BIPOLAR

STERNO-MASTOID TENOTOMY FOR INFANTILE (CONGENITAL) TORTICOLLIS.

Dr. Syed Shahidul Islam (Assistant Professor 1-5, Dr. Paritosh Ch. Debnath (Associate Professor) 2-6, Dr. Md.Nazrul Islam (Resident Surgeon) 3-6, Dr. Md. Subir Hossain (Assistant Registrar) 4-6, NITOR-Nation Institute of Traumatology & rehabilitation5 Shaheed Suhrawardy Medical College Hospital Dhaka, Bangladesh.6.
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ABSTRACT:

This prospective study carried out over 10 patient in Shaheed suhrawardy hospital & sadar hospital, Madaripur between the period of july 2004 to june 2007 were evaluated after an average follow up of 2 yrs (range 1.5-3.0 yrs).Out of 10 patient 3 were female and 7 were male and age range of the patient was 4-10 yrs and had right side involvement 6, left side 4. The excellent result was found in 5 patient (50%), good in 3 patients (30%) fair in 1 pt.(10%)and poor result in 1 pt.(10%).
INTRODUCTION:

This is not an uncommon condition. The sternocledomastoid muscle on one side is fibrous and fails to elongate as the child grows. Consequently progressive deformity develops. The cause of infantile torticollis is unknown.The muscle may have suffered from ischaemia from a distorted position in utero or it may have been injured at birth. Deformity become apparent at the age of 1-2 yrs.

The head is tilted to one side so that the ear approaches the shoulder; the sternomastoid on that side may feel tight and hard. As the child grows the features become increasingly prominent and the child develops asymmetrical development of the face. Management starts during infancy. If the diagnosis is made early, daily muscle stretching by the parents may prevent the incipient deformity. The guideline for treatment is conflicting specially in connection with surgical intervention. It is the purpose of the study to evaluate the result of bipolar tenotomy .
MATERIAL AND METHOD:

The current study is a prospective study of all congenital torticolis patients operated on in two centres over 3 year period. Patients with congenital anomalies of the cervical spine, spasmodic torticollis, and other forms of neurogenic, ocular and organic torticollis were excluded from the study. All patients had muscular torticollis without palpable or visible tumour but with clinical thickening or tightness of the sternomastoid muscle on the affected site. Preoperative radiographs of the cervical spine, which had been made for all of the patients, were available for 10 patients at the time if last follow up. Cervico-thoracic scoliosis was present in all patients. Radiographs of the cervical spine in two planes were included in the follow up examination. Hip dysplasia and congenital anomalies of foot was not present in our patients. In all patients a uniform method of proximal (cephalad) and distal (caudad) open release and partial excision of the clavicular and sternal heads of the sternomastoid muscle were performed. Postoperatively 5-7 days immobilization with cervical collar followed by an intensive program of physiotherapy was prescribed that included scar treatment, maintenance of full passive range of motion of the neck, and active strengthening exercises for a period of 3 to 4 months. There were no complications intraoperatively or postoperatively in our patients.

At the final assessment the overall results were graded by a scoring system based on both subjective and objective criteria and grouped as excellent, good, fair & poor respectively. The subjective score was based on interviewing the patients at the final follow-up and inquiring about the overall cosmetic and functional results of the patients.
RESULTS:

Seven patients were male and four female. Facial asymmetry was equally distributed in all age groups. The right sternocledomastoid muscle was affected in 7 patients and the left in 3 patients. All patients had muscular torticollis without a visible tumour in the sternocleidomastoid muscle. The age of the patients at the time of operation ranged from 4 years to 10 years(average approximately 7.1 years). All patients treated with bipolar tenotomy were followed between 2 and 4 years postoperatively. All of the patients had full flexion and extension of the cervical spine at follow-up examination. Compared with the findings on preoperative radiographs that were available in every patient, these findings suggested complete resolution of the scoliosis in majority of the patients. However, scoliosis improved more rapidly in younger children than in older patients.

Pre operative

1st week after operation

Six weeks after operation

DISCUSSION:

If congenital muscular torticollis persists beyond the age of one year, it does not resolve spontaneously. Children with torticollis who were treated during the first year of life had better results than those treated later, and an exercise programmed was more likely to be successful when the restriction of motion was less than 30 degrees and there was no facial asymmetry. Non-operative therapy after the age of one year was rarely successful. Controlled manual stretching is safe and effective in the treatment of CMT when a patient is seen before the age of one year. In this age group only 8-10% of patients required surgery. Shim et al. treated CMT surgically in 32 patients over 8 years of age who had not received any prior medical treatment. They concluded that in patients older than school age, even for those who have finished growth, sufficient bipolar release of sternomastoid muscle and intensive postoperative care are expected to yield satisfactory treatment results. An assessment with three dimensional computed tomography imaging for craniofacial deformity in patients with uncorrected CMT showed that the cranium and cranial base deformity occurred early in patients with uncorrected torticollis, while the facial bone deformity occurred in the childhood stage. The cranial and facial deformity becomes more severe with age. Early release of the muscle restriction is advised to prevent craniofacial deformation.

References

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