Recalcitrant Torticollis: A Formidable Treatment Challenge

IntroductionThere are few evidence-based practice guidelines for recalcitrant torticollis (RT), defined as torticollis that persists past 1 year of age despite conservative therapy. Available evidence recommends a combination of physical therapy (PT), occupational therapy (OT), botulinum toxin injection (BTI), and in the most severe cases, surgical release.MethodsThis is a single-center, retrospective study conducted with Institutional Review Board approval. Inclusion criteria were diagnosis of congenital muscular torticollis before 1 year old and persistence of symptoms past 1 year despite conservative treatment between January 1, 2005, and January 30, 2023. Patients with incomplete data, acquired torticollis, confounding diagnoses, or who did not receive a diagnosis or conservative therapy before 1 year of age were excluded.ResultsSeventy-seven patients met the inclusion criteria. The average age at diagnosis was 4.5 ± 2.5 months. Initial treatment consisted of PT for 61 patients (79.2%), stretching exercises for 11 patients (14.3%), and OT for 4 patients (5.2%). Regardless of timing, 74 patients in total (96.1%) received PT for an average of 13.3 ± 8.6 months. Conservative treatment modalities led to the resolution of symptoms for 40 patients (51.2%) and improvement of symptoms for 35 patients (45.5%). Two patients received at least 1 BTI which led to further improvement of symptoms. One patient underwent operative intervention which consisted of sternocleidomastoid release.ConclusionsRT is a challenging clinical entity that requires diligent multidisciplinary care. Patients who present and begin conservative therapy before 1 year of age are likely to have improvement or resolution of symptoms without more advanced therapies.