Cervical kyphosis after resolution of myopathic head drop. A case report

Conservative treatment for dropped head syndrome

PURPOSE

Previous reports on the outcome of conservative treatment for dropped head syndrome (DHS) are scarce. The purpose of this study was to elucidate the efficacy of conservative treatment for DHS and to identify possible predictive factors relating to the outcome.

METHODS

Among 76 DHS patients, conservative treatment (2-3 months collar application, active neck range of motion exercise, and occasional prescription of analgesics) succeeded in 17 patients (22.4%, group S, 4 male, 13 female, mean age 75.9 years). The treatment failed in the remaining 59 patients (group F). Clinical and radiological parameters were compared between the groups. Radiological findings of group S were compared between before treatment and at follow-up.

RESULTS

Duration of disease was 6.6 ± 9.3 months in group S and 20.0 ± 27.6 months in group F. C2-7 angle (degree), the incidence of anterior slippage of the vertebra (%), reducibility (%), and upper thoracic kyphosis angle (degree) in group S/F were - 19.2 ± 17.5/- 34.6 ± 26.6, 23.5/62.7, 100/52, and 6.7 ± 8.6/17.9 ± 13.7, respectively. C2-7 angles were - 19.2 ± 17.5 degrees at pre-treatment and 10.2 ± 20.7 degrees at follow-up. These differences were statistically significant.

CONCLUSIONS

The present study indicated that conservative treatment was successful in 22% of DHS patients, with improvement in their cervical kyphotic alignment. Shorter duration of disease, relatively smaller cervical kyphosis without anterior slippage of the vertebra, reducibility, and abundant compensation at the upper thoracic region were good indications for the success of conservative treatment.

Dropped head syndrome: a treatment strategy and surgical intervention

PURPOSE

The pathology of dropped head syndrome (DHS) is diverse, and reports of surgery for DHS are scarce. We aimed to describe surgery for DHS and to investigate the surgical outcomes thereof.

METHODS

We enrolled 40 consecutive patients (six males and 34 females; average age at surgery, 72.0 years) with DHS who underwent correction surgeries at a single institute. Short fusion (SF), with the extent of fixation mainly at the cervical region, was performed for 27 patients; long fusion (LF), involving the cervical and thoracic spine, for 13. Clinical and radiological outcomes were investigated, and factors analyzed using the Japanese Orthopedic Association Cervical Myelopathy Evaluation Questionnaire (JOACMEQ).

RESULTS

All patients were able to gaze horizontally at the follow-up. Instances of five transient C5 palsy results, and five distal junctional kyphosis results were found, but no revisions were reported due to recurrence. Patients whose T1 slope-20° was smaller than the C2-7 angle postoperatively exhibited better clinical outcomes in the three domains of the JOACMEQ, regardless of the extent of fixation.

CONCLUSION

For cases where the T1 slope is relatively small, and approximately 10° of cervical lordosis is predicted to be obtained postoperatively, SF is appropriate. Alternatively, for cases with higher T1 slope, obtaining a cervical lordosis over 20° has a risk of postoperative complications. For such cases, it is an option to perform an LF involving the cervical and thoracic spine.

Eight cases of sudden-onset dropped head syndrome: patient series

BACKGROUND

As the proportion of elderly people continues to increase, the number of patients with dropped head syndrome (DHS) also grows. However, the relationship between onset and clinical course of DHS has hardly been studied, particularly, that of sudden-onset DHS has not been reported and remains unclear.

OBSERVATIONS

Sudden-onset DHS was defined as presenting with chin on chest deformity within 3 days from the time of awareness of cervical weakness. Sixty-six patients with DHS visited our facility. Among them, 8 of the total cases (12.1%) had experienced sudden onset DHS (6 females and 2 males; average age: 71.9 ± 10.9 years). Six of 8 cases showed recovery by conservative treatment, whose first interventions were from 0.1 to 12 months, but 3 experienced recurrence. Diffuse spinal kyphotic-type DHS was seen in 2 cases, and both had recurring horizontal gaze disturbance after initial recovery. Two unimproved cases underwent surgery of combined anterior and posterior cervical fixation, and their first interventions were at 5 and 24 months. After surgery, cervical sagittal alignment was improved, and they could walk maintaining horizontal gaze.

LESSONS

Sudden-onset DHS can be expected to have a better outcome, but recurrence is possible in global imbalanced-type DHS.

Histopathological characteristics of cervical extensor tissue in patients with dropped head syndrome

Background

To date, the histopathologic characteristics of dropped head syndrome (DHS) have not been reported sufficiently. The present study investigates the histopathology of biopsy specimens from the cervical paravertebral region in patients with DHS.

Methods

Histopathological parameters were evaluated in biopsy specimens of the cervical paravertebral soft tissue from 15 patients with DHS.

Results

Among the 15 cases of DHS examined, skeletal muscle was identified in 7 cases, all of which showed necrosis, microvessel proliferation and atrophy. The ligament was identified in 12 cases, 8 of which showed degeneration. The lag time between the onset of symptoms and the performance of a biopsy in all 8 cases, which showed degeneration was over 3 months. Microvessel proliferation in the ligament was observed in 1 of the 4 cases, in which the lag time between the onset of symptoms and the performance of a biopsy was less than 3 months (acute or subacute phase), and in 7 of the 8 cases, in which the lag time between the symptoms and the performance of a biopsy was over 3 months (chronic phase). Chronic inflammation in the ligament was identified in 1 of the 12 cases.

Conclusions

The identification of necrosis, microvessel proliferation, and atrophy in the skeletal muscle of patients with DHS and the presence of ligament degeneration and microvessel proliferation in the chronic but not acute or subacute phases may suggest that persistent skeletal muscle damage of the cervical paravertebral region causes subsequent ligament damage in patients with DHS.

Surgical Management of Post-Radiation, Dropped Head Spinal Deformity in Head and Neck Cancer Patients

BACKGROUND

Dropped head syndrome is a morbid condition, which affects daily functionality, causing pain and dysphagia and respiratory compromise. Reported causes of dropped head syndrome include neuromuscular disorders, iatrogenic from cervical spine surgery, idiopathic and post-radiation for head and neck cancers. Management of this spinal disorder remains challenging, as the complication rates are high. We present our series of 7 patients who underwent surgical correction of dropped head syndrome, all resulting from radiation for head and neck cancers.

METHODS

Retrospective review of 7 patients who underwent surgery between 2016 and 2019 for dropped head syndrome secondary to post-radiation cervical spine deformity. Clinical variables were obtained from medical records. Radiographic parameters pre- and post-surgery including T1 slope, sagittal vertical axis, and C2-7 cervical lordosis were examined.

RESULTS

Seven patients were included in the study, with an average age 69 years. Two patients underwent traction pre-operatively. Five patients had posterior fixation and fusion only and two patients had a combined anterior and posterior fixation and fusion. Overall, there was improvement in average pre/post-op SVA (6.96cm to 3.04cm), T1 slope (33.61^o to 24.34^o) and C2-7 lordosis (-21.65^o to -0.03^o).

CONCLUSION

Surgical correction of post-radiation dropped head spinal deformity involving anterior and posterior fixation with osteotomies provides improvement in functional and radiographic outcomes as shown in our series. These cases are technically challenging and have a high rate of peri-operative complications. Approaches must be tailored to the patient with attention to their specific surgical and radiation history.

Mode of onset of dropped head syndrome and efficacy of conservative treatment

PURPOSE

The initial treatment of dropped head syndrome (DHS) is basically nonsurgical, but the mode of onset of DHS and efficacy of conservative treatment have not been fully clarified.

METHODS

The subjects were 38 DHS patients without neuromuscular disease (11 men and 27 women, average age 74.5 years). Cervical collar, physical therapy, and temporary medication for cervical pain were provided for all DHS patients. The following parameters were measured on lateral global spine standing radiographs: sagittal vertical axis (SVA), cervical sagittal vertical axis, C2-C7 angle, first thoracic slope, thoracic kyphosis, lumbar lordosis, sacral slope, pelvic tilt, and pelvic incidence. According to the mode of onset of DHS, the subjects were classified into acute-onset group (<3 months) and chronic-onset group (≥3 months).

RESULTS

Acute- and chronic-onset DHS were observed in 20 and 18 patients, respectively. A history of cervical trauma was involved in nine and two cases of acute- and chronic-onset DHS, respectively. Acute-onset DHS included more balanced-SVA (B-SVA: -30 mm <SVA ≤40 mm) than chronic-onset DHS. In conservative cases, the recovery rate was better in acute-onset DHS with B-SVA. In acute-onset DHS treated conservatively, the recovery rate was significantly poor in cervical trauma cases.

CONCLUSIONS

Acute-onset DHS includes more balanced SVA and a history of cervical trauma, while acute-onset DHS without a history of cervical trauma has better prognosis by conservative treatment. Surgical indications for DHS should be carefully determined, and sufficient conservative treatment is essential.

Radiologic features of dropped head syndrome in the overall sagittal alignment of the spine

PURPOSE

Dropped head syndrome (DHS) is a rare clinical entity which is defined as a chin-on-chest deformity in the standing or sitting position, resulting from sagittal imbalance of the cervical region. The purpose of the present study was to clarify the radiologic features of DHS in the overall sagittal alignment of the spine. We also investigated the changes in sagittal alignment after correction surgery for DHS.

METHODS

Twenty DHS patients [1 male and 19 female, with an average age of 78.9 years (range 59-88)] with a main complaint of horizontal gaze disorder were enrolled in this study. Spino-pelvic lateral radiographs in the free-standing clavicle position were taken of all patients. Parameters such as sagittal vertical axis (SVA), C2-7 angle, clivo-axial angle (CAA), C2-7 SVA, T1 slope, thoracic kyphosis (TK), lumbar lordosis (LL), pelvic incidence (PI), sacral slope (SS), and pelvic tilt (PT) were measured, and the radiologic features of DHS in the overall sagittal alignment of the spino-pelvis were investigated. Eight patients underwent correction surgery, and the parameter changes between pre- and post-operative radiographs were also examined.

RESULTS

DHS appeared to have two distinct types: SVA+ and SVA-. Seven of 20 cases were SVA+, and 13 were SVA-. The radiologic parameters in which we found statistically significant differences between the groups were: 80.2 ± 68 and -44.5 ± 40 (SVA), 42.1 ± 16.8 and 18.4 ± 11.4 (T1 slope), and 21.1 ± 19.2 and 44.2 ± 19.8 (LL) in SVA+ and SVA-, respectively. After surgical intervention, T1 slope and LL appeared to approach normal in the SVA- group, because compensation at downward spine was no longer necessary. In SVA+ group, although the patients gained horizontal gaze after surgery, abnormality of the sagittal alignment in the whole spine remained, because compensation in the thoracic and lumbar spine was still insufficient.

CONCLUSIONS

The present study has indicated that radiologic feature of DHS in the sagittal alignment of the overall spino-pelvis can be categorized into two types: SVA+ and SVA-.

An unusual cause of cervical kyphosis

BACKGROUND CONTEXT

Acute fixed cervical kyphosis may be a rare presentation of conversion disorder, psychogenic dystonia, and potentially as a side effect from typical antipsychotic drugs. Haldol has been associated with acute dystonic reactions. In some cases, rigid deformities ensue. We are reporting a case of a fixed cervical kyphosis after the use of Haldol.

PURPOSE

To present a case of a potential acute dystonic reaction temporally associated with Haldol ingestion leading to fixed cervical kyphosis.

STUDY DESIGN

This is a case report.

METHODS

A patient diagnosed with bipolar disorder presented to the emergency room several times with severe neck pain and stiffness. The neck appeared fixed in flexion with extensive osteophyte formation over a 3-month period.

RESULTS

The patient's condition was resolved by a posterior-anterior-posterior surgical approach. It corrected the patient's cervical curvature from 88° to 5°.

CONCLUSIONS

Acute dystonic reactions have the potential to apply enough pressure on bone to cause rapid osteophyte formation.

Camptocormia due to inclusion body myositis

Inclusion body myositis is the most common idiopathic inflammatory myopathy in elderly individuals. It typically causes proximal and distal limb weakness with forearm flexors and quadriceps being the most severely affected muscles. Axial musculature is infrequently involved. Here, we report an 80-year-old man who presented with an 18-month history of progressive truncal weakness causing stooped posture while standing and walking. Neurologic examination revealed no limb weakness. magnetic resonance imaging studies showed atrophy and findings, suggesting fatty replacement of paraspinal muscles. Needle electromyography confirmed the presence of an axial myopathy. Thoracic paraspinal muscle biopsy showed canonical features of inclusion body myositis. The current patient broadens the clinical presentation of inclusion body myositis.

Dramatic response of dropped head sign to treatment with steroid in Parkinson's disease: report of three cases

Neck dystonia is the most common cause of dropped head sign in parkinsonism. Isolated neck extensor myopathy, which is a rare condition, can also cause dropped head sign in parkinsonism, but no improvement has been achieved with immunosuppressive therapy. We report three cases of treatable neck extensor myopathy causing dropped head sign in patients with Parkinson's disease. Needle electromyography and magnetic resonance imaging suggested a restrictive active myopathy affecting neck extensor muscles. All cases responded dramatically to steroid therapy. Routine needle electromyography should be performed to explore treatable myopathy in Parkinson's disease.

Dropped head syndrome: a case series and literature review

STUDY DESIGN

Case series and literature review.

OBJECTIVE

To describe Dropped Head Syndrome (DHS) to the orthopedic community and examine the management of this condition including the role of surgery.

SUMMARY OF BACKGROUND DATA

DHS is characterized by severe neck extensor weakness, resulting in chin-on-chest deformity in the standing or sitting position, which is correctable by passive neck extension. The syndrome is familiar to neurologists but is little known in the orthopedic community and literature. DHS patients may present to the spinal surgeon to consider surgical management.

METHODS

We summarize the case histories of 7 patients who presented to the Exeter Spinal Unit with this disabling condition. Investigation, management, and the few publications on surgical management of DHS are discussed. One of the patients in our series underwent surgical management, and we discuss the possibilities for surgical management, along with the outcome of surgery in this case.

RESULTS

Seven cases of DHS presented to our unit, 4 with acute presentation and 3 with gradual onset. Six patients were treated conservatively. One patient was treated surgically but was unhappy with the outcome.

CONCLUSION

We conclude that the option of surgical management must be carefully considered in each case, especially with respect to the potential disadvantages in elderly patients.

Síndrome da cabeça caída em doença do neurônio motor

A síndrome da cabeça caída é causada por diminuição de força nos músculos extensores do pescoço sendo encontrada em diversas doenças neuromusculares, bem como, na esclerose lateral amiotrófica. Descrevemos o caso de três mulheres com diagnóstico de doença do neurônio motor com quadro clínico de disfagia e diminuição de força em músculos cervicais que evoluiu com queda da cabeça. A investigação mostrou ressonância magnética de crânio e coluna cervical normais; e a eletromiografia de agulha com desinervação ativa e crônica em músculos bulbares e dos segmentos cervical, torácico e lombo-sacro. Discutimos as características da doença, especialmente suas manifestações clínicas e os achados eletroneuromiográficos, dando ênfase à necessidade de investigação da cabeça caída na suspeita de doença do neurônio motor.

"Dropped-head" syndrome due to isolated myositis of neck extensor muscles: MRI findings

MRI findings of a patient with dropped-head syndrome due to focal myositis of the neck extensor muscles are presented. MRI showed oedematous changes and marked enhancement of the neck extensor muscles. After therapy MRI demonstrated disappearance of the abnormal findings.

Tête tombante fixée : efficacité d'une rééducation intensive

OBJECTIVES

To point out the diagnostic and etiologic context of neck extensor weakness and to consider orthopedic and rehabilitation treatment of dropped head syndrome.

METHODS

We report a case of a 68-year-old hospitalized woman with atypical and serious idiopathic neck extensor weakness who was treated by orthopedic measurements and intensive rehabilitation.

RESULTS

Our patient had progressive neck extensor weakness and total inflection of the cervico-cephalic axis over two years. Fixed and permanent contact of the chin and the sternum severely affected her ability to eat, and mandibular and sternal pressure ulcers developed. Cervical spine radiography revealed degenerative lesions. Other clinical and biological parameters were normal. Atypical idiopathic head drop was diagnosed because of painful and fixed head position. Rehabilitation consisted of cervical traction with a halo apparatus during eight weeks and an exercise programme based on cervical proprioception and muscular work. Orthopedic management consisted of cervical collar immobilization after cutaneous cicatrization. After ten weeks of treatment, the patient was able to raise her head and maintain it horizontally. Two years later, clinical results were stable.

DISCUSSION

Neck extensor weakness may be the presenting feature of several neuromuscular disorders. Generally, idiopathic dropped head syndrome appears to be the most likely diagnosis in patients with isolated neck extensor involvement. For our patient, clinical findings and cervical computed tomography showed important muscular weakness. However, painful passive extension and progressive stiffness of the neck do not represent the typical clinical course of idiopathic head drop. Neither degenerative lesions of the cervical spine nor other joint diseases can cause head drop. This case may result from the combined effects of idiopathic dropped head syndrome and cervical arthrosis. Orthopedic treatment and intensive rehabilitation had spectacular effects. Clinical management of head drop syndrome should always consist of orthopedic and rehabilitation treatment.

Dropped head syndrome in mitochondriopathy

In a 63-year-old, 165-cm-tall woman with a history of repeated tick bites, dilative cardiomyopathy, osteoporosis, progressive head ptosis with neck stiffness and cervical pain developed. The family history was positive for thyroid dysfunction and neuromuscular disorders. Neurological examination revealed prominent forward head drop, weak anteflexion and retroflexion, nuchal rigidity, weakness of the shoulder girdle, cogwheel rigidity, and tetraspasticity. The lactate stress test was abnormal. Electromyograms of various muscles were myogenic. Muscle biopsy showed non-specific myogenic abnormalities and generally weak staining for cytochrome oxydase. Mitochondriopathy with multi-organ involvement was suspected. The response to anti-Parkinson medication was poor. In conclusion, dropped head syndrome (DHS) may be due to multi-organ mitochondriopathy, manifesting as Parkinsonism, tetraspasticity, dilative cardiomyopathy, osteoporosis, short stature, and myopathy. Anti-Parkinson medication is of limited effect.

Focal, steroid responsive myositis causing dropped head syndrome

The dropped head syndrome, which occurs in a variety of neuromuscular disorders, is usually not due to an inflammatory process and generally either self-limited or nonresponsive to therapy. We present an 80-year-old woman who developed progressive neck weakness over a few months due to a focal and restricted inflammatory process involving the neck extensor muscles. She responded dramatically to treatment with immunosuppressive therapy.