinal curves measuring greater than 40 degrees, which is the point at which surgery becomes a consideration. Girls are more likely to be affected than boys. Idiopathic scoliosis is most commonly a condition of adolescence affecting those ages 10 through 16. There are three other main types of scoliosis: o Functional  In this type of scoliosis, the spine is normal, but an abnormal curve develops because of a problem somewhere else in the body. This could be caused by one leg being shorter than the other or by muscle spasms in the back. o Neuromuscular  In this type of scoliosis, there is a problem when the bones of the spine are formed. Either the bones of the spine fail to form completely, or they fail to separate from each other.  This type of scoliosis develops in people with other disorders including birth defects, muscular dystrophy, cerebral palsy, or Marfan's disease.  If the curve is present at birth, it is called congenital. This type of scoliosis is often much more severe and needs more aggressive treatment than other forms of scoliosis. o Degenerative  Occurs in older adults.  It is caused by changes in the spine due to arthritis.  Weakening of the normal ligaments and other soft tissues of the spine combined with abnormal bone spurs can lead to an abnormal curvature of the spine.

Spinal problems at birth. Children who are born with scoliosis (congential scoliosis) may experience rapid worsening of the curve.

Causes There are many types and causes of scoliosis, including:

y y y y

Congenital scoliosis. Due to a bone abnormality present at birth. Neuromuscular scoliosis. A result of abnormal muscles or nerves. Frequently seen in people with spina bifida or cerebral palsy or in those with various conditions that are accompanied by, or result in, paralysis. Degenerative scoliosis. This may result from traumatic (from an injury or illness) bone collapse, previous major back surgery, or osteoporosis (thining of the bones). Idiopathic scoliosis. The most common type of scoliosis, idiopathic scoliosis, has no specific identifiable cause. There are many theories, but none have been found to be conclusive. There is, however, strong evidence that idiopathic scoliosis is inherited. Signs and Symptoms y Abnormal curve of the spine y Scoliosis may cause the head to appear off center or one hip or shoulder to be higher than the opposite side. If the scoliosis is more severe, it can make it more difficult for the heart and lungs to work properly. This can cause shortness of breath and chest pain. y In most cases, scoliosis is not painful, but there are certain types of scoliosis than can cause back pain. Diagnostic Procedures y The doctor will ask questions, including if there is any family history of scoliosis, or if you have had any pain, weakness, or other medical problems. o The physical examination involves looking at the curve of the spine from the sides, front, and back. o The person will be asked to undress from the waist up to better see any abnormal curves. o The person will then bend over trying to touch their toes. o The doctor will also look at the symmetry of the body to see if the hips and shoulders are at the same height. o Any skin changes will also be identified that can suggest scoliosis due to a birth defect. y X-ray to evaluate the magnitude of the curve. Treatment

Risk Factors

y y y y

Sex. Girls ages 3 and older are more likely to have scoliosis than boys. In contrast, boys are more likely to have the disorder than girls before age 3. Age. The younger a child is when scoliosis begins, the more severe the condition is likely to become. Angle of the curve. The greater that angle of curve, the increased likelihood that the condition will get worse. Location. Curves in the middle to lower spine are less likely to worsen than those of the upper spine.

Braces. Bracing is the usual treatment choice for adolescents who have a spinal curve between 25 to 40 degrees -- particularly if their bones are still maturing and if they have at least two years of growth remaining.

The purpose of bracing is to halt progression of the curve. It may provide a temporary correction, but usually the curve will assume its original magnitude when bracing is eliminated.

Surgery. Those who have curves beyond 40 to 50 degrees are often considered for scoliosis surgery. The goal is to make sure the curve does not get worse, but surgery does not perfectly straighten the spine. During the procedure, metallic implants are utilized to correct some of the curvature and hold it in the correct position until a bone graft, placed at the time of surgery, consolidates and creates a rigid fusion in the area of the curve. Scoliosis surgery usually involves joining the vertebrae together permanently -- called spinal fusion. In young children, another technique that does not involve fusion may be used since fusion stops growth of the fused part of the spine. In this case, a brace must always be worn after surgery. Posterior Spinal Fusion o surgeons often use a modification of a two-rod system (or instrumentation) for spinal fusions Two metal rods and hooks or screws are attached to the spine to o provide as much correction as possible. o A portion of the spine fuses (heals together) to hold the correction in place. The patient's ability to bend or move may be altered minimally. o The instrumentation is left in the body, even after the bones have o fused, to avoid another surgery. In addition to supporting the fused area, instrumentation also applies o force to the spine to help correct the deformity. y Growing Rods o Surgeons are investigating a technique that employs "growing rods." o Surgeons anchor two parallel rods to bone at either end of the spinal curve; the middle section of the rods is adjustable. o Periodic lengthening of the adjustable section is performed during outpatient procedures. (Pictures of xray) y Prior to surgery y Educate each patient prior to scoliosis surgery. They also work with patients to review the details of surgery and educate y them about how it will affect their child's lifestyle. o These help patients learn the reasons for surgery, the risks and complications of surgery, steps to recovery, deep breathing and coughing exercises, movement while in bed, how to get in and out of bed, how to manage pain, and how to use drainage tubes. o Patients should plan for a six-day hospital visit; parents may stay with their children during surgery hospitalization. y y After Surgery o A red or pink scar typically appears on the back, along the spine, but it will fade. Following surgery, there is usually no need for a brace.

Once a patient returns home, activity should be limited to allow the spinal fusion to heal. During the days and months after the surgery, patients may reinstate activity incrementally:  For three months after the surgery, the patient should refrain from physical activity such as gym class or running.  After three months, the patient may return to normal activity, except gym class, diving, contact sports, horseback riding, amusement park rides and lifting more than 25 pounds.  At six months, with a doctor's permission, the patient may resume all activity except contact sports.  After one year, with a doctor's permission, patients can resume all activity including contact sports.