Transaxillary endoscopic release of restricting bands in congenital muscular torticollis – a novel technique

Transaxillary endoscopic subfascial operation for persistent muscular torticollis in pediatric patients: A 13-year retrospective study in Taiwan

BACKGROUND

The endoscopic surgery for persistent muscular torticollis has been well-described and most are subcutaneous working caverns. As the sternocleidomastoid muscle is located beneath the deep cervical fascia that corresponds to the pectoral fascia, this study aimed to review our results of the transaxillary approach under the pectoral fascia and the deep cervical fascia.

METHODS

Between November 2009 and January 2022, pediatric patients with persistent muscular torticollis receiving transaxillary endoscopic subfascial operation were retrospectively reviewed and analyzed.

RESULTS

There were thirty-three consecutive patients with median age of 6.5 years (range, 5.5 months-15.7 years). The median operating time was 90.0 min. With a median follow-up of 14.8 months (range, 5.0-127.7), the final outcomes showed excellent-to-good results in 90.9%, fair results in 6.1%, and poor results in 3.0%. Univariate analysis revealed that the long-term outcomes of the operation were independent of gender, age, involved side and previously open myotomy (p = 0.662, 0.818, 0.740 and 0.596, respectively).

CONCLUSIONS

The subfascial working cavern would be technically achievable for the transaxillary endoscopic approach with good functional and cosmetic outcomes.

Subcutaneous Endoscopy in Plastic and Reconstructive Surgery

Background Scar visibility is a major deterrent to patients seeking reconstructive surgery. Endoscopic surgery can address a wide range of problems, from minimizing or concealing scars to improving access and outcomes in certain situations. This case series includes a wide range of reconstructive surgery problems addressed by subcutaneous endoscopic surgery. Having one or more trained assistants is a major deterrent to the performance of endoscopic surgery by the lone practitioner. The single (or two-port technique for muscle harvest) used in most cases simplifies subcutaneous endoscopic surgery. Methods A single-port endoscopy technique, with a 4-mm, 30-degree side viewing telescope and sheath, optical camera and cold light source, was used. Case records were reviewed for access incisions, procedure abandonment, postoperative pain, complications, and patient satisfaction. Results A total of 53 endoscopic surgical episodes between 2003 and 2013 were reviewed. Using a single port, most cases were done successfully. The access site was changed peroperatively in one case. Complications included transient nerve palsy in one case, which recovered completely. There was minimal intraoperative bleeding. Postoperative pain was low except in one case and managed with minimal analgesia. Patient satisfaction was high in all cases. Conclusions Subsurface endoscopy done on a wide range of reconstructive surgery procedures and resulted in minimal scars and high patient satisfaction.

Physical Therapy Management of Congenital Muscular Torticollis: A 2018 Evidence-Based Clinical Practice Guideline From the APTA Academy of Pediatric Physical Therapy

BACKGROUND

Congenital muscular torticollis (CMT) is a postural deformity evident shortly after birth, typically characterized by lateral flexion/side bending of the head to one side and cervical rotation/head turning to the opposite side due to unilateral shortening of the sternocleidomastoid muscle; it may be accompanied by other neurological or musculoskeletal conditions. Infants with CMT should be referred to physical therapists to treat these postural asymmetries as soon as they are identified.

PURPOSE

This update of the 2013 CMT clinical practice guideline (CPG) informs clinicians and families as to whom to monitor, treat, and/or refer and when and what to treat. It links 17 action statements with explicit levels of critically appraised evidence and expert opinion with recommendations on implementation of the CMT CPG into practice.

RESULTS/CONCLUSIONS

The CPG addresses the following: education for prevention; referral; screening; examination and evaluation; prognosis; first-choice and supplemental interventions; consultation; discontinuation from direct intervention; reassessment and discharge; implementation and compliance audits; and research recommendations. Flow sheets for referral paths and classification of CMT severity have been updated.

Endoscopic release of congenital muscular torticollis with radiofrequency in teenagers

Background

Congenital muscular torticollis (CMT) is due to contracture of the sternocleidomastoid muscle which may cause activity limitations of the neck, tilt of the head, craniofacial asymmetry, and deformity of the skull. The authors present their experience of arthroscopic tight fibrous band release with radiofrequency in teenagers under local anesthesia and evaluate the clinical results.

Methods

A total of 69 patients who underwent arthroscopic release of CMT with radiofrequency under local anesthesia by a single surgeon could participate in this study. Before operation, surface landmarks of sternocleidomastoid muscle, bone, and neurovascular structures were marked. Local infiltrating anesthesia of the surgical region was then performed. Through a working space created by blunt dissection, the arthroscopy and radiofrequency devices were introduced. Then, the clavicular and sternal heads of the sternocleidomastoid muscle were identified and gradually transected. The patients were followed up postoperatively with Cheng’s scoring system.

Results

There were 31 male patients and 38 female patients. The mean age of the patients was 16.1 years. The mean length of follow-up in this series was 36.7 months (range, 28 to 67 months). During the operation, 62 patients (89.9%) had no pain, 6 patients (8.7%) felt mild pain, and only 1 patient (1.4%) regarded the procedure as very painful. At all follow-up periods, there were no repeat arthroscopies for any of these patients. At the final follow-up, the average rotation deficit improved from 22.5° to 4.1° postoperatively, and the average lateral bending deficit improved from 14.6° to 3.3° (p < 0.05). Overall, the clinical result was good or excellent in 65 patients (94.2%), fair in 4 patients, and poor in 0 patients within the follow-up period according to Cheng’s scoring system. To date, no patients had any intraoperative or postoperative complications from this procedure.

Conclusion

The arthroscopic release with radiofrequency under local anesthesia provides surgeons with an alternative to traditional open techniques for the management of congenital muscular torticollis (CMT). Our date shows that this method is minimally invasive and provides good functional recovery with a lower risk of complications.

Surgical management of congenital torticollis in children older than 7 years with an average 10-year follow-up

The aim of the present study is to present the results of the surgical management of late presenting cases of congenital muscular torticollis. Between 1990 and 2010, 31 cases of late presenting congenital muscular torticollis were managed surgically in our department. Postoperatively, head halter traction was applied for 10 days; a cervical brace was applied for 5 weeks, followed by a soft one collar for 3 months. The final result was assessed on the basis of the criteria of Cheng and Tang. In total, 84% of patients achieved an excellent final result and 16% of the patients achieved a good result. Our results indicated that in children older than 7 years, surgical release combined with appropriate orthosis and a structured physiotherapy regime can lead to satisfactory results.

Arthroscopic surgical treatment for neglected congenital muscular torticollis in adults

BACKGROUND

Congenital muscular torticollis (CMT) is the third most common congenital musculoskeletal anomaly. The efficacy of surgical treatment of neglected CMT after skeletal maturity in adults remains controversial. The aim of this retrospective study was to determine the efficacy of arthroscopic release of the sternocleidomastoid (SCM) muscle for the treatment of neglected CMT in adult cases.

METHODS

From April 2008 to July 2013, a total of 20 adult patients (9 men and 11 women) with a mean age of 23.0 years were surgically treated for neglected CMT with local anesthesia. The SCM muscle and clavicle were preoperatively marked. Through an artificial lacuna, an arthroscope and a radiofrequency probe were inserted. The sternal and clavicular attachments were dissected and divided via radiofrequency. Clinical evaluation was assessed using a modified Cheng and Tang score.

RESULTS

The operation was successfully completed in all the patients. Follow-up examinations from 12 to 40 months in the 20 patients showed complete muscular release and satisfactory cosmetic appearance with no recurrence. There was no evidence of serious complications. The neck scars were no longer visible after several weeks. According to the modified Cheng and Tang scale, 11 patients displayed an excellent result and 9 patients had a good result.

CONCLUSIONS

Arthroscopic release of the SCM muscle with local anesthesia is a simple and effective way to surgically manage neglected CMT without any risk for either damage to the neurovascular structures or leaving visible scars.

Congenital muscular torticollis in older children: treatment with Z-plasty technique

Congenital muscular torticollis (CMT) is a common congenital disorder of the musculoskeletal system in neonates and infants. The aim of this study was to evaluate the results of inferior Z-plasty in older children with CMT. They had mean age of 10 years (range, 5-14 years) and were followed up for 1 to 6 years. Postoperative protocol included a neck exercise program composed of active and passive movements in all cases and immobilization with a cervical collar in only 4 patients. This study concluded that surgical management of older children with CMT using Z-lengthening gives excellent clinical and functional results. The procedure is much more effective than other techniques and relatively complication-free and safe. Postoperative cervical collar and a well-planed physiotherapy protocol go a long way toward ensuring good to excellent results. Early diagnosis and treatment are necessary for good results.

Is craniofacial asymmetry progressive in untreated congenital muscular torticollis?

BACKGROUND

Although craniofacial asymmetry is frequently involved in patients with congenital muscular torticollis, it has not been evaluated appropriately. The authors analyzed preoperative craniofacial asymmetry objectively and confirmed the relationship between craniofacial asymmetry and aging in congenital muscular torticollis patients who underwent surgical release.

METHODS

The authors retrospectively measured preoperative craniofacial asymmetry using the Cranial Vault Asymmetry Index and intercommissural angle and reviewed preoperative rotational and flexional deficit of neck movement for 123 congenital muscular torticollis patients who underwent surgical release at Ajou Medical Center from February of 2007 to February of 2011. The relationships among Cranial Vault Asymmetry Index, intercommissural angle, rotational deficit, flexional deficit, and age were analyzed. Mean values of dependent variables were compared after patients were grouped by age.

RESULTS

Mean age at operation was 82.5 months (range, 5 to 498 months). Seventy-one percent (n=87) of patients had a significant cranial asymmetry and 87 percent (n=107) had a significant facial asymmetry. In correlation analysis, intercommissural angle increased proportional to age (r=0.334, p=0.000), especially before 3 years (r=0.42, p=0.001). Cranial Vault Asymmetry Index was unrelated to age or rotational or flexional deficit. Rotational deficit decreased proportional to age (r=-0.229, p=0.032). By analysis of variance test, intercommissural angle and rotational deficit between the age groups were statistically significantly different (p<0.05).

CONCLUSIONS

In congenital muscular torticollis, facial asymmetry is progressive if the contracted sternocleidomastoid muscle is not released, although cranial asymmetry is already determined in those younger than 6 months. Early correction of torticollis should be considered to prevent progression of facial asymmetry in congenital muscular torticollis patients.

CLINICAL QUESTION /LEVEL OF EVIDENCE

Risk, III.

Physical therapy management of congenital muscular torticollis: an evidence-based clinical practice guideline: from the Section on Pediatrics of the American Physical Therapy Association

BACKGROUND

Congenital muscular torticollis (CMT) is an idiopathic postural deformity evident shortly after birth, typically characterized by lateral flexion of the head to one side and cervical rotation to the opposite side due to unilateral shortening of the sternocleidomastoid muscle. CMT may be accompanied by other neurological or musculoskeletal conditions.

KEY POINTS

Infants with CMT are frequently referred to physical therapists (PTs) to treat their asymmetries. This evidence-based clinical practice guideline (CPG) provides guidance on which infants should be monitored, treated, and/or referred, and when and what PTs should treat. Based upon critical appraisal of literature and expert opinion, 16 action statements for screening, examination, intervention, and follow-up are linked with explicit levels of evidence. The CPG addresses referral, screening, examination and evaluation, prognosis, first-choice and supplemental interventions, consultation, discharge, follow-up, suggestions for implementation and compliance audits, flow sheets for referral paths and classification of CMT severity, and research recommendations.

Efficacy of bipolar release in neglected congenital muscular torticollis patients

Surgical correction of the congenital muscular torticollis (CMT) is recommended for patients with unsuccessful conservative treatment. The aim of this study is to evaluate the efficacy of surgical release of congenital muscular torticollis in neglected cases. We retrospectively evaluated the data of our patients in terms of age, sex, clinical presentation, localization of the lesion, diagnostic tests, and additional abnormalities. The age at operation ranged from 6 to 23 years. Complete muscular release as determined by pre-operative and postoperative range of motion measurements was achieved in all of the patients by bipolar release. In this study, neck motion and head tilt showed marked improvement with surgical treatment in cases with CMT who were admitted to the hospital lately. Congenital muscular torticollis patients can benefit from surgical intervention above the age of 5. Bipolar release is an adequate and complication-free method.

Endoscopic transaxillary approach for congenital muscular torticollis

BACKGROUND

Surgical correction of the congenital muscular torticollis (CMT) is recommended for patients with unsuccessful conservative treatment. Open operative techniques all leave noticeable scars. We proposed a modified endoscopic 1-trocar transaxillary and neck microincision approach for the treatment of CMT.

METHODS

Endoscopic release of the sternocleidomastoid (SCM) muscle was performed in 45 infants and children aged 6 months to 15 years. One 5-mm incision was made in the anterior axillary fold, and a subcutaneous tunnel over the clavicular and sternal heads of the SCM muscle was made. A subcutaneous space was established by CO₂ inflation at a pressure of 8 mm Hg and then endoscopically using a 5-mm endoscope. Two additional 1.5- to 2-mm supraclavicular mini-incisions were made beside the SCM muscle for the introduction of miniforceps and electrocautery, respectively. The sternal and clavicular attachments were dissected and divided by electrocautery. Clinical evaluation was performed using the Lee scoring system.

RESULTS

The operation was successfully completed endoscopically in all 45 children. The mean operative time was 40 minutes. No injuries of major blood vessels or nerves were encountered. A small bleed was noted in 1 child owing to reoperation. Follow-up for 6 months to 3 years in 42 patients showed complete muscular release and satisfactory cosmetic appearance with no recurrence. The results were classified as excellent in 88.1% (37/42), good in 9.5% (4/42), fair in 2.4% (1/42), and poor in 0 using the Lee scoring system. The neck scars were not visible 1 month after the procedure.

CONCLUSIONS

The subcutaneous endoscopic transaxillary and micro-neck incision approach for the treatment of CMT is a safe, practical procedure that provides good functional and cosmetic outcomes without vascular or neural injury.

Complete tight fibrous band release and resection in congenital muscular torticollis

Congenital muscular torticollis (CMT) is caused by shortening of the sternocleidomastoid (SCM) muscle, which may lead to neck movement limitation and craniofacial deformity. The authors retrospectively reviewed clinical experiences of CMT at their hospital from February 2007 to June 2008. During the study period, 20 CMT patients underwent complete tight fibrous band release and resection. Mean patient age was 47.6 months at operation. Eighteen of the 20 patients started a programme of physical therapy preoperatively. All patients received well-controlled postoperative physical therapy and wore a soft neck collar to correct head position for at least 3 months. At 3 months postoperatively, passive ranges of neck motion were determined, and compared with those of uninvolved sides. Eighteen patients showed a full range of motion of neck rotation and lateral flexion, but one patient showed a 10 degrees limitation in lateral flexion, and another showed 10 degrees limitations of neck rotation and lateral flexion. The authors recommended that the described operative technique involving complete fibrous band release and resection, combined with intensive postoperative physical therapy and application of a soft neck collar, provides good functional and cosmetic results.

A brief history of minimally invasive plastic surgery

It could be argued that a basic principle establishing plastic surgery as a distinct specialty always has been minimal invasive surgery. Although perhaps lagging behind the other surgical specialties specifically in adopting the surgical endoscope, this merely is a new tool to better achieve just that objective. Outcome enhancements initially predominated in aesthetic applications, but widespread use also in reconstructive endeavors has proved that there is indeed today a broad role for minimally invasive plastic surgery.