Spasmodic Torticollis after Endoscopic Thyroidectomy: A Case Report

Sanjay Kumar¹, Gyan Chand² https://orcid.org/0000-0002-4605-3816, Anjali Singh³ https://orcid.org/0000-0002-0273-5436, Sandeep Khuba⁴

^1,3,4Department of Anaesthesiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India

²Department of Endocrine Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India

Corresponding Author: Anjali Singh, Department of Anaesthesiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India, Phone: +91 8439160050, e-mail: anjalisingh111296@gmail.com

Received on: 02 September 2022; Accepted on: 10 February 2023; Published on: 15 April 2023

ABSTRACT

Aim: Management of spasmodic torticollis after endoscopic thyroidectomy.

Background: Spasmodic torticollis is a disorder of movement of neck musculature characterized by involuntary posturing of the head. This results in postural deviations of the head and intermittent or continuous diffuse pain (70–80%) in the area of the neck and shoulder region associated with stiffness. Numerous neck complaints are present in patients who have undergone thyroid surgery, and even after surgery, this discomfort may continue for a long time and become severe if there is a lack of movement of the neck and shoulders postsurgery. At present, the most used endoscopic thyroidectomy method is the bilateral axillo-breast approach endoscopic thyroidectomy (BABA-ET).

Case description: We report a case of a 44-year-old female who underwent BABA-ET and 6 months later came with a complaint of pain over the right and front of the neck associated with the sensation of burning, pinpricking, and numbness. The patient was posted for trigger point injection of the right-side sternocleidomastoid and front of neck under ultrasonography and advised for neck stretching exercises along with physiotherapy. On follow-up patient weeks later, the patient reported improvement in pain scores, no neuropathic features, as well as stiffness, and profound improvement in range of motion, which continued for 6 months.

Conclusion: Myofascial trigger point neutralization followed by physical therapy significantly alleviates symptoms; therefore, it is a safe, minimally invasive, and diagnostic as well as a therapeutic modality in torticollis.

Clinical significance: Neck surgeries predispose patients to neck myofascial pain and the development of trigger points, which may manifest as disturbed motor function in the form of muscle stiffness, weakness, restricted range of motion, and pain. Identifying the culprit’s muscle and, along with it, physical therapy and trigger point neutralization helps in a significant reduction in pain and motor activity and improve overall wellbeing.

How to cite this article: Kumar S, Chand G, Singh A, et al. Spasmodic Torticollis after Endoscopic Thyroidectomy: A Case Report. World J Endoc Surg 2022;14(2):63-65.

Source of support: Nil

Conflict of interest: None

Patient consent statement: The author(s) have obtained written informed consent from the patient for publication of the case report details and related images.

Keywords: Bilateral axillo-breast approach endoscopic thyroidectomy, Endoscopic thyroid surgery, Spasmodic torticollis, Trigger point neutralization.

BACKGROUND

Spasmodic torticollis is a disorder marked by involuntary movement of neck muscles, characterized primarily by tremors or sustained or intermittent muscle contractions of the head in a rotated, twisted, or abnormally flexed or extended posture or some combination of these.¹ It is a form of cervical dystonia (CD) and features of abnormal posturing, movement, and rotation of the head help this disorder to be clinically diagnosed.² Epidemiological studies have shown mostly adult onset with a ratio of men to women of 1:2.2 and a predominance of females for idiopathic CD.³

The main characteristics of CD are uncontrolled intermittent or sustained contractions of neck muscles, resulting in postural deviations of the head, and intermittent or continuous diffuse pain (70–80%) in the area of neck and shoulder region associated with stiffness.⁴ This is mostly asymmetrical and involves sternocleidomastoid muscle in 75% and trapezius in 50% of cases, and involved hypertrophied muscles can readily be palpated.¹

For surgical thyroid nodules, conventional thyroidectomy has been the standard of care. Various minimally invasive and remote-access surgical methods have been developed for cosmetic purposes. At present, the most commonly used endoscopic thyroidectomy approach is the BABA-ET.⁵ Various complaints are present in patients who have undergone thyroid surgery, and even after surgery, this discomfort may continue for a long time and become severe if there is a lack of movement of the neck and shoulders postsurgery.⁶

CASE DESCRIPTION

We report a case of a middle-aged female in her 40s with complaints of multinodular goiter who underwent BABA and presented to our pain clinic with complaints of pain over the neck, more on the right side and front, stretching in nature with visual analog scores of 50–80, associated with the sensation of burning, pin pricking, numbness, radiating to the right side of the head, and the pain increased on neck movements.

On inspection, the patient had a postural tilt on the right side with a prominent right-side sternocleidomastoid (Fig. 1), and on palpation, severe tenderness was present over the front of the neck and right sternocleidomastoid. All ranges of motion of the neck were significantly reduced. Neurological examination was within normal limits, and the patient was on anti-neuropathic treatment and methylcobalamin supplementation for 1 month with no relief. The patient was investigated for the X-ray of the cervical spine, which was reported normal (Fig. 2) and the patient was posted for trigger point injection of the right-side sternocleidomastoid and front of neck under ultrasonography (Fig. 3) using local anesthetic 0.5% lignocaine after hydro dissection (Fig. 4). Patient-reported significant relief in neck pain, and stiffness with an increased range of motion of the neck. The patient was advised analgesics—non-steroidal anti-inflammatory drugs (NSAIDs) and told to do neck stretching exercises along with physiotherapy. Following the patient 2 weeks later, the patient reported improvement in pain scores with a decrease in visual analog scale (VAS) score to 10–30 with no neuropathic features as well as stiffness. The patient was able to do stretching exercises with ease and was undergoing physiotherapy; thus, there was a profound improvement in range of motion, and post 6 months follow-up, the patient reported significant relief in pain scores and stiffness and gave consent for sharing experience in journals for academic purposes.

Fig. 1: Prominent right-side sternocleidomastoid

Fig. 2: Normal cervical spine X-ray

Fig. 3: Right sternocleidomastoid ultrasonographic visualization

Fig. 4: Ultrasonography-guided trigger point injection

DISCUSSION

Spasmodic torticollis diagnosis is mostly clinical in most cases; therefore, comprehensive history should be taken, and family history should be carefully reviewed, followed by a proper neurological examination should be done in patients presenting with symptoms of torticollis. It is important to rule out “pseudodystonia” and look for factors suggesting secondary causes like structural abnormalities.²

Treatment of CD is challenging, and the plan usually depends on the age of the patient, previous or concurrent medications exposure, or medical comorbidity. Botulinum toxin type A injections into the involved muscles are the first-line treatment of CD, but selecting musculature for injection and choosing an effective dosage is the key to the outcome. However, Botulinum toxin injections may be associated with needle injection pain, hematoma, pneumothorax or irritation of local nerves, neck weakness (strong response to the toxin), and rarely dysphagia; all these adverse effects are self-limited and well tolerated.² Physical measures or pharmacotherapy are quite helpful measures for patients with mild symptoms; however, their role and effectiveness remain unclear. Behavioral therapy and pharmacological therapy (anticholinergics or muscle relaxants) are other treatment modalities with variable success rates.³

Trigger point neutralization eliminates or reduces the hyperactive palpable nodule in muscle; this destroys motor end plates and causes distal axon denervation and thus causing a reduction in acetylcholine levels and decreasing spontaneous electrical activity also activates descending supraspinal inhibitory system.⁷ Thus, using local anesthetic in dilute concentrations for trigger point injection followed by rehabilitation helps in reduction of pain and improvement of function without any adversity. A permanent alternative to the medical treatment of spasmodic torticollis is selective peripheral denervation. For patients who had an initial favorable response to botulinum toxin and then became secondary nonresponders in them, surgery is recommended.²

CLINICAL SIGNIFICANCE

Spasmodic torticollis is a poorly understood disorder marked by hyperkinesis of the cervical musculature resulting in unwanted sustained head postures causing discomfort and difficulty in movement of the neck. Information found on the history and physical examinations are the key to diagnosis and treatment. Identifying the culprit muscle along with-it physical therapy and trigger point neutralization helps in a significant reduction in pain and motor activity and improves overall wellbeing.

Here, the patient had abnormal posturing of the neck post endoscopic thyroid surgery leading to the sustained contraction of sternocleidomastoid of the right side with trigger zones which on manual compression reproduced the symptoms and was managed previously with many analgesic medications, including NSAIDs with muscle relaxant combinations. She reported no significant relief with any of these medications, and her pain was severe, with a VAS score above 7 out of 10 on most days. Hence, we decided not to go for a trial with muscle relaxants or NSAIDs but proceeded with a trigger point injection. During ultrasonography, there were abnormal hypoechoic areas nodular bundles in the right sternocleidomastoid muscle. Thus, myofascial trigger point neutralization followed by physical therapy significantly alleviates symptoms; therefore, it is a safe, minimally invasive, and diagnostic as well as a therapeutic modality in torticollis.

Postneck surgeries, due to the limited movement of the neck and shoulder with preferential posturing of the neck in a specific manner, predispose patients to neck myofascial pain and development of trigger points, which may manifest as disturbed motor function in the form of muscle stiffness, weakness, restricted range of motion, and pain. Rehabilitation in the form of stretching exercises along with postural precautions and optimal pain relief postsurgery will help in avoiding these complications.

ORCID

Gyan Chand https://orcid.org/0000-0002-4605-3816

Anjali Singh https://orcid.org/0000-0002-0273-5436

REFERENCES

1. Smith DL, DeMario MC. Spasmodic torticollis: a case report and review of therapies. J Am Board Fam Pract 1996;9(6):435–441. DOI: 10.3122/jabfm.9.6.435

2. Velickovic M, Benabou R, Brin MF. Cervical dystonia pathophysiology and treatment options. Drugs 2001;61(3):1921–1943. DOI: 10.2165/00003495-200161130-00004

3. De Pauw J, Van der Velden K, Meirte J, et al. The effectiveness of physiotherapy for cervical dystonia: a systematic literature review. J Neurol 2014;261(10):1857–1865. DOI: 10.1007/s00415-013-7220-8

4. Takemoto M, Ikenaga M, Tanaka C, et al. Cervical dystonia induced by cervical spine surgery: a case report. Spine (Phila Pa 1976) 2006;31(1):E31–E34. DOI: 10.1097/01.brs.0000193928.16048.cb

5. de Vries LH, Aykan D, Lodewijk L, et al. Outcomes of minimally invasive thyroid surgery - a systematic review and meta-analysis. Front Endocrinol (Lausanne) 2021;12(12):719397. DOI: 10.3389/fendo.2021.719397

6. Takamura Y, Miyauchi A, Tomoda C, et al. Stretching exercises to reduce symptoms of postoperative neck discomfort after thyroid surgery: prospective randomized study. World J Surg 2005;29(6):775–779. DOI: 10.1007/s00268-005-7722-3

7. Gaspersic R, Koritnik B, Erzen I, et al. Muscle activity-resistant acetylcholine receptor accumulation is induced in places of former motor endplates in ectopically innervated regenerating rat muscles. Int J Dev Neurosci 2001;19(3):339–346. DOI: 10.1016/s0736-5748(01)00018-1

________________________
© The Author(s). 2022 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and non-commercial reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.