'Idiopathic' torticollis: have you ruled out a spinal tumour?

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A 70-year-old woman presented with a 6-month history of progressive torticollis accompanied by low back pain and mild lower limb weakness (Figure 1). Apart from grade IV power and diminished reflexes in the lower limbs, her neurological examination was normal. Plain X-rays and magnetic resonance scan of the cranio-cervical junction and cervical spine did not detect any significant abnormality apart from age-related degenerative changes. The torticollis was thus thought to be idiopathic in aetiology. However, in view of her lower limb symptoms, a magnetic resonance scan of the lumbar spine was performed which revealed an intradural extramedullary tumour opposite the L1 and L2 vertebrae (Figure 2). Following excision of the tumour (schwannoma), her symptoms improved gradually. Nine months later, not only was she pain free and walking independently, but the torticollis had also reversed remarkably (Figure 3).