Disorders of the Neck and Spine

Published on 06/06/2015 by admin

Filed under Pediatrics

Last modified 06/06/2015

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24 Disorders of the Neck and Spine

Pediatric disorders of the neck and spine are generally rare. The majority of these conditions can be treated with rest, antiinflammatory medications, targeted physical therapy, and orthotics. Operative management is typically reserved for severe or refractory pathology and symptoms.

Congenital Muscular Torticollis

Torticollis, from the Latin words for “twisted neck,” is lateral neck flexion with contralateral head rotation (Figure 24-1). Although the majority of torticollis cases result from sternocleidomastoid muscle (SCM) shortening, other causes include neurologic conditions, cervical spine abnormalities, and vision or hearing deficits.

Congenital muscular torticollis (CMT) occurs in 0.3% to 2% of newborns. Although the cause is unknown, intrauterine crowding or birth trauma may cause muscle damage. More than half of infants with CMT are firstborn or had a history of difficult delivery, including use of forceps or breech presentation. Magnetic resonance imaging (MRI) and surgical histopathology have demonstrated muscle atrophy and fibrosis similar to the vascular complications of compartment syndrome. Abnormal head positioning in CMT can cause plagiocephaly and facial asymmetry.

Evaluation of CMT should include a thorough birth history and description of presenting symptoms. The physical examination classically demonstrates an infant with the head tilted towards the side of SCM contraction with the chin pointed in toward the opposite shoulder (see Figure 24-1). A soft, nontender mass may be palpable in the body of the SCM. Visual tracking, hearing, and neurologic function should also be assessed to rule out nonmuscular causes. Patients should be evaluated for other associated conditions such as developmental dysplasia of the hip and referred for diagnostic imaging or surgical consultation as necessary.

Cervical spine radiographs can rule out osseous causes, including congenital spinal fusion (e.g., Klippel-Feil syndrome, unilateral atlantooccipital fusion), hemivertebrae, and rotational cervical instability. Ultrasonography, the diagnostic modality of choice, demonstrates a hyperechogenic muscle mass. Computed tomography (CT) and MRI can help exclude suspected neurologic or osseous etiologies of torticollis. However, these modalities may not be as sensitive as ultrasonography in diagnosing CMT, and exposure to radiation or sedation limits their role in routine evaluation of torticollis.

The majority of CMT resolves spontaneously or with regular physical therapy. If muscle shortening persists beyond 6 months of therapy or 12 months of life, orthopedic referral is necessary for surgical SCM lengthening. Although successful CMT therapy typically resolves the associated plagiocephaly and facial asymmetry, patients with residual symptoms may require referral for further evaluation and treatment.