WRYNECK (torticollis, caput obstipum) — deformations of a neck, various on an etiology, a pathogeny, clinic, combining the leading symptom — the wrong position of the head. There are many various forms K., but, since the etiology and a pathogeny of most of them are unknown, at classification it is necessary to be guided by time of emergence of deformation and to consider what defeat of fabric (bone, muscular, etc.) defines a wedge, a picture.
The deformations of a neck which are followed To., can be inborn and acquired.
Inborn deformations of a neck
I. Most often meets inborn muscular To., caused by discrepancy of length of one of grudino - clavicular and mastoidal muscles (very seldom two) and cervical department of a backbone. Insufficient length grudino - a clavicular and mastoidal muscle is caused by its inborn underdevelopment and changes happening during a childbed and after it under the influence of the external reasons. It causes a ducking towards the affected muscle and turn in opposite that is followed by changes of a backbone, clavicles, skulls.
Inborn muscular To. in relation to other inborn deformations of a musculoskeletal system makes from 3 to 13%.
The uniform point of view on an etiology and a pathogeny of this To. no. The major factors causing developing of a disease: a rupture of fibers grudino - a clavicular and mastoidal muscle in a transition range in a sinew at the time of delivery; long inclined position of the head of a fruit in a cavity of the uterus therefore the muscle is shortened; hron. an intersticial miositis with the subsequent To.; the dystrophic changes in a muscle caused by arterial ischemia or venous stagnation in it at the time of delivery, napr, owing to pressure twisted around necks of a fruit of an umbilical cord; a malformation grudino - a clavicular and mastoidal muscle.
Grudino - the clavicular and mastoidal muscle phylogenetic develops from a first line of a wide trapezoid muscle by separation from the main array of the last. grudino - clavicular and mastoidal and trapezoid muscles of the person it is also necessary to explain with complexity of a phylogenetic origin big variability of their structure. So, grudino - the clavicular and mastoidal muscle can have from 2 to 4 legs and additional muscle bundles. At inborn muscular To. the underdevelopment of these muscles and even emergence on their place of the fibrous connecting fabric, on a structure reminding a sinew takes place. It allows to consider increase and reduction of amount of fibers grudino - clavicular and mastoidal and trapezoid muscles extreme opposite deviations from normal development of these muscles, and the last option causes development of deformation — inborn muscular To.
According to this latest theory, children at whom the amount of underdeveloped muscle fibers is considerable or a part of a muscle represents fibrous connecting fabric, are born with clinically expressed To. At an insignificant underdevelopment grudino - a clavicular and mastoidal muscle deformation at the birth is not be expressed, and at the most part of children these phenomena of an underdevelopment are gradually compensated and deformation does not develop.
In other cases at the time of delivery and in the first days after the birth the underdeveloped muscle stretches considerably, broken its food therefore in it there is a cicatricial process which increases its inborn inferiority. Thus, inborn deformation is formed under the influence of endogenous and amplifies under the influence of the exogenous reasons.
According to V. M. Afanasyeva (1944) data, at children with inborn muscular To. in the first days and weeks of life there is fibrosis and an underdevelopment of a muscle. At children, teenagers, adults of change of a muscle increase: the remained muscle fibers are exposed to dystrophy and are replaced with cicatricial fabric. The superficial fascia has a usual structure without traces of inflammatory or cicatricial process. According to R. F. Bashkinova (1974), characteristic and continuous process is an exit of a glycogen from underdeveloped dysplastic fiber. Weak fixing of a glycogen, perhaps, is connected with the fact that in underdeveloped muscle fiber there is also an insufficiency of enzymes. Neutral mucopolysaccharides collect in interstitial connecting fabric, volume a cut generally increases due to their accumulation. It is the main reason for change of interstitial connecting fabric and emergence of a thickening grudino - a clavicular and mastoidal muscle.
The expressed deformation in the first 10 days of life is noted only at an insignificant part of patients. At most of them at the end of the 2nd — the beginning of the 3rd week of life the middle or srednenizhny part of a muscle is thickened and in this place becomes more dense. The thickening grudino - a clavicular and mastoidal muscle gradually increases (on length of 2 — 4 cm, width of 1 — 1,5 cm), parallel to it the ducking towards the changed muscle increases and the volume of its movements decreases.
At a part of patients the thickening and consolidation grudino - a clavicular and mastoidal muscle after the nek-ry period of increase gradually regress and disappear (by 2 — 12 months), and the muscle gains normal elasticity. At other patients (a smaller part) with reduction of a thickening and consolidation of a grudinoklyuchichno-mastoidal muscle it becomes less elastic, lags behind in growth a muscle of the opposite side, becomes thinner and condensed.
With growth of the child shortening grudino - a clavicular and mastoidal muscle, the inclination, turn and asymmetry of the head progress, and by 3 — 6 years deformation considerably increases (fig. 1).
At survey asymmetry of a neck (the head is inclined towards the changed muscle, a little forward and is turned to the opposite side), higher standing of a shoulder girdle from the changed muscle is in front noted, asymmetry of the person and skull. Most of patients has a tension of one or all legs grudino - a clavicular and mastoidal muscle. At survey of the patient asymmetry of a neck and head, an inclination and its turn, scoliosis is behind noted. Electroexcitability struck grudino - a clavicular and mastoidal muscle is lowered, is absent or the motive chronaxia is sharply increased.
The phenomena of asymmetry from the person, the skulls, clavicles, a backbone observed at patients with inborn muscular To., are adaptive compensatory changes which extent is in direct dependence on expressiveness To. These phenomena of asymmetry decrease or disappear if timely operation possible to destroy an inclination and turn of the head.
From the moment of establishment of the diagnosis it is necessary to begin conservative treatment: corrective gymnastics (a ducking to the opposite side and turn towards the shortened muscle), the skolzyashche-pressing stroking of the changed muscle and more vigorous massage of a healthy half of a neck, warming of a neck by means of a lamp «соллюкс», the device «Hair dryer», a hot-water bottle; to children at the age of 6 — 8 weeks is also more senior to carry out an electrophoresis with potassium iodide. It is necessary to put the child to bed so that the curvature of a neck amplified, not to hold it ahead of time vertically. It is recommended to apply to deduction of the head in the correct situation a plaster bed, sacks with sand, the cap with the tapes which are attached to a brassiere, different bandages etc. of R. F. Bashkinov with 10 — after the birth of the child applies the 15th day injections of a lidaza and a hydrocortisone. Such treatment allows to achieve treatment to age of 5 — 6 months more than from 92% of patients.
Since, according to a wedge, to observations, at the vast majority of children the changes which are available at the birth grudino - a clavicular and mastoidal muscle disappear within the first year of life, it is essentially wrong to operate children with inborn muscular To. at the age of the first weeks and months of life as it is recommended Chandler, Altenberg (F. A. Chandler, And. Altenberg), etc.
Indications to operational lengthening grudino - a clavicular and mastoidal muscle arise in the absence of effect of a complex of conservative actions at children is more senior than one year, it is better at the age of 3 — 4 years. Most of orthopedists does not recommend plastic elongation of a muscle.
The greatest distribution was gained by the following method of operation. 1 — 2 cm above clavicles a horizontal section bare legs grudino - a clavicular and mastoidal muscle which an extent allocate for nek-rum and press styptic clips, then from legs excise pieces from 1 to 6 cm long to create, whenever possible, bigger diastases (fig. 2,1). Cross all found tyazh and a back leaf of a fascia if it is tense. Sometimes it is necessary to cross also a first line of a trapezoid muscle. Recovery of a continuity of a clavicular leg at the expense of a hem happens several times more often than sternal leg. This results from the fact that the clavicular leg is fixed by a superficial fascia of a side triangle of a neck, and also a deep leaf of a superficial fascia of a neck therefore it is recommended, except crossing of legs of a muscle, obligatory at all patients to cross a superficial fascia in a side triangle of a neck and a deep leaf of its (fig. 2,2). It is the one skin best to put cosmetic stitches from a plastic string or a horsehair.
In 2 — 3 hours after operation impose excentric extension by a loop made of cloth for the head; at the same time the thorax of the patient is fixed a brassiere to this or that edge of a bed, and draft of the second loop lower the corresponding (lifted) shoulder girdle down. In 2 — 3 days after operation when pains in the field of an operational wound disappear, remove extension and impose a plaster collar with a semi-corset, using Zatsepin's (fig. 3) adaptation. To patients who had a considerable deformation impose a plaster collar with a frontal ring. In a month the plaster collar is removed and if the continuity of legs grudino - a clavicular and mastoidal muscle was not recovered, and the patient holds the head correctly, begin to lay down. gymnastics, physical therapy, massage. If the continuity of legs of a muscle was recovered and there is a bent it is wrong to hold the head, the plaster collar is done removable, out to lay down. gymnastics, massage, a paraffinotherapy, mud cure, an electrophoresis with potassium iodide and novocaine, bandages with ronidazy, and a nek-eye the patient apply injections of a lidaza in cicatricial commissures, and also conduct a course of injections of pyrogenal. Formation cicatricial tyazhy if they were formed, happens to 4 — to the 5th month.
Extremely seldom the so-called bilateral wryneck which is observed at inborn shortening both grudino - clavicular and mastoidal muscles meets. The head of these patients or is rejected back (at the same time the nape approaches a back, and the face is turned up), or inclined forward so that its assignment becomes impossible back. Besides, in view of unequal shortening of muscles the head is inclined aside, the volume of its movements is sharply limited. An operative measure during the shortening both grudino - clavicular and mastoidal muscles shall consist in their simultaneous resection. Treatment in the postoperative period is carried out as well as at unilateral inborn muscular To., but during the imposing of a plaster collar the head of the patient shall be fixed on the centerline in the provision of sharp extension in cervical department of a backbone.
II. Inborn muscular To. owing to shortening of the trapezoid muscle and a muscle raising a shovel, meets seldom. The head of these patients is a little inclined back and turned to the opposite side, the corresponding shovel is a little raised. Treatment: at little changes — to lay down. gymnastics; operational treatment consists in crossing and a resection of the changed parts of muscles.
III. Alate neck — one of rare inborn deformations of a neck, edge received the name thanks to the main characteristic symptom — existence of two skin folds tense in the form of triangular sails from side surfaces of the head to shoulder girdles. More often folds are only duplikatury skin, but sometimes in them nerves and vessels are located. For the purpose of treatment apply the plastic surgeries consisting in movement of counter triangles of skin.
IV. Union of cervical vertebrae (Klippel's syndrome — Feylya) — see. Klippelya — Feylya a disease .
V. Cervical edges lead to noticeable change of a configuration of a neck only at considerable extents of their development. At bilateral anomaly the so-called symptom of Manuylov is observed: the neck is thick, a cone-shaped form with expansion from top to bottom and it is a little thickened in the perednezadny diameter; shoulders are low lowered, make as if continuation of a neck that gives to patients a tyulenepodobny look. Quite often there is scoliosis of a cervical part of a backbone, the followed K. Inogda cervical edges can squeeze a subclavial artery. For establishment of the diagnosis the method of a research is rentgenol, decisive. Conservative methods of treatment are usually not effective. In the presence of constant pains and others patol, changes from nervous and vascular systems the operational treatment consisting in an extirpation of an edge together with a periosteum is shown.
VI. Wedge-shaped cervical vertebrae (additional or underdeveloped) are the most frequent reason of development of sharp K. Nablyudayetsya right-or left-side To. with insignificant turn of the head. Asymmetry of the person happens considerable, the active movements of the head are sharply limited.
Treatment shall consist in to lay down. gymnastics, massage and fixing of the head in the correct situation a collar.
The acquired deformations of a neck.
I. Spastic To. arises owing to involuntary reductions of muscles of a neck and increase in their tone, and is considered as a disease of extrapyramidal system, related to a number of hyperkinesias more often — to the torsion spasm, an athetosis, tics.
Characteristic for a wedge, pictures of a disease, in addition to typical signs To., arrhythmic clonic and tonic myotonia are. Sometimes at dominance of one type of spasms allocate tonic and clonic forms. Three main directions of the movement are noted: the horizontal, followed by spastic turn heads; perednezadny nodding; combined — peremenno the arising horizontal and nodding movements. E. I. Kandel, S. V. Voytyna specify that if in a wedge, a picture the dystonic movements dominate, then owing to a sharp tonic muscle tension of a neck the head alternately can bend forward, be thrown back back or turn aside. At a prevalence of dystonia of back or front muscles of a neck the head with firmness deviates kzad (a so-called syndrome of retrocollis) or kpered (antecollis).
As a rule, at emotional and physical. tension symptoms of a disease amplify. In some cases To. arises only during the walking, food, a conversation. Often the role of uslovnoreflektorny mechanisms in the factors influencing emergence or reduction of involuntary movements comes to light (applying of a hand or finger to a cheek, a nape, etc. for reduction or removal of hyperkinesias).
Most of authors considers that spastic To. is a consequence of encephalitis and are the cornerstone of it local patol. changes. Spastic To. meets also after strokes, a craniocereberal injury, often is a component of a syndrome the torsion dystonia (see), a double athetosis (see. Athetosis double ), Littl's diseases (see. Children's paralyzes ). It can have also reflex character at diseases of a backbone, disturbance of functions of a vestibular mechanism. Pilot studies showed also obvious role medial mezentsefalnoy to a reticular formation in emergence spastic To.
The indication to operation at spastic To. considerable changes of position of the head or the expressed involuntary movements, inefficiency of conservative treatment, an invalidism of the patient are. The nature of surgery at spastic To. is defined by its type and the nature of a disease. The main objective of operation consists in elimination of the changed situation and involuntary movements of the head.
Participation in mechanisms of a disease of the majority of muscles of a neck, as a rule from two parties, explains a rarity of use of operations on muscles. The main operations offered for treatment spastic To.: the subdural crossing of back verkhnesheyny roots on IAC-Kenzi (McKenzie, 1924) left in view of unstable effect; the upper cervical radicotomy (I. S. Babchin, L. V. Abrakov), edges is the most radical. Injury and technical complexity of operation limit its use. In process of development of a stereotaxic method of operations (see. Stereotaxic neurosurgery ) at spastic To. destructions of subcrustal structures (a pale sphere, kernels of a thalamus, a kortiko-kapsulyarny adversivny bunch, etc.) began to be applied.
Operational treatment at all stages is combined with medicamentous therapy, to lay down. physical culture, psychotherapy, physical therapy. Patients at expressed spastic To., as a rule, are disabled people. Disease is chronic, spontaneous; recovery is observed extremely seldom. Operative measures more than at a half of patients recover working capacity, improve self-service.
II. Grizel's disease (synonym: Grizel's contracture, a nasopharyngeal wryneck, rotational removal of the Atlas) is shown To., the caused contracture of the paravertebral muscles which are attached to a front hillock of the Atlas and a skull. The contracture of these muscles develops owing to an inflammation back and pharyngeal limf, nodes. The disease is rather rare. Occurs at the weakened children at the age of 6 — 11 years. The head is inclined in one party and a little turned in another.
Radiological removal of the Atlas of a kpereda decides on turn around a vertical axis. To. eliminate with extension for the head by means of Gleason's loop within several weeks, apply also to lay down. gymnastics, massage, thermal procedures.
III. Dermatogenny form K. after extensive injuries of skin of a neck. Wounds with extensive injury of skin of a neck at their secondary healing sometimes cause pulling of the head hems to a shoulder girdle and to a thorax. Especially often it is observed after burns.
IV. To. owing to deep hems, various inflammatory processes which are formed on site on a neck. Owing to cicatricial changes in superficial and deep fastion of a neck the head can lose the mobility. Plastic surgeries are shown.
V. To. owing to acute and hron, inflammatory processes in grudino - a clavicular and mastoidal muscle at typhus, malaria, scarlet fever, diphtheria, syphilis.
VI. To. can cause diseases or damages of cervical department of a backbone. Tuberculosis, osteomyelitis, an actinomycosis, malignant new growths of cervical department of a backbone bring to patol, to compression changes, cause emergence of deformation. To. it is observed also at fractures or dislocations of cervical vertebrae.
VII. Reflex form K. at inflammatory processes of a middle ear, a mastoid, perichondrites of edges, inflammations of a grudino-clavicular joint at the typhus, an inflammation of a parotid gland and other inflammatory processes which are located near places of an attachment of cervical muscles. At the same time the patient for reduction of the pains amplifying at a muscle strain inclines the head.
VIII. To. because of an ossifying miositis of cervical muscles, sarcomas of one of grudino - clavicular and mastoidal muscles, sluggish paralysis of cervical muscles after the postponed poliomyelitis, scolioses of various etiology, ankylosing spondylarthritis.
At the V—VIII forms of the acquired deformations of a neck along with treatment of a basic disease the corrective gymnastics and physiotherapeutic events at the same time are held.
IX. Compensatory forms K. At some diseases of an inner ear (labyrinth) patients give to the head the provision of such inclination, at Krom they have no dizziness. At the formed cataract, especially bilateral, incomplete cataracts, squint and other diseases of eyes patients also keep the head in such situation, at Krom can use better the fields of vision which remained at them or at Krom their doubling of objects is reduced. In these cases of intervention, the eliminating diplopias and other vision disorders, can promote treatment To.
Bibliography: Babchin I. S. About surgical treatment of a spastic wryneck, Owls. hir., t. 6, No. 3-4, page 432, 1934; R. R Is harmful. Practical guidance on orthopedics, page 172, L., 1936; D au-letsky S. Ya., Fishchenko P. Ya. and Simeon I. L. Some questions of diagnosis and treatment of an inborn muscular wryneck, Vestn, hir., t. 100, No. 6, page 86, 1968, bibliogr.; Zatsepin S. T. the device for measurement of an inclination and turn of the head, Surgery, No. 11, page 85, 1949; it, the Applier of a plaster collar with a semi-corset (To Engelman devices for imposing of plaster corsets), in the same place, No. 4, page 79, 1951; it, Orthopedics of children's and teenage age, page 118, M., 1956; Kandel E. I. S. V ivoytyna. The deforming muscular (torsion) dystonia, M., 1971, bibliogr.; Mezhenina E. P. Cerebral spastic paralyzes and their treatment, Kiev, 1966, bibliogr.; Poyemny F. River, Barsukova M. D. and at t about r about in and Yu. V. O treatment of a spastic wryneck fenolglitse-rinovy and spirtonovokainovy blockade, Zhurn, a neuropath, and psikhiat., t. 76, No. 9, page 1326, 1976, bibliogr.; Surgery of malformations at children, under the editorship of G. A. Bairov, page 104, L., 1968; D i e with k-m a n n G. Traitement of st£r6otaxique du torticolis extrapyramidal, Neuro-chirurgie, t. 22, p. 568, 1976; Hernesniemi J. et Laitinen L. Resultats tardifs de la Chirurgie dans le torticolis spasmo-dique, ibid., t. 23, p. 123, 1977.
C.T. Zatsepin; O. A. Laponogov (neyrokhir.).