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LETTER TO EDITOR
Year : 2017  |  Volume : 65  |  Issue : 2  |  Page : 411-413

Dropped head syndrome in brachial plexus injury: A technical note


1 Department of Neurosurgery, Nizam's Institute of Medical Sciences, Hyderabad, Telangana, India; Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada
2 Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada

Date of Web Publication10-Mar-2017

Correspondence Address:
Ashish Kumar
Department of Neurosurgery, Nizam's Institute of Medical Sciences, Hyderabad - 500082, Telangana

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/neuroindia.NI_1160_15

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How to cite this article:
Kumar A, Leodante D. Dropped head syndrome in brachial plexus injury: A technical note. Neurol India 2017;65:411-3

How to cite this URL:
Kumar A, Leodante D. Dropped head syndrome in brachial plexus injury: A technical note. Neurol India [serial online] 2017 [cited 2017 Aug 24];65:411-3. Available from: http://www.neurologyindia.com/text.asp?2017/65/2/411/201821


Sir,

Dropped head syndrome (DHS) is defined as the forward movement of head secondary to the weakness of neck extensor muscles. It has been associated with multiple pathologies including neuromuscular disorders,[1] syringomyelia,[2] chemoradiation in cases of nasopharyngeal carcinoma,[3] cervical spondylotic myelopathy,[4] and cervical spine trauma.[5] We encountered a patient with DHS after brachial plexus injury (BPI), which has been never reported in literature till date. A 27-year-old male patient was transferred to our hospital after a snowmobile accident. Neurological examination showed left upper limb paralysis suggestive of BPI. A magnetic resonance imaging (MRI) of the cervical spine revealed no cord injury [Figure 1]. He was managed conservatively with a cervical collar and was discharged subsequently. At a 6-month follow up, cervical spine X-rays showed an initial mild kyphosis centered at the C5-6 level, and 4 months later, he presented with rapid progression of severe neck deformity. Computed tomography (CT) scan showed severe kyphotic deformity of the cervical spine, mainly at the C5-6 level with unilateral facet dislocation on the left side [Figure 2]. Anterior fusion of the C5-6 bodies was also evident (arrow). MRI showed gross cervical kyphosis along with pseudomeningocele on the left side. The bulk of paraspinal muscles was also grossly reduced [Figure 3]. He underwent anterior discectomy (C4-5 and C5-6) at two levels followed by deformity correction and posterior fusion from C3-T1. Surgery was uneventful and his deformity improved to a significant extent after surgery [Figure 4]. He was doing well at follow-up visit at 6 months, and there is no evidence of recurrent deformity.
Figure 1: Magnetic resonance imaging of the cervical spine showing no evidence of cord injury, although root injury can be seen in the form of pseudomeningocoele on axial imaging (arrow). A small epidural hematoma behind C2 is also seen

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Figure 2: Computed tomography of the cervical spine showing the progressive deformity after 10 months. Anterior fusion at C5-6 is evident along with facet overriding at the same level posteriorly (arrows)

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Figure 3: Magnetic resonance imaging showing cervical kyphosis along with pseudomeningocoele on coronal imaging. Cervical dorsal musculature is clearly atrophic on axial images

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Figure 4: Postoperative computed tomography showing reversal of cervical kyphosis and a good cervical spine alignment. Anterior cervical spacers are seen in the C4-5 and C5-6 disc spaces

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DHS, also known as chin on chest deformity, is caused by weakness of the neck extensor muscles, leading to progressive kyphosis of the cervical spine and forward bending of the neck. Apart from the causes already mentioned, neurodegenerative diseases such as Parkinson's disease have also been linked with DHS.[6]

Cervical spinal trauma, more specifically central cord syndrome, has been reported as a cause for DHS. The explanation for this association is based on the theory that proximal neck musculature is supplied by nerve fascicles placed centrally in the spinal cord.[7],[8] An idiopathic form is also often described, termed as “isolated neck extensor myopathy.”[9] DHS can be symptomatic due to the deformity only or present with signs of cervical myelopathy.[10] With gradual weakening of the neck muscles, the posterior tension-band is disrupted, which can lead to widening and forward movement of the facets. A circumferential approach is the recommended surgical treatment in most reports,[5] although a long segment posterior fusion and deformity correction might be a possible treatment if performed before anterior bony fusion.[11]

BPI has never been reported as a cause for DHS. A possible anatomical basis for this association would be based upon the myotomal pattern in the neck i.e. the paraspinal musculature is supplied by the dorsal rami of cervical nerves from C3 downwards.[12] In the case reported here, multiple root avulsions were present with damage very close to the nerve root entry zones. It is, therefore, reasonable to speculate that the dorsal branches coming off from these roots were damaged to different degrees, leading to denervation of the paraspinal musculature of the neck and progressive weakness after the root avulsion. The key point and importance of this report is to ensure that BPI patients are not lost to follow-up as there may be an associated delayed complication (apart from the already existing nonfunctional arm) resulting from it.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Zenmyo M, Abematsu M, Yamamoto T, Ishidou Y, Komiya S, Ijiri K. Dropped head syndrome due to myogenic atrophy - A case report of surgical treatment. Diagn Pathol 2011;6:9.  Back to cited text no. 1
    
2.
Nalini A, Ravishankar S. “Dropped head syndrome” in syringomyelia: Report of two cases. J Neurol Neurosurg Psychiatry 2005;76:290-1.  Back to cited text no. 2
    
3.
Hashimoto Y, Maebayashi K, Izumi S, Motegi A, Mitsuhashi N. Dropped head syndrome induced by chemoradiotherapy for nasopharyngeal carcinoma: A case report. Jpn J Clin Oncol 2012;42:1091-3.  Back to cited text no. 3
    
4.
Kawaguchi A, Miyamoto K, Sakaguchi Y, Nishimoto H, Kodama H, Ohara A, et al. Dropped head syndrome associated with cervical spondylotic myelopathy. J Spinal Disorder Tech 2004;17:531-34.  Back to cited text no. 4
    
5.
Rust CL, Ching AC, Hart RA. Dropped-head syndrome resulting from injury to the central spinal cord at the upper cervical level. J Bone Joint Surg Br 2011;93:503-6.  Back to cited text no. 5
    
6.
Kashihara K, Ohno M, Tomita S. Dropped head syndrome in Parkinson's disease. Mov Disord 2006;8:1213-6.  Back to cited text no. 6
    
7.
Heller JG, Pedlow FX Jr, Gill SS. Anatomy of the cervical spine. In: Clarke CR, Benzel EC, Currier BL, et al., editors. The cervical spine. 4th ed. Philadelphia: Lippincott, Williams & Wilkins; 2005. p. 3-37.  Back to cited text no. 7
    
8.
Parke WW, Sherk HH. Normal adult anatomy. In: Sherk HH, Dunn EJ, Eismont FJ, et al., editors. The cervical spine. 2nd ed. Philadelphia: JB Lippincott; 1988. p. 11-32.  Back to cited text no. 8
    
9.
Katz JS, Wolfe GI, Burns DK, Bryan WW, Fleckenstein JL, Barohn RJ. Isolated neck extensor myopathy: A common cause of dropped head syndrome. Neurology 1996;46:917-21.  Back to cited text no. 9
    
10.
Nakanishi K, Taneda M, Sumii T, Yabuuchi T, Iwakura N. Cervical myelopathy caused by dropped head syndrome. J Neurosurg Spine 2007;6:165-8.  Back to cited text no. 10
    
11.
Martin AR, Reddy R, Fehlings MG. Dropped head syndrome: Diagnosis and management. Evid Based Spine Care J 2011;2:41-7.  Back to cited text no. 11
    
12.
Zhang J, Tsuzuki N, Hirabayashi S, Saiki K, Fujita K. Surgical anatomy of the nerves and muscles in the posterior cervical spine: A guide for avoiding inadvertent nerve injuries during the posterior approach. Spine 2003;28:1379-84.  Back to cited text no. 12
    


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