Management of two patients with dropped head syndrome utilizing anterior-posterior cervical surgery.

BACKGROUND: Two elderly patients with dropped head syndromes (DHS) were successfully treated with circumferential cervical surgery. CASE DESCRIPTION: The two patients, respectively, 72 and 53 years of age, both underwent two-staged surgical procedures. The first surgery included the posterior placement of bilateral pedicle screws with multilevel facetectomies, followed by multilevel anterior cervical discectomy/fusion and posterior rod fixation.
CONCLUSION: Circumferential decompression/fusion successfully addressed chin on chest deformity in two older patients. Copyright:

INTRODUCTION

Dropped head syndrome (DHS) is a chin-on-chest deformity attributed to a noninflammatory myopathy of the cervical paraspinal muscles resulting in weakness of the cervical extensor musculature.[3,10] Conservative nonsurgical treatment is rarely successful. Rather, most patients warrant surgical correction (i.e., circumferential 360 degree decompression/fusion).[6,7] Here, we present two older patients with DHS who were successfully treated with circumferential cervical surgery.

CASE PRESENTATION

Case 1

A 72-year-old female presented with a progressive DHS syndrome and mild myelopathy (i.e., bilateral C5-C7 hyperreflexia). X-rays showed DHS, while the magnetic resonance images documented posterior compression at C-2 to C-3, and stenosis from C-5 to C-7 [Figure 1]. For progressive DHS, the patient underwent posterior placement of pedicle screws C2-C7 and C4-C5 facetectomy, followed by anterior cervical diskectomy/fusion from C2-C3 to C6-C7 and posterior C2-C7 rod/pedicle screw fusion [Table 1]. The 5-year postoperative X-rays showed resolution of the DHS and the patient remained neurologically intact [Figure 2].

Figure 1:

Preoperative radiological findings (Case 1) (a-f). The midline sagittal preoperative cervical MR documented a tortuous/compressed cord at the C2 to C3 level without myelomalacia and C-5 to C-7 stenosis (g).

Table 1:

X-ray, clinical, and surgical findings for two patients with DHS.

Figure 2:

Postoperative radiological findings (Case 1) (a-f). After 360° surgery, the postoperative MRI documented correction of the preoperative cervical deformity (g).

Case 2

A 53-year-old male presented without myelopathy. Preoperative X-rays demonstrated DHS, while the MR showed C-5 to C-6 cord compression [Figure 3]. The patient underwent circumferential surgery for DHS; bilateral facetectomies C3-C7 with posterior pedicle screw placement, followed by C3-C4 to C6-C7 ACDF and posterior rod/screw placement C3-C7 and laminoplasty C3-C6 [Table 1]. Six years postoperatively, the X-rays showed continued stability, while the patient remained clinically/neurologically intact [Figure 4].

Figure 3:

Preoperative radiological findings (Case 2) (a-f). The preoperative midline sagittal MR showed both anterior and posterior cord compression at the C5-C6 level (g).

Figure 4:

Postoperative radiological findings (Case 2) (a-f). Following 360-degree circumferential decompression/fusion, including a C3-C6 laminectomy, the postoperative sagittal MR documented spinal cord decompression (g).

DISCUSSION

DHS can be classified into three groups based on preoperative radiological parameters; Type 1 (SVA ≤0 mm and PI-LL ≤10°), Type 2 (SVA > 0 mm and PI-LL ≤10°), and Type 3 (PI-LL >10°).[5] Several surgical strategies for DHS have been reported including; posterior multiple-level fixation or combined anterior and posterior cervical fixation [Table 2].[1,2,4,7-9] In our two cases of DHS, we chose first to perform posterior cervical facetectomies with pedicle screw application, followed by multilevel ACDF with posterior rod/pedicle/screw fusion. The final posterior fixation was accompanied in the second case by an additional laminoplasty.

Table 2:

Summary of surgical strategy in the previous cases from the literature.

CONCLUSION

Here, we corrected the DHS syndrome in two older patients utilizing a combined circumferential 360 degree decompression/fusion.