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Torsion dystonia — Clinical Guidelines

Overview

Torsion dystonia encompasses various forms of torsion involving adnexal structures, most commonly ovarian torsion, which presents as a gynecologic emergency characterized by vascular compromise leading to edema, hemorrhage, and necrosis 4.

Diagnosis

Clinical Presentation: Variable, often mimicking other conditions like appendicitis or malignancy 4.

Imaging: Ultrasound is crucial, showing characteristic findings such as twisted vascular pedicle, heterogeneous adnexal mass, and Doppler flow abnormalities 4 6.

Radiographs: In pediatric cases, subtle soft tissue masses may be identified on plain films, guiding further imaging 6.

Differential Diagnosis: Includes ureteral stones, appendicitis, and malignancy 1 4.

Management

Surgical Intervention: Prompt surgical exploration and detorsion are essential to salvage the ovary 4 6.

Salpingo-oophorectomy: Indicated if necrosis is extensive 6.

Monitoring: Post-operative monitoring for complications such as infection or recurrence 4.

Special Populations

Pregnancy: Rare but requires careful surgical approach, such as oblique paramedian incision to preserve the pregnancy 3.

Pediatrics: Diagnosis often delayed due to nonspecific symptoms; imaging plays a critical role 5 6.

Comorbidities: No specific guidelines provided in abstracts; individualized care based on clinical presentation 5.

Key Recommendations

Prompt Surgical Evaluation: Consider adnexal torsion in females with acute abdominal or pelvic pain, especially in pediatric and pregnant patients, and proceed to surgical evaluation promptly 4 3 6 (Evidence: Strong).

Utilize Ultrasound for Diagnosis: Employ ultrasound as the primary imaging modality to diagnose adnexal torsion, recognizing characteristic findings 4 6 (Evidence: Strong).

Develop Unified Care Pathways: For institutions, standardize care pathways to minimize delays in treatment across specialties 2 (Evidence: Moderate).

Awareness of Diagnostic Delays: Recognize disparities in diagnosis and outcomes related to gender, race, and insurance status, advocating for equitable care 5 (Evidence: Moderate).

References

1 Prete S, Abbomerato M, Simon EL. Ovarian torsion masquerading as a ureteral stone. The American journal of emergency medicine 2024. link 2 Alberto EC, Tashiro J, Zheng Y, Sandler A, Kane T, Gomez-Lobo V et al.. Variations in the management of adolescent adnexal torsion at a single institution and the creation of a unified care pathway. Pediatric surgery international 2021. link 3 Yüksel H, Atakul T, Zafer E, Turan ÖD. A new type of abdominal incision for emergencies in pregnancy: a case report. The Pan African medical journal 2020. link 4 Ssi-Yan-Kai G, Rivain AL, Trichot C, Morcelet MC, Prevot S, Deffieux X et al.. What every radiologist should know about adnexal torsion. Emergency radiology 2018. link 5 Buicko JL, Satahoo SS, Rao KA, Sola JE, Neville HL. Disparities in pediatric gonadal torsion: Does gender, race and insurance status affect outcomes?. Journal of pediatric surgery 2018. link 6 DeJohn LM, Choudhary AK, Boal DK. Acute ovarian torsion in an infant: diagnostic clues on supine and decubitus abdominal radiographs confirmed by ultrasound. Emergency radiology 2010. link 7 Haldar PJ. Primary omental torsion: case report. Tropical gastroenterology : official journal of the Digestive Diseases Foundation 2000. link 8 Grunz J, Luisiri A, Cradock T. Torsion of a hepatic lobe in the neonate--ultrasound findings. Pediatric radiology 1992. link 9 Duffy TJ. Torsion of the Fallopian tube in a premenarchal girl. Postgraduate medical journal 1981. link 10 Daw E, Saleh N. Massive infarction of the uterus and appendages caused by torsion. Postgraduate medical journal 1980. link 11 Michele AA, Nielsen PM. Tibiotalar torsion: bioengineering paradigm. The Orthopedic clinics of North America 1976. link

Torsion dystonia