Abstract

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.

Keywords: Anterior fixation, Dropped head syndrome, Laminoplasty, Posterior fixation, Surgery

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.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Acknowledgements

We would like to thank Dr. Ryota Ishibashi for his support of this study.

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