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correspondence

Indian Pediatr 2011;48: 989-990

Cervical Spine Injury - A Rare Cause of Torticollis


Ravi Mittal and Vijay Sharma

Department of Orthopaedics, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India.
Email: [email protected]


A 9-month-old male child had a fall on his head from a height of 4 feet when he was being carried in arms by the elder sibling. The child developed tilt of his head to left and resisted any attempts to passively correct the tilt. The child did not have any other injury and there was no neurological deficit. Radiographs of the cervical spine showed fracture of lamina at C2 level. The child was given a Minerva jacket plaster for 3 weeks. When the plaster was removed at the end of 3 weeks, the child could freely move his head and neck without any tilt and had no tenderness in the cervical spine. The follow-up radiographs showed healing of fracture.

Congenital torticollis is the commonest cause of torticollis in children. It is caused by injury to sternocleidomastoid during a difficult labor when it undergoes ischemic necrosis and contracture. The occiput is deviated towards the ipsilateral shoulder and chin is deviated towards the contralateral side. The other common causes include cervical lymphadenitis causing reflex spasm of sternocleidomastoid and dystonic side effects of some drugs like phenothiazines, metoclopramide, haloperidol, carbamazepine and phenytoin. Congenital cervical spine and craniovertebral region abnormalities are the true congenital reasons of torticollis. Post-burn contractures and neoplastic lesions of posterior cranial fossa and spinal cord can be the other causes. Benign paroxysmal torticollis is a self-limiting condition in infants characterized by episodes of head tilting.

Injuries to cervical spine in children are very uncommon and account for 1% of paediatric fractures and 2% of all spinal injuries [1]. These children have high mortality rates because of associated lethal head injuries [1,2]. Cervical spine injury in the 0-2 year age group occur mainly at C1 – C2 level [3]. There are many anatomical reasons for this difference. Younger children have relatively large head size, increased ligament laxity, poor musculature, anterior wedging of cervical vertebral bodies, horizontally oriented facet joints and a higher fulcrum at C1 – C2 [2]. We could not find a similar case in the English literature where the patient had an isolated fracture of C2 lamina without neurological deficit in infancy. We also could not find any report of pediatric cervical spine injury where torticollis was the presentation. This report highlights the fact that the survivors of upper cervical spine injury can present with very subtle signs and symptoms, including torticollis. It is important to screen the cervical spine before excluding any injury to this part. Most of these fractures when detected early can be managed non-operatively and usually have a favorable outcome.

References

1. Patel JC, Topas JJ III, Mollitt DL, Pieper P. Pediatric cervical spine injuries: Defining the disease. J Pediatr Surg. 2001;36: 373-6.

2. Kokoska ER, Keller MS, Rallo MC, Weber TR. Characteristics of pediatric cervical spine injuries. J Pediatr Surg. 2001;36: 100-5.

3. Sullivan JA. Fractures of spine in children. In: Green NE, Swiontkowski MF, editors. Skeletal Trauma in Children. Pennsylvania: Saunders; 2003. p. 344-70.
 

 

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