A rare case of 9 years congenital muscular torticollis treated with complete unipolar sternocleidomastoid release: A case report and literature review

INTRODUCTION: Congenital muscular torticollis (CMT), when left untreated, may result in numerous complications such as eye movement disorder, craniofacial asymmetry, neck pain and compensatory asymmetrical spine curvature that worsens with age. We reported a 9-year-old boy with neglected CMT treated with complete unipolar sternocleidomastoid release. PRESENTATION OF CASE: A 9-year-old boy presented with his head tilted to the left since he was born. Physical examination revealed tense and uptight sternocleidomastoid muscle. The patient then underwent complete unipolar stenocleidomastoid release. Postoperatively, the patient completed 3 months of aggressive physical therapy thrice a week followed by a home exercise regimen once the patient was discharged from therapy. At six months of follow-up, the active range of motion of his neck was markedly improved in all directions, and his cervical spine was noted to be straight. The CMA was also decreased from 14 to 0 degree. DISCUSSION: It is recommended that, in those with CMT, the surgery should be performed between 1 and 4 years of age. However, in our case, the patient was already 9 years old. Nevertheless, he had achieved regained full cervical range of motion, and significant improvement of CMA angle (from 14 to 0 degree postoperatively) after undergoing unipolar sternocleidomastoid release and three months of aggressive physical therapy. CONCLUSION: Surgical intervention followed by aggressive physical therapy for patients with neglected CMT, despite late presentation, may still carry a favourable outcome.