Neck and back abnormalities can be caused by soft-tissue or bony injuries or by vertebral anomalies. Vertebral anomalies can be singular or part of a syndrome.
The head becomes tilted at or soon after birth. The most common cause is neck injury during delivery. Torticollis that develops within the first few days or weeks of life may result from hematoma, fibrosis, and contracture of the sternocleidomastoid (SCM) muscle. A nontender mass may be noted in the SCM, usually in the midsegment.
Other causes include spinal abnormalities, such as Klippel-Feil syndrome (fusion of the cervical vertebrae, short neck, and low hairline, often with urinary tract abnormalities) or atlanto-occipital fusion. CNS tumors, bulbar palsies, and ocular dysfunction are common neurologic causes but are rarely present at birth (see Movement and Cerebellar Disorders: Cervical Dystonia). Fractures, dislocations, or subluxations of the cervical spine (especially C1 and C2) or odontoid abnormalities are rare but serious causes; permanent neurologic damage may result from spinal cord injury.
Cervical imaging should be done to exclude bony causes, which may require stabilization.
When torticollis is due to birth trauma, frequent passive SCM stretching (rotating the head and stretching the neck laterally to the opposite side) is indicated. Injections of botulinum toxin into the SCM may help in refractory cases. Untreated torticollis may lead to plagiocephaly (flattening of one side of the head) and asymmetrical facies.
Examples are idiopathic scoliosis (see Bone Disorders in Children: Idiopathic Scoliosis), which is rarely apparent at birth, and isolated vertebral defects (eg, hemivertebrae, wedge or butterfly vertebrae), which are more likely to be diagnosed at birth. Vertebral defects should be suspected when posterior midline cutaneous, renal, or congenital lower-limb abnormalities exist. Some syndromes or associations such as VACTERL (vertebral anomalies, anal atresia, cardiac malformations, tracheoesophageal fistula, renal anomalies and radial aplasia, and limb anomalies) include vertebral defects.
As children grow, the spinal curve caused by a vertebral defect or defects can progress rapidly; therefore, the spine should be monitored closely. Braces or body jackets, which may have to be worn 18 h/day, are often necessary initially. Surgery may be needed if the curvature progresses. Because renal abnormalities commonly coexist, renal ultrasonography is indicated for initial screening.
Last full review/revision January 2010 by Gregory S. Liptak, MD, MPH
Content last modified February 2012