Definition
Secondary Torticollis
Spasmodic torticollis
- is thought to be due to neurological or psychological disorders. The sternomastoid muscle is in marked spasm & the head grossly twisted
Aetiology
The commonest cause in adults is an acute disc prolapse
May also follow –
- skin scarring particularly burns
- inflamed cervical glands
- vertebral tuberculosis
- ocular disorders
- injuries of the cervical spine
Epidemiology
- Less common than congenital muscular torticollis in infants
- Acquired painful torticollis in children often follows minor trauma or upper respiratory infection
- Grisel syndrome affects children after pharyngeal infection or ENT surgery
- Spasmodic torticollis presents in adults, more often in women
Anatomy
- Sternocleidomastoid tilts the head to the same side and rotates the face to the opposite side
- Atlantoaxial joint provides about half of cervical rotation
- Transverse ligament restrains anterior translation of C1 on C2
- Pharyngovertebral venous connections carry inflammation to the upper cervical ligaments in Grisel syndrome
- Ocular and vestibular input adjust head posture, so imbalance produces compensatory tilt
Pathology
- Head tilt arises from a lesion outside the sternocleidomastoid
- Inflammation causes ligament laxity and C1 C2 rotatory subluxation in Grisel syndrome
- Protective muscle spasm around a painful lesion such as tumour, infection or fracture
- Ocular torticollis compensates for diplopia, often from fourth nerve palsy
Classification
| Category | Causes |
|---|---|
| Osseous | Klippel Feil syndrome, hemivertebra, C1 C2 rotatory subluxation and fracture |
| Neurogenic | Posterior fossa tumour, syringomyelia and Chiari malformation |
| Inflammatory | Grisel syndrome, cervical adenitis, retropharyngeal abscess and discitis |
| Ocular | Superior oblique palsy and strabismus |
| Other | Sandifer syndrome, benign paroxysmal torticollis and cervical dystonia |
History
- Onset after birth with no neonatal neck mass favours an acquired cause
- Recent upper respiratory infection, ENT surgery or trauma
- Pain, fever and dysphagia suggest infection
- Headache, vomiting, ataxia or visual change suggest a neurological cause
- Tilt that resolves when one eye is covered suggests ocular torticollis
- Episodic tilt with feeds and reflux suggests Sandifer syndrome
Examination
- No sternocleidomastoid tumour or contracture
- Rotatory subluxation gives a cock robin posture with spasm of the sternocleidomastoid on the chin side
- Full neurological examination including cranial nerves and fundoscopy
- Eye examination for strabismus and fourth nerve palsy
- Lymphadenopathy, pharyngeal swelling and fever
- Low hairline and short neck suggest Klippel Feil syndrome
Investigations
- Cervical spine X-rays including open mouth view for bony anomalies and C1 C2 alignment
- Dynamic CT in neutral and rotated positions confirms fixed rotatory subluxation
- MRI brain and cervical spine with neurological signs
- FBC, CRP and ESR when infection is suspected
- Ophthalmology review for suspected ocular torticollis
Differential Diagnosis
- Congenital muscular torticollis
- Positional plagiocephaly with head tilt
- Benign paroxysmal torticollis of infancy
- Cervical dystonia in adults
- Functional torticollis
Treatment
- The treatment is that of the underlying condition
Complications
- Facial asymmetry and plagiocephaly with persistent tilt in early childhood
- Chronic fixed rotatory subluxation needing C1 C2 fusion
- Neurological deficit from a missed tumour or instability
- Recurrence after reduction of rotatory subluxation
Prognosis
- Outcome depends on the cause
- Rotatory subluxation treated within a week usually reduces with collar and analgesia
- Subluxation present beyond a month is harder to reduce and may need fusion
- Ocular torticollis resolves with correction of the eye disorder
- Sandifer syndrome resolves with treatment of reflux
- Benign paroxysmal torticollis resolves spontaneously in early childhood
Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 10 October 2026.