Posttraumatic painful torticollis

Abstract

The development of abnormal posturing of the neck or shoulder after local injury has been termed posttraumatic cervical dystonia (PTCD). Certain features seem to distinguish a unique subgroup of patients with this disorder from those with features more akin to typical idiopathic cervical dystonia, such as onset and maximum disability that occurs very quickly after injury, severe pain and a fixed abnormal posture. In an attempt to clarify the nature of this syndrome further, we evaluated 16 such patients (8 men, 8 women). Motor vehicle accident and work-related injuries were common precipitants, with posturing usually developing shortly after trauma, and little progression occurring after the first week. A characteristic, painful, fixed head tilt and shoulder elevation were present in all but one patient, who had a painless elevated shoulder and painful contralateral shoulder depression, as well as nondermatomal sensory loss in 14 patients. Additional abnormalities included dystonic posturing in a limb (2 patients) or jaw (1 patient), limb tremor (3 patients) and "give-way" limb weakness (8 patients). The tremor and the jaw dystonia demonstrated features suggestive of a psychogenic movement disorder, most commonly distractibility. Litigation or compensation was present in all 16 patients. Intravenous sodium amytal improved the posture, pain or both in 13 of 13 patients; in 7 of 13 the sensory deficit either markedly improved or normalized. General anesthesia demonstrated full range of motion in all 5 patients assessed. Psychological evaluations suggested that psychological conflict, stress, or both were being expressed via somatic channels in 11 of 12 tested patients. Our results suggest an important role of psychological factors in the etiology or maintenance of abnormal posture, pain and associated disability of these patients. The role of central factors triggered in psychologically vulnerable individuals after physical trauma is discussed. We propose that the disorder be referred to as "posttraumatic painful torticollis" rather than characterize it as a form of dystonia until further information on its pathogenesis is forthcoming.

Natural history of posttraumatic cervical dystonia

“…Sa and coworkers 15 reported on 16 patients with features of posttraumatic cervical dystonia comparable to those reported previously. Alleviation of the dystonic posture with sodium amytal and return of range of motion during general anesthesia in addition to psychological profile suggestive of somatization were reported as substantiation of a psychological manifestation of this disorder.…”

“…Schott 12 described 6 of 10 cases of dystonia after peripheral trauma, and cervical dystonia was reported in 1 of the 6 patients. Recently, Sa and coworkers 15 reported on 16 patients with a similar presentation. The 9 patients described in the present study exhibit characteristics similar to those reported on previously and provide additional support for classification of posttraumatic cervical dystonia as a distinct syndrome.…”

“…Alleviation of the dystonic posture with sodium amytal and return of range of motion during general anesthesia in addition to psychological profile suggestive of somatization were reported as substantiation of a psychological manifestation of this disorder. 15 All 16 of their patients were involved in litigation and 14 of 16 patients displayed nonanatomical sensory disturbances. In contrast, none of our patients were involved in litigation, nor did they report any sensory abnormalities.…”

Evaluation of Neurologic Deficit Without Apparent Cause: The Importance of a Multidisciplinary Approach

“…The resolution of psychogenic symptoms after the administration of sodium Amytal has been reported in multiple case studies (22,23). This short-acting barbiturate has sedative, hypnotic, and anticonvulsant properties.…”

Functional movement disorders

“…Classical phenotype is the painful torticollis with sudden onset often after trivial trauma [16,17]. Often, predominant laterocollis with ipsilateral shoulder elevation and contralateral shoulder depression is seen.…”