Katz 5 isolated neck extensor myopathy VAS Fig.1 C27 Cobb 26 C mm MRI MRI C45 C45 C45 C36 Fig.2

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ふじきみふしはら
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1 2 Dropped Head Syndrome with progressing Cervical Spondylotic Myelopathy undergone Anterior and Posterior Combined ApproachTwo Cases Report and Review of Literature Takeshi Miyata, M.D., Junya Hanakita, M.D., Ph.D., Toshiyuki Takahashi, M.D., Ph.D., Mizuki Watanabe, M.D., Taigo Kawaoka, M.D., Takahiro Kitahara, M.D., and Etsuko Hattori, M.D. Spinal Disorders Center, Fujieda Heisei Memorial Hospital Dropped head syndrome is a rare symptom with inability of horizontal gaze or gait disturbance, resulting in a chinonchest deformity in the standing or sitting position. In past reports, dropped head syndrome may be caused by various disease. The authors present two cases of dropped head syndrome with progressing cervical myelopathy undergone by anterior and posterior combined cervical fixation. In the first case, a 70yearold female was admitted with the chief complaint of a severalyear history of progressing neck stooping in the standing position and numbness of limbs. In the second case, a 83yearold female was admitted with a 9month history of progressing spontaneous neck hanging and neck pain in standing position. She suffered from disturbance of hand skill movement 4 months before admission. Cervical Xray of these cases revealed dynamic instability of the C45 vertebra. The authors determined to undergo surgery of anterior and posterior combined cervical fixation for both patients. In both patients, postoperative course was uneventful and recurrence of dropped head syndrome has not been detected during 9 and 3 months of followup. Recently, some surgical cases of dropped head syndrome have been reported. The authors review literature of these cases and discuss surgical therapeutics of dropped head syndrome. Suitable surgery with preoperative deliberate consideration and postoperative close observation should be done for each cases with dropped head syndrome. Received December 12, 2014accepted March 25, 2015 Key wordsdropped head syndrome, cervical spondylotic myelopathy, anterior and posterior combined approach Jpn J NeurosurgTokyo , 2015 dropped head Suarez 22 dropped head syndrome Address reprint requests totakeshi Miyata, M.D., Department of Neurosurgery, National Cerebral and Cardiovascular Center, 571 Fujishirodai, Suitashi, Osaka , Japan

2 Katz 5 isolated neck extensor myopathy VAS Fig.1 C27 Cobb 26 C mm MRI MRI C45 C45 C45 C36 Fig MMT VAS 7 Fig.3 C27 Cobb 53 C45 12 mm MRI CTMC45 Fig.4C45 C45 C45 Fig Jpn J NeurosurgVOL. 24 NO

3 A B C D Fig.1Patient 1Preoperative dynamic cervical Xray images showed dynamic instability at C45 vertebra. FlexionA, neutralband extensioncposition. T2weighted sagittal MR imagedrevealed mild cord compression at C45 level. A B C Fig.2Patient 1Postopetaive cervical Xray images showed correction of cervical kyphosis. FlexionA, neutralband extensioncposition C5C

4 A B C D Fig.3Patient 2Preoperative dynamic cervical Xray images showed subluxation of C4 vertebra. FlexionA, neutralband extensioncposition. T2weighted MR sagittal imagedrevealed mild cord compression at C45 level. A B C Fig.4Patient 2Intraoperative cervical Xray lateral images showed correction of cervical kyphosis at pronea, supineband pronecposition in anterior and posterior combined approach Jpn J NeurosurgVOL. 24 NO

5 A B C Fig.5Patient 2Postoperative cervical Xray lateral images showed correction of cervical kyphosis at flexiona, neutralband extensioncposition Table Katz 6 Table2A laminoplasty Table2B

6 Authors Year Simmons 1988 Shirasawa 2001 Kawaguchi 2004 Amin 2004 Shinohara 2006 Nakanishi 2007 Petheram 2008 Miyamoto 2008 Miura 2008 Noguchi 2008 Yamada 2011 Ota2010 Komatsu 2010 Hiraiwa 2011 Terashima 2011 Zenmyo 2011 Takahashi 2011 Sakuda 2013 Tokioka 2013 Present case2014 AgeSex 71M 66F 74M 81M 73F 80F 50M 68F 68F 79F 66M 70M 77F 71F 81F 90F 79F 72F 60F 74F 85F 68F 79F 72F 69M 71F N.A. F 79F 83F 70F Table1Literature review of surgical cases of dropped head syndrome Diagnosis,, dislocation fracture at C34, severe thoracic kyphosis Thoracic bone osteoporotic fracture Multiple cervical bone fracture,,, RA,,,, Myelopathy N.A. N.A. N.A. Radiograph findings Kyphotic deformity, chinblow angle measured 75 Cervical kyphosis of 70 C34, 45 subluxation, chinblow angle measured 80 Cervical kyphosis 68vertebral wedging anteriorly at C6 Kyphotic deformityc27, bone fracture of spinous process at C4 Cervical kyphotic deformityc27, severe thoracic kyphosis, cord compression at C56 level Collapse of Th3, with a posteriorly displaced fragment impinging upon the spinal cord Cervical kyphotic deformity Cervical instability at C45, cord compression at C34, 45, increased signal intensity within paraspinal muscles in MRI GdT1WI Wedging of C7 body with undisplaced fracture of the arch of C2 Kyphotic deformity, 10 cord compression at C34, 45, 56 Cervical kyphosis of 50 cord compression at C34, 45 level Cervical kyphosis of 40 Cervical kyphosis of 40 Cervical instability at C35 Cervical kyphosisc27cord compression at C45 Cervical kyphotic deformityc27, cord compression at C37 Cervical kyphosis of 53 Cervical kyphosis of 37 Cervical kyphosis of 60 Cervical kyphosis of 46, at C34 level Cervical kyphosis of 35 at C34, cord compression at C36 level Cervical kyphosis of 26, cord compression at C36 level, muscle atrophy of neck extensors Cervical kyphosis of 48 Cervical kyphosis of 56 Cervical kyphosis of 47 Cervical kyphosis of 50, cord compression at C34 level Cervical kyphosis of 53 Cervical kyphosis of 26, at C45, cord compression at C57 Cervical kyphosis of 54, subluxation at C34, cord compression at C45 Initial surgery C4Th2 posterior fixation C3Th1 posterior fixation C3Th2 posterior fixation C3Th3 posterior fixation C35 posterior fixation Posterior decompression laminoplasty C2Th11 posterior fixation Posterior decompression laminoplasty OC1Th2 posterior fixation C4Th2 posterior fix with external fixation C36 anterior and C3Th2 posterior fixation C27 posterior fixation Posterior decompression laminoplasty Single surgery Anterior release, vertebrectomy, discectomy and posterior fixation C2Th2 posterior fixation C2Th1 posterior fixation C27 posterior fixation C27 posterior decompression and fixation C27 posterior decompression and fixation OTh2 posterior fixation C35 anterior fixation C35 anterior fixation and posterior decompression laminoplasty C36 anterior fixation Multistaged surgery C47 anterior fixation Multistaged surgery C36 anterior release and external fixation Single surgery C37 anterior and posterior fixation C34 posterior decompression laminectomy C2Th2 posterior fixation Single surgery C36 anterior and posterior fixation Single surgery C36 anterior and posterior fixation Additional surgery Anterior fixation 2 weeks later C35 anterior and C27 posterior fixation 1 month later Outcome, but further kyphosis in 5 years failure of posterior wiring Unhappy outcome gradually worsening of kyphosis back out of pedicle screw Gradually worsening of kyphosis loosening of posterior wiring but unhappy outcome backing out of graft bone C36 posterior fix sinking of vertebral cage two weeks later C47 posterior fix two weeks later C36 anterior and posterior fixation two weeks later cervical spondylosis, isolated neck extensor myopathy, N.A.unknown or not available data for the literature, RArheumatoid arthritis postoperative C5 palsy Jpn J NeurosurgVOL. 24 NO

7 Table 2Literature review of surgical management of cases with dropped head syndrome A B Causes of surgical cases of dropped head syndrome 30 Surgery of dropped head syndrome 30 Cervical spondylosis 17 Posterior fixation alone 16 Cervical instability 8 Cfusion 5 Neck muscle atrophy due to cervical spondylotic 5 CT fusion 9 myelopathy OCT fusion 2 Combined with severe thoracic kyphosis 1 Additional anterior fixation 1 Combined with dislocation fracture 1 Anterior fixation alone 3 Osteoporotic thoracic bone fracture 1 Additional posterior fixation 3 Multiple cervical bone fracture 1 Anterior and posterior fixationsingle and multistage6 6 Posterior decompression alone 4 5 Anterior fixation and posterior decompression 1 2 C45 2 C Gerling C45 2 COI COI 1Amin A, Casey AT, Etherington GIs there a role for surgery in the management of dropped head syndrome? Br J Neurosurg , Gerling MC, Bohlman HHDropped head deformity due to cervical myopathysurgical treatment outcomes and complications spanning twenty years. Spine Phila Pa , J Spine Res Katz JS, Wolfe GI, Burns DK, Bryan WW, Fleckenstein JL, Barohn RJIsolated neck extensor myopathya common cause of dropped head syndrome. Neurology , Kawaguchi A, Miyamoto K, Sakaguchi Y, Nishimoto H,

8 Kodama H, Ohara A, Hosoe H, Shimizu KDropped head syndrome associated with cervical spondylotic myelopathy. J Spinal Disord Tech , Nakanishi K, Taneda M, Sumii T, Yabuuchi T, Iwakura N Cervical myelopathy caused by dropped head syndrome. Case report and review of the literature. J Neurosurg Spine , Petheram TG, Hourigan PG, Emran IM, Weatherley CR Dropped head syndromea case series and literature review. SpinePhila Pa , Dropped head syndrome Simmons EH, Bradley DDNeuromyopathic flexion deformities of the cervical spine. SpinePhila Pa , Suarez GA, Kelly JJ JrThe dropped head syndrome. Neurology , Takahashi H, Yokoyama Y, Terajima F, Hasegawa K, Suguro T, Shibuya K, Wada AIsolated neck extensor myopathy causing a dropped heada case report. J Orthop SurgHong Kong , Zenmyo M, Abematsu M, Yamamoto T, Ishidou Y, Komiya S, Ijiri KDropped head syndrome due to myogenic atrophya case report of surgical treatment. Diagn Pathol 69, C Jpn J NeurosurgVOL. 24 NO

9 1992 Neurology myopathy 1996 ADL long fusion anterior plate lordosis tailored surgery

a b Fig. The typical extent of corpectomy at C as represented by the images of case 6 Dotted line indicates the corpectomy area. a Anterior view of di

a b Fig. The typical extent of corpectomy at C as represented by the images of case 6 Dotted line indicates the corpectomy area. a Anterior view of di Spinal Surgery 8 8 0 Original Article Successful Treatment of Proximal type Cervical Spondylotic Amyotrophy by Anterior Decompression, Miyuki Fukuda, M.D., Shiro Chitoku, M.D., Hiroyuki Yoneda, M.D., Iwao