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CONGENITAL MUSCULAR TORTICOLLIS US의 임상 적용
성균관의대
강북삼성병원 재활의학과
이 용택
강의내용
• CMT의 정의
• 임상상
• CMT에서의 US 임상적용
• 검사방법
• Case
Torticollis
• 1912, Tubby
“a deformity by lateral inclination of the head
to the shoulder, with torsion of the neck and
deviation of the face”
Latin word for twisted neck
• Sign of an underlying disease
process, not a specific diagnosis
• Congenital torticollis
• Ocular abnormalities
• Strabismus, congenital nystagmus
• Acquired torticollis in older
children
• Trauma, infection, tumor
• Torticollis in adults
• Neck muscle injury
• Muscle spasm
Torticollis
Congenital Muscular Torticollis
•1969, MacDonald
•SCM tumor (SMT): Mass (+)
•Muscular torticollis (MT): Mass (-), tightness (+)
•1950, Hulbert
•Postural torticollis (POST): Mass (-), tightness (-)
Fine needle aspiration Bx.
Reactive skeletal muscle cell (large arrows)
Spindled fibroblast (small arrows)
Pediatr Radiol 1998;28:230-233
Etiology • Unclear
• Intrauterine mechanical factor
• Intrauterne crowding: small uterus in the firstborn, breech,
oligohydroaminos
• Birth trauma Hx. : 30-60%
• Fibrosis from peripartum bleeding
• Breech presentation, forceps delivery, difficult delivery
• Occlusion of the venous outflow
• Compartment syndrome
Curr Opin Pediatr 2006;18:26-29
Clinical Features • MC congenital problems of
MSK in neonates & infants
• Incidence: 0.3-2.0%
• Clinical symptom
• Neck mass
• Shortened SCM & limitation of
ROM
• Ipsilateral head tilt
• Contralateral rotation of the face and
chin
• Associated Sx
• DDH
• Plagiocephaly
• Facial asymmetry
Curr Opin Pediatr 2006;18:26-29
Clinical Course • 50 -70 % tumor
• Spontaneously resolve during the first year of life
• Early & intensive treatment (Celayir et.al) • Good response
• No surgery, mean Tx duration 3.2 m
• Some cases • 10 %Persistent functional asymmetry
(Binder et al.)
• Craniofacial growth • Facial asymmetry
• Deformational plagiocephaly: 사두증
• Spine growth during childhood • Scoliosis
→ Surgical release
• Any limitation of rotation • Early physical therapy
• f/u every 3 month
Plagiocephaly
Diagnosis
• Clinical Dx. • Hx.
• Palpation of neck mass
• Limited neck ROM
• Imaging study for DDx. • Nonmuscular causes > 18% of the torticollis
• US
Curr Opin Pediatr 2006;18:26-29
Clinical Features
• 821 pts. with CMT (< 1 yr)
• Δ passive rotation > 10° • Standardized measure of PROM
• Standardized manual stretching program
• 3 times a week
Outcome of Manual Stretching
Treatment
• Manual stretching
• Safe and effective < 1yr
• Prognosis factor
• Patients’ age
• Initial rotational deficit
• Surgery
• Recommend for resistant
cases after 6 m manual
stretching
JBJS Am 2001;83:679-687
Findings of US
• 36 CMT patients (< 6 mo) • Echo-texture
• Hyperechoic
• Heterogeneous (49%) vs. homogeneous (51%)
• Hypo-echoic rim
• Well-defined margin of the mass
• Sternal portion (57%) vs. clavicular portion (0%)
• Sternal & clavicular portion (43%)
Pediatr Radiol 1992;22:356-360
J Pediatr Surg 1997; 32: 1648-1651
Extent of fibrosis on US vs. Prognosis
• 197 CMT (1mo ~ 16yr)
• 362 US exam • Sternal (24%), Sternal & clavicle (76%)
• clavicular portion (0%)
• Transverse scan • Homogeneous hyperechoic lesion (36.7 %)
• Heterogeneous, hyper & isoechoic (63.3%)
• Fibrosis L/M ratio • OP (63%) vs. Non-op (55%), p < 0.05
• Longitudinal scan • 32 operative group
• 81.3 % fibrotic lesion in the entire length of muscle
• 256 CMT pts ( 9d~16y)
• 4 Type according to extent of
fibrosis
• Average f/u: 6 mo
• Op
• Prominent clinical feature after
physiotherapy for 6 mo
• Age > 1 yr
Arch Phys Med Rehabil 1999; 80: 637-641
Extent of fibrosis on US vs. Prognosis
Normal
Type 1
Type 3
Type 4
Arch Phys Med Rehabil 1999; 80: 637-641
Type 2
Arch Phys Med Rehabil 1999; 80: 637-641
Type 1 Type 2 Type 3 and 4
Ultrasound Med Biol 2000; 26: 1237-1241
US findings vs. Clinical Severity
• 436 CMT pts. (< 1yr) • US before any treatment
• SMT, MT, POST group
• 4 groups according to rotation limitation
Clin Orthop Relat Res2002; 403: 179-186
Longitudinal F/U of Extent of fibrosis
• 73 Pts (1mo~ 11yr)
• Type 1~4
• Mean 8 mo F/U
Irreversible !!
J Pediatr Orthop 2005; 25: 812-814
Extent of fibrosis on US vs. Prognosis
• 26 CMT Pts with palpable neck mass (1 w~ 16 w)
• Type 1~2
• All vaginal delivery (4 traumatic) • Complete recovery of torticollis 1-6 w after Dx. (mean 2.8 w)
• Palpable mass disappearance 2-8.5 w (mean 3.5 w)
• US mass disappearance 3-10 w (mean 5.5 w)
• F/U after 6 months • Clinical and US abnormality (-)
• OP (-)
Normal Type 1 Type 2 Type 3
Extent of fibrosis on US vs. Etiology
• 67 CMT pts (< 3 m) • palpable neck mass
• Δ passive rotation > 10°
• Type 1~3, Type 4 (-)
J Pediatr Surg 2011;46:514-519
J Pediatr Surg 2011;46:514-519
• 21 breech presentation + C-sec
• *OR (95% CI): 6.393 (1.398-29.225)
• P = 0.017
J Pediatr Surg 2011;46:1526-1531
Extent of fibrosis on US vs. PTx. Duration
• 50 CMT pts (< 3 m.) • palpable neck mass
• Δ passive rotation > 10°
• Type 1~3, Type 4 (-)
• Standardized manual stretching • Treatment failure
• ᇫrotation > 6° at 10 m.
• No improvement after 6 m.
• Success rate: 98 %
The Clinical Features and Outcome of Sono-negative Congenital Torticollis with Limitation of Passive Range of Motion
An Ju-ha, MD, Yong-Taek Lee*, MD, Soo Kyoung Cho, MD
Number of cases
ᇫRotatio
n (°)
ᇫLateral
Flex (°) Age at
presentation (month)
Duration of Treatment
(month)
23 9.13 (0~20)
13.26 (0~25)
4.23 (1.2~6.0)
1.13 (0.5~2.0)
• 23 Pts with normal US (< 6 mo )
• Δ Passive rotation or Δ lateral flexion > 10 ̊
Normal US vs. Prognosis
2009 대한재활의학회 추계학술대회
AJNR 2013; www.ajnr.org
US Thickness Ratio vs. ROM
• 48 CMT pts (mean 3.9m)
• Standardized manual stretching • Clinical score
• ᇫrotation &ᇫlateral flexion
• SCM thickness ratio • Excellent intra- &
interobserver agreement
• Most correlated w clinical improvement
• Overcome of false-positive aggravation
Methods of US
• Position
• Supine with small pillow placed under the shoulders
• Head slightly rotated to the opposite side
• Equipment
• 5-13 MHz real-time linear-array transducer
• Transverse scan
• Perpendicular to the long axis of the muscle
• Origin (clavicle and sternal head), Belly, Insertion (mastoid process)
• Maximal A-P diameter
• Longitudinal scan
Methods of US
• Location
• Sternal or clavicular head
• Lower, middle or upper thirds
• Internal echo-texture
• Homogeneous/Heterogeneous
• Hyperechoic/isoechoic/hypoechoic
• Margin of mass
• Definable/poorly visualized
• Both side
• Normal: the findings were similar to the uninvolved SCM
SCM
US Findings
CASE 1: 고 OO 8y/M
CASE 2: 5y/M
• GA 40+6자, 3543gm, vacuum delivery
• 출생 시부터 오른쪽으로 고개 기운 증상으로 외부병원 내원하여 US • Neck mass 1.75 cm/0.5 cm
• TYPE 3
• 생후 80일 경 재활치료 위해 본원 내원 • Neck mass 3.5 cm/0.5 cm,
• Plagiocephaly (-)
• Rotation 100/45, lateral flexion 50/20
• PTx 6개월 지속
• 생후 9개월 • Neck mass 2 cm/0.5 cm
• Rotation 100/70, lateral flexion 60/25
• Op 의뢰
• 생후 13개월 • Neck mass 1.7 cm/0.7 cm
• Rotation 100/90, lateral flexion 50/45
• 증상 갑자기 좋아져 observation 하기로 함
• 4세 증상 유지 중
• 5세 RT SCM muscle이 도드라져 내원함.
CASE 2: 최 OO 5y/M
CASE 2: 최 OO 5y/M
CASE 3 장 OO 2mo/M • Rotation 95/65,
lateral flexion 60/40
• 4개월 PTx
• Rotation 95/90, lateral flexion 50/45
“Take Home Message”
• CMT는 SCM의 involvement와 LOM이 증명되어야 함.
• US는 P/E의 보완 및 CMT의 DDx.를 위해 꼭 필요함.
• 초음파 상의 Fibrosis의 정도가 임상상을 반영하므로 F/U에
적용할 수 있다.
• Thickness ratio, Fibrosis의 정도.
• 향후 fibrosis의 정도를 객관적으로 측정할 수 있는 방법에
대한 연구 필요.
• Fibrosis의 정도와 임상양상과의 관계에 대한 연구가 더 필요함.
THE END 경청해 주셔서 감사합니다^^