Lessons From Recurrent Dropped Head Syndrome After Inadequate Short Fixation: A Case Series

Abstract

Dropped head syndrome (DHS) is a condition in which the head falls forward due to dysfunction or atrophy of the cervical extensor muscles. It is more commonly observed in elderly women and significantly affects horizontal gaze and activities of daily living (ADL). For cases in which conservative treatment is ineffective, surgical corrective fixation is considered; however, indications and standardized procedures have not yet been fully established. We retrospectively analyzed five cases of DHS treated surgically at our institution and examined the efficacy of corrective fixation and potential treatment strategies. Five patients (mean age: 82.6 years; all female) who underwent surgery for DHS between 2018 and 2024 were included. Three patients initially underwent short-segment fixation or laminoplasty, but DHS recurred. Eventually, all cases required long-segment fixation extending from C2 or the occiput to Th1/Th2. Radiological evaluations included measurements of the C2-C7 Cobb angles, sagittal vertical axis (SVA), and T1 slope before and after surgery. All patients exhibited cervical kyphosis and sagittal imbalance. Postoperatively, cervical lordosis was restored, and improvements were noted in SVA and T1 slope. In four cases, patients were able to maintain horizontal gaze for over 30 minutes, and improvements in ADL living were observed. One patient died from aspiration pneumonia, although horizontal gaze was maintained postoperatively. Long-segment corrective fixation within an appropriate range is considered a safe and effective treatment option.

Keywords: activities of daily living; cervical kyphosis; cervical sagittal alignment; corrective spinal fusion; dropped head syndrome; isolated neck extensor myopathy; long-segment fixation; sagittal vertical axis.

Figure 1. Preoperative neutral lateral cervical radiographs

A: Case 1; B: Case 2; C: Case 3; D: Case 4; E: Case 5. Lateral cervical radiograph demonstrating kyphosis. The curvature is emphasized using a red curved line to illustrate the abnormal alignment. The numerical identifiers (e.g., Case 1, Case 2, Case 3, etc.) are arbitrary and were created solely for the purpose of referencing specific cases within this article. These identifiers do not correspond to any patient-identifying information.

Figure 2. Postoperative neutral lateral cervical radiographs

A: Case 1; B: Case 2; C: Case 3; D: Case 4; E: Case 5. Posterior fixation from the occiput or C2 to Th1/Th2 was performed. Cervical kyphosis was corrected in all cases. The numerical identifiers (e.g., Case 1, Case 2, Case 3, etc.) are arbitrary and were created solely for the purpose of referencing specific cases within this article. These identifiers do not correspond to any patient-identifying information.

Figure 3. Preoperative Images

A: Lateral plain radiograph showing cervical kyphosis; B: Cervical CT and C: MRI reveal local kyphosis at the C4–C6 levels with bony changes on the anterior vertebral bodies (arrows); D: Anteroposterior and posterior fixation was performed from C4 to C6.

Figure 4. Intraoperative and postoperative images

A: Intraoperative photograph showing occiput to T2 posterior fixation. The upper and lower ends of the rods are secured using Nesplon tape (arrows); B: Postoperative anteroposterior radiograph; C: Lateral radiograph demonstrating correction of cervical kyphosis following posterior fixation.