|Year : 2014 | Volume
| Issue : 5 | Page : 584-588
Outcome of bipolar release of the sternocleidomastoid muscle in neglected congenital muscular torticollis
Basant Kumar Bhuyan
Department of Orthopaedics and Trauma, R. D. Gardi Medical College and C. R. G. Hospital, Surasa, Ujjain, Madhya Pradesh, India
|Date of Web Publication||10-Sep-2014|
Basant Kumar Bhuyan
Professor and Unit Head, Department of Orthopaedics and Trauma, R. D. Gardi Medical College and C. R. G. Hospital, Agar Road, Surasa, Ujjain - 456 006, Madhya Pradesh
Source of Support: None, Conflict of Interest: None
Purpose: Neglected congenital muscular torticollis (CMT) is a common presentation in our country, which poses largely a cosmetic disability. Surgical correction is recommended for patients with late reporting cases. The aim of this study is to evaluate the efficacy of surgical release of CMT in neglected cases. Materials and Methods: In the present retrospective case series, eleven patients of neglected CMT were treated by a modified Ferkel's release which comprising a bipolar release of the sternocleidomastoid muscle with Z-lengthening. The age at operation ranged from 4 to 18 years (mean 8.3 years). Post-operative protocol included head halter traction for 6 weeks and physiotherapy. Results were evaluated by the scoring system of Lee et al. Results: At an average follow-up of 4.4 years (range: 2-8.6 years), excellent results were noted in 8 patients (72.7%) and good in 3 (27.2%). In this study, significant improvement of neck motion, head tilt, chin deviation and cosmesis were observed with surgical treatment. There were no surgery-related complications or recurrences occurred in any of these patients. Conclusions: Patients with neglected CMT can benefit from surgical treatment and bipolar release is an effective and complication-free method for such patients.
Keywords: Bipolar lengthening, congenital muscular torticollis, neglected cases
|How to cite this article:|
Bhuyan BK. Outcome of bipolar release of the sternocleidomastoid muscle in neglected congenital muscular torticollis. Med J DY Patil Univ 2014;7:584-8
|How to cite this URL:|
Bhuyan BK. Outcome of bipolar release of the sternocleidomastoid muscle in neglected congenital muscular torticollis. Med J DY Patil Univ [serial online] 2014 [cited 2021 Oct 19];7:584-8. Available from: https://www.mjdrdypu.org/text.asp?2014/7/5/584/140407
| Introduction|| |
Congenital muscular torticollis (CMT) is a postural deformity of head and neck detected at birth or shortly after birth, primarily resulting from unilateral shortening of sternocleidomastoid (SCM) muscle. It is the third most common congenital pediatric orthopedic diagnosis in childhood after dislocation of the hip and clubfoot with reported incidence of 0.3-1.9% respectively. 
Patients with CMT present with lateral inclination of the head to the side of the muscle involved, with torsion of the head and hence that the chin points to the opposite shoulder. Skull and facial asymmetry or plagiocephaly may occur in the presence of prolonged uncorrected head tilt. 
In neonates and infants, patient may cure conservatively by a regimen of stretching exercises is the most common form of treatment with positive outcomes for over 90% of the identified cases. , In patients over 1 year of age, corrective surgery has both cosmetic and functional benefits, with the best outcomes being obtained between the ages of one and four. 
A number of articles have been published on the long-term follow-up of patients who have surgical treatment for CMT. Despite this, the indications for the timing of surgery are still unclear, although early surgical intervention has been recommended to obtain better correction of the deformity. ,, Neglected CMT is quite common in our country due to late reporting of cases. The aim of our study was to evaluate the results of bipolar release in this age group.
| Materials and Methods|| |
During the period of months from January 2005 to June 2011, eleven patients were surgically treated for neglected CMT. Neck deformities in all the patients were first noticed during infancy by their parents. The age at presentation ranged from 4 to 18 years (mean 8.3 years). Seven of the patients were boys while four were girls. Eight of the patients had involvement of the right side, while three had left side involvement.
Radiographs of the cervical spine were obtained in all patients to evaluate for any congenital anomalies of the cervical spine. Careful neurological examination performed to rule out any spastic paralytic lesions. Only patients with idiopathic CMT were included in this study. Patients with neurogenic torticollis, those with congenital cervical spine anomalies were excluded from the study.
The indications of surgery were persistent head tilt, deficits of passive rotation and lateral banding of the neck >15°. Pre-operative range of motion of the neck was documented in all patients. In view of the late presentation, they were treated by a modified Ferkel's release comprising a bipolar release of SCM muscle with Z-lengthening. 
Under general anesthesia the involved side was placed under tension by hyper extending the neck and rotating the head toward the shoulder on the unaffected side [Figure 1]. Proximal incision was made behind the ear just distal to the tip of the mastoid process and the mastoid head of SCM muscle was released [Figure 1]b. With this limited incision it avoids injury to the spinal accessory nerve. A distal incision was made in line with the cervical skin creases one finger breadth proximal to the medial end of the clavicle and sternal notch. The clavicular head of SCM muscle was released while the sternal head was lengthened by Z-plasty [Figure 1]c and d. The desired degree of correction was obtained by manipulating the head and neck during the release.
Occasionally, there requires additional release of contracted bands of fascia or muscle. Wounds were closed with subcuticular sutures and skin staples [Figure 1]e.
|Figure 1: (a) Position of patient (b) isolation and release of mastoid head of sternocleidomastoid (SCM) muscle (c) isolation of sternal and clavicular head of SCM muscle (d) release of clavicular head and Z-plasty of sternal head of SCM muscle (e) closure|
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Post-operatively, all the patients had head halter traction in bed for 7-10 days until the wound healed. After that traction was applied during the night time only for further 6 weeks and during the day patient was put on a cervical collar. A neck exercise program consisting of stretching and muscle strengthening exercises was started as soon as possible under the supervision of a physiotherapist.
Patients were reviewed every 3 weeks for 3 months, 6-weekly for 1 year and thereafter every 6 months. At each follow-up, patients were assessed by evaluating the following parameters: Deficits of lateral flexion and rotation of the head, craniofacial asymmetry, surgical scarring, residual contracture and degree of head tilt. The neck movement and lateral band were compared with the uninvolved side and the head tilt and operative scar were evaluated by clinical observation and a questionnaire.
The outcome of surgery was analyzed and graded according to a scoring system of Lee et al. which graded as excellent (17-18 points), good (15-16 points), fair (13-14 points) or poor (less than 12 points) on the basis of both function and cosmetic results.  [Table 1].
|Table 1: Scoring system for assessment of congenital muscular torticollis; Lee et al.,/sup>|
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| Results|| |
The mean follow-up for the patients was 4.4 years (range: 2-8.6 years). The surgical results are listed in [Table 2]. According to the Lee's scoring system, excellent results were noted in 8 patients (72.7%) and good in 3 (27.2%). There were no surgery-related complications or recurrences.
Complete muscular release as determined by pre-and post-operative neck range of motion measurements, which was achieved in all of the patients. The range of neck movements was within the normal limits except three (Case 5, 7 and 11) had a less than 10° limitation of rotation in the latest follow-up visit.
Cosmetic improvement in the form of reduction in head tilt and chin deviation was present in all patients. Post-operative head tilt was fully corrected in eight patients, while three had residual mild tilt (Case 4, 8 and 11). There was no cosmetically unacceptable scar visible at either of the two surgical sites in seven patients, but three patients developed slight scar formation at the surgical site (Case 5, 7 and 10). Case 1 illustrative of excellent results [Figure 2]a and b and Case 7 showed good results [Figure 3]a-e.
|Figure 2: Case 1-(a) A 4-year-old boy with right congenital muscular torticollis (b) follow-up shows excellent function with full correction of deformity|
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|Figure 3: Case 7-(a-c) A 17-year-old boy with right congenital muscular torticollis, marked head tilt, clavicular and sternal head are tight (d-e) follow-up; 2 years after bipolar release shows good function|
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There was no post-operative infection or hematoma formation. No injuries to major blood vessels or nerves were encountered. None of the patients had a loss of the normal V-contour of the neck.
| Discussion|| |
Macdonald divided patients with CMT into two groups: Those with a sternomastoid tumor and those with tightness of the SCM but no clinical tumor, which he termed muscular torticollis. Postural torticollis is a term used to describe patients with congenital torticollis who have all the clinical features of torticollis but with no demonstrable tightness or tumor of the muscle.  However, a clear distinction has not been made between postural torticollis and CMT in the literature and in most series the term CMT includes all three groups. 
Besides the benign muscular tightness of the SCM muscle leading to the classic head position, it should be differentiated from many other congenital and acquired types of torticollis [Table 3]. Therefore, it requires a thorough and systematic work-up, including a complete physical and neurologic examination and cervical spine radiographs.
The etiology of CMT is still unclear. Trauma at birth with subsequent hematoma and myositis of the SCM muscle or with vascular occlusion has been described, but a direct relationship to the histological changes of CMT has not been demonstrated.  The frequent occurrence of CMT after a complicated pregnancy or delivery has been linked to abnormal intrauterine position and to trauma at birth. , Heredity appears to play a certain role in the etiology of CMT; however no precise path of hereditary transmission has been identified. 
In neonates and infants, majority of patients of CMT resolve spontaneously or by a series of passive muscle stretching exercises. When persists beyond the age of 1 year it does not resolve if left untreated. Surgery is the treatment of choice for children and adolescents as non-operative therapy after the age of 1 year is unlikely to be successful. ,
The primary goal in the treatment of CMT is an improvement of the cosmetic deformity which is achieved by release of the contracture and maintenance of normal contour of the neck.
Surgical correction of the CMT is recommended for patients with unsuccessful conservative treatment and in late reporting or neglected cases. Various operations have been recommended i.e., tenotomy, open tenotomy of sternal and clavicular heads, superior open SCM tenotomy (mastoid release), SCM excision and combined approach. ,, Botox injections, arthroscopically release of SCM are a new form of treatment being used by some practitioners. 
The most popular is bipolar release by Ferkel et al. which comprises of cutting of clavicular and mastoid attachments in addition Z-plasty of sternal attachment of SCM muscle. Incisions should be placed low in the neck along skin lines and not over the clavicle in order to avoid hypertrophic scarring. It produced superior cosmetic result compared with other methods by preserving V-contour of neck. Ferkel's original series with the described operation showed 92% excellent or good results, with only one fair rating which is due to an unsightly scar. 
Omidi-Kashani et al. showed 86% excellent to good results by bipolar release in skeletally mature patients with CMT.  Sudesh et al. operated 14 patients older than 10 years with neglected CMT showed 71% of excellent to good results. Post-operative improvements in the range of motion, head tilt, chin deviation and cosmesis were noted in all patients and these improvements were statistically significant.  Patwardhan et al. in their study have reported 67% excellent to good results in the age group of 17-31 years by modified Ferkel's method.  Seyhan et al. showed marked improvement in neck motion and head tilt with bipolar surgical release in late cases those who presented in between 6 and 23 years. They found CMT patients can benefit from surgical intervention above the age of 5. 
Late presentation of CMT is quite common in our scenario. Surgical management of neglected CMT using a modified Ferkel's bipolar release gives excellent results. In this study, we observed functional and cosmetic improvements in all the patients in the age group of 4-18 years with 72.7% excellent and 27.2% good results.
| Conclusion|| |
Bipolar release of the SCM muscle should be considered in neglected CMT even in adults with irreversible facial and skeletal deformities. The surgery restores the range of neck motion and resolves the head tilt; hence, it improves the quality of life and cosmesis. Good results can be obtained in patients with late presentation provided that optimum surgery and rehabilitation are carried out.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]