—According to circumstances significant pathological changes may be found in the affected muscles. These are usually the sternomastoid and the trapezius, although in long-standing or complicated cases the deeper muscles of the neck may also participate. A long contracted muscle may change almost into mere fibrous tissue.
The secondary effects of contraction of the sternomastoid and the trapezius are really far-reaching and noteworthy. The jaw may be drawn down and to one side, so that teeth do not appose each other as they should, or perhaps even do not meet. Compensatory curvatures occur also in the spine and there is well-marked change in gait and in most of the body habits. In the young and rapidly growing cranial and facial asymmetry also become pronounced. The later results and deformities of torticollis are not to be mistaken for congenital elevation of the scapula, sometimes known as “Sprengel’s deformity,” which consists not merely in elevation, but in rotation of the shoulder-blade so that its lower angle is too near the spine. There may be some limitation of motion of the scapula and of the arm. Sprengel accounted for this abnormality by maintenance of the intra-uterine position of the arm behind the back. The acute forms of torticollis occur nearly always in acute phlegmons of one side of the neck, and should subside with the other and causative lesions. Nevertheless from such spasm may develop a chronic form which may persist.
The position of the head varies with the muscles particularly involved and the associated spasm. The sternomastoid muscle alone will draw the mastoid down toward the sternum, with rotation of the face to the other side. When the trapezius is involved the head is drawn backward and the chin raised. The more the platysma, scaleni, splenii, and deep rotators are involved the more complex becomes the condition, to such an extent even that in serious cases it is almost impossible to decide which muscles really are at fault. When the superficial muscles are involved they can usually be distinctly felt to be firm and contracted, while the sternomastoid will stand out like a cord. Pain is a rare complaint, but a feeling of tenderness or soreness is not unusual.
The spasmodic or intermittent form is less common, but more difficult to account for and even to treat. It seems to be due to choreiform spasm of those muscles which produce it, and here the condition is reflex, the causes lying deeply in the nervous system. In some instances, however, they are of ocular origin and can be relieved by correcting refractive errors. Intermittent spasm is usually absent during sleep and quiescent in the recumbent position; it is usually confined to one side.
Diagnosis.
—In the matter of diagnosis it is necessary mainly to eliminate only spinal caries, while as between involvement of the anterior and posterior groups of muscles the determination is made by palpation and inspection.
Treatment.
—There are few morbid conditions whose cause it is more necessary to discover. Could this be done operative treatment would be less often demanded. Treatment should depend, therefore, on the exciting cause and the possibility of its removal. The spasmodic or intermittent form may spontaneously subside. Cases of essentially ocular origin need the services of the oculist, and other acute cases usually subside with the successful treatment or the subsidence of their causes. On the other hand, chronic cases usually need either mechanical or operative treatment.
The most common operation for relief of torticollis is simple tenotomy of the sternomastoid, taking care to divide the sheath and everything which resists, and, at the same time, to avoid the external jugular vein as well as the deeper structures. Mere tenotomy of one or both of its lower tendons is an exceedingly simple measure, but in serious cases an open division will permit of more thorough work. Here an incision made one inch above the clavicle and parallel to it will permit division of everything which resists and also any recognition of that which should be spared. In any event the position of the head should be immediately rectified, and kept so either by plaster or starch bandage, or by a traction apparatus applied to the head, the body being in the recumbent position, while later some efficient and well-fitting brace should be worn for some time. The posterior cases, i. e., those where the posterior muscles are involved, afford greater operative difficulty, muscles involved lying too deeply and being in too close relation with important vessels and nerves to justify the ordinary wide-open division. Nevertheless in extreme cases there need be no hesitation in extirpating completely those muscles which are primarily and mainly at fault. The writer has removed the sternomastoid and the trapezius, with sections of the still deeper muscles, and has seen nothing but benefit follow the procedure. It should be resorted to when repeated anesthesia with forcible stretching and a suitable brace fail to give relief. These forms of wryneck which are due to contraction of muscles infiltrated from the presence of neighboring phlegmons, etc., will usually subside with massage and semiforcible stretching under an anesthetic. They need conservative rather than operative treatment. Attack upon the spinal accessory and the deep cervical nerves will be described in the chapter on Surgery of the Nerves. It, however, will rarely be justified, since the primary causes inhere not so much in those nerve trunks as in the nerve centres. Such operations are usually of questionable benefit, and cases should be carefully watched before being submitted to them.