CPT® Code 21725

1. Indications

The open division of the sternocleidomastoid muscle, as described by CPT® Code 21725, is indicated for the following conditions:

• Congenital Muscular Torticollis - A condition present at birth where the neck muscles are shortened, leading to an abnormal head position.
• Acquired Torticollis - A condition that develops later in life, which may result from muscle spasms, injury, or other underlying issues affecting neck mobility.

2. Procedure

The procedure for the open division of the sternocleidomastoid muscle involves several critical steps to ensure effective treatment of torticollis:

• Step 1: Incision - An incision is made above the medial aspect of the clavicle to access the sternocleidomastoid muscle. This incision allows the surgeon to expose the tendons of the muscle originating from the sternum and clavicle.
• Step 2: Tendon Exposure - The tendon sheaths are incised longitudinally, which facilitates access to the tendons. The inferior ends of the tendons are then partially resected to relieve tension.
• Step 3: Head Positioning - The patient's head is turned towards the affected side, and the chin is depressed to assist in the surgical release of the muscle.
• Step 4: Muscle Division - The platysma muscle and adjacent fascia are divided, allowing for exploration of the surgical wound. Any remaining bands of contracted sternocleidomastoid muscle or fascia are identified and divided to further alleviate the condition.
• Step 5: Bipolar Release (if necessary) - In cases of severe torticollis, a bipolar release is performed. This involves a small incision behind the ear to release the sternocleidomastoid muscle just distal to the tip of the mastoid process, followed by the release at the sternum and clavicle as previously described.
• Step 6: Cast Application - After the surgical procedure, the patient may be placed in a cervical collar or an upper body cast may be applied. The cast includes metal rods on either side of the neck attached to the cast, along with a head immobilizer that secures around the forehead and upper skull to maintain proper alignment during recovery.

3. Post-Procedure

Post-procedure care for patients undergoing the open division of the sternocleidomastoid muscle includes monitoring for any complications and ensuring proper alignment of the head and neck. The application of a cervical collar or cast is crucial for maintaining the desired position during the healing process. Patients will require follow-up visits to assess recovery and may need physical therapy to improve neck mobility and strength. It is essential to provide instructions on care for the surgical site and to monitor for signs of infection or other complications during the recovery period.