Fever and acquired torticollis in hospitalized children

Acute torticollis due to non-traumatic atlanto-axial subluxation (AAS) is often seen in children presenting with inflammatory conditions of the upper respiratory tract and the neck. Grisel's syndrome is the eponym given to this condition. These patients may present earlier in the disease process without evident subluxation. Thus, early recognition of the condition with prompt commencement of appropriate conservative treatment could halt the progression into Grisel's syndrome. The purpose of this study is to address the importance of early recognition of inflammatory torticollis that can be treated successfully by conservative methods. A retrospective review was made of the case files and radiological investigations of 13 children with fever and torticollis who were treated in the neurosurgery unit of Hamad General Hospital in Qatar, over a two-year period from July 1996 to July 1998. The children were aged between three and 12 years with a male to female ratio of 3:1. All patients arrived at the hospital within 48 hours of onset of torticollis and almost all had manifestations of upper respiratory tract or head and neck infections. Radiological examination by cervical spine X-rays, computerized tomography (CT) or magnetic resonance images (MRI) revealed that only three cases out of 13 had AAS. All patients underwent conservative treatment that included rest, neck collar, simple analgesics and antibiotics, where appropriate. A muscle relaxant was used in nine cases and Halter traction was applied to the three with AAS. All patients responded well to treatment and none required surgical intervention for AAS. We conclude that the majority of children presenting acutely with inflammatory torticollis have rotational deformity only without AAS. Progression to the latter, i.e. Grisel's syndrome, may be aborted should the diagnosis be made early and conservative treatment initiated in time. On the other hand, delay in diagnosis would deprive these children an opportunity of receiving effective conservative treatment.