Outcomes of Conservative Versus Surgical Treatment of Dropped Head Syndrome in a Single Institution: A Case Series and Review of the Literature

Abstract

Dropped head syndrome (DHS), also known as camptocephalia, is characterized by a mobile chin-on-chest deformity from hypotonia of the cervical extensor muscle or hypertonia of the anterior neck muscles. There remains a paucity of quality published literature on this topic, particularly its management. The objective of this study is to identify radiographic and clinical outcomes of surgery as compared to nonsurgical treatment, to summarize the literature, and to create a decision-making paradigm for managing patients with DHS. As such, we report outcomes of our retrospective chart review series as well as a literature review on the etiology, management options, and outcomes. In our series, we examined the radiographic parameters of the C2-C7 Cobb angle, C2-C7 sagittal vertical axis (SVA), and T1 slope, as well as clinically reported outcomes of conservatively managed (CM; N = 8) and surgically managed (SM; N = 5) interventions on 13 patients with DHS at a single institution. At initial presentation, the CM group had poorer C2-C7 Cobb angle (-37.8 ± 3.2 degrees) and C2-C7 SVA (77.1 ± 10.6 mm) in comparison to the SM group (-21.0 ± 30.3 degrees and 56.9 ± 16.2 mm, respectively). We found a statistically significant improvement in the C2-C7 Cobb angle and T1 slope (p-value of 0.024 and 0.019, respectively) after surgery. Clinically, only one patient in the CM group (20%) reported improvement versus six patients in the SM group (80%). Our study is limited by its small sample size, albeit it is the largest cohort of patients treated at a single institution in the United States to our knowledge. Although our cohort was comprised of heterogeneous etiologies and patient comorbidities, we found that surgery can be beneficial in the right patient. To aid in proper surgical selection, we provide an algorithm for workup and management of DHS.

Keywords: camptocephalia; cervical deformity; cervical kyphosis; chin-on-chest deformity; dropped head syndrome.

Figure 1. Pictorial representation of measurements calculated on lateral cervical spine radiographic imaging.

C2-C7 cobb angle is obtained by drawing a line parallel to the inferior endplate of C2 and the inferior endplate of C7. C2-C7 SVA is the horizontal offset from a plumb line originating at the C2 vertebral body center to the posterosuperior corner of the C7 vertebral body. T1 slope is the angle between the upper-end plate of T1 to a horizontal line. SVA: sagittal vertical axis.

Figure 2. Proposed algorithm for workup and management of DHS.

DHS: dropped head syndrome.

Figure 3. Pre- and postoperative images of a post-cervical laminoplasty cervical kyphosis patient.

The patient presented with loss of neck mobility and difficulty swallowing. Note the significant swan neck deformity (Panel A) and C3-4 autofusion (Panel B) without cord compression (Panel C). The patient opted for surgical correction. Anteriorly, the patient was placed in Gardner Wells tongs, followed by C5 and C6 corpectomy, C4-5 and C6-7 discectomy, C5-6 cage, and C4-7 plate. The patient was then placed in the Mayfield, flipped prone, and underwent C2-T1 fusion and C3-7 decompression. Note the correction of the swan neck deformity and restoration of sagittal balance in the lateral radiograph (Panel D) and elevated chin in the anteroposterior radiograph (Panel E). The patient remains well eight years postoperatively.

Figure 4. Pre- and postoperative images of a patient with post-surgical dropped head syndrome (DHS).

A 79-year-old male presented five months after C1-2 fusion for type II odontoid fracture and Jefferson fracture (Panel A) with mobile chin-on-chest deformity. Eight months after the original surgery, the patient underwent the removal of hardware, followed by occipital to T3 posterior instrumented fusion (Panel B). At six months post operation, the patient had improvement in his symptoms and acceptable clinical kyphosis. At a three-year follow-up, the patient complained of shuffling gate and axial neck pain. He was referred to physical therapy for balance training and muscle strengthening.