BACKGROUND: Dropped head syndrome (DHS) is caused by dysfunction of the cervical musculature. It is classified into two groups according to the cause: one is weakness of the neck extensors and the other is hypercontraction of the cervical flexors associated with Parkinson\'s disease and other disorders. Although some drugs have previously been reported as suspected causes of DHS, we are unaware of any reports in which oxaliplatin was suspected. In this report, we describe a case of DHS during adjuvant chemotherapy for gastric cancer, along with a review of the relevant literature.
METHODS: A 72-year-old man was diagnosed with gastric cancer, cT3N0M0 cStage IIB, and underwent laparoscopic total gastrectomy with D2 lymphnode dissection and Roux-en-Y reconstruction. The operative time was 311 min, intraoperative blood loss was 40 g, and he was discharged without any post-operative complications. The histopathological diagnosis was pT4aN2M0 pStage IIIA, and S-1 + oxaliplatin (SOX) therapy was started as adjuvant chemotherapy. On the 4th course of SOX, he complained of neck heaviness and a blood test revealed that his creatine kinase (CK) level was elevated to 2464 IU/L. After consultation with an orthopedic surgeon and a neurologist, DHS due to localized cervical extensor myositis was suspected. Therefore, the 6th course of SOX was postponed, and 30 mg of oral steroids were initiated. His symptoms improved, and his CK level decreased within 2 weeks. After resuming S-1 monotherapy and tapering off oral steroids, no recurrence of symptoms has been observed.
CONCLUSIONS: We experienced one case of DHS during adjuvant chemotherapy for gastric cancer. If DHS develops after starting oxaliplatin, involvement of the drug should be suspected, and discontinuation of chemotherapy and introduction of oral steroids should be considered.

Complications from medial branch blocks (MBBs) are rare when following proper procedural protocol. Dropped head syndrome (DHS) is characterized by profound muscle weakness in the cervical spine, resulting in a failure to maintain a level horizontal gaze and, in the worst cases, a chin-on-chest deformity. In this case report, we described DHS developing after cervical MBBs using short-acting anesthetic agents and subsequent management. A 69-year-old woman with a previous C6-C7 anterior cervical discectomy and fusion (ACDF) underwent bilateral posterior cervical MBBs targeting the C4-C5 and C5-C6 levels. Immediately following the injection, she reported a sudden inability to lift her head and was subsequently diagnosed with DHS. This condition continued with minimal improvement for over six months. After weighing the risks, the patient elected to avoid surgery, and she was provided a soft cervical collar and prescribed physical therapy. DHS is a debilitating condition more commonly associated with neurodegenerative conditions and inflammatory myopathy, which has received limited attention due to its rarity as a complication of cervical radiofrequency neurotomy. Surgery for this condition, when considered, typically involves long-segment posterior cervical instrumented fusion. Undergoing such a surgery is a complicated discussion that should consider patient clinical factors and preferences. The clinical impact of loss of strength in paraspinal musculature in this patient population is clearly deserving of further study.

Some myopathies can lead to dropped head or bent spine syndrome (DH/BS). The significance of this symptom has not been studied in inflammatory myopathies (IM).
To assess the significance of DH/BS in patients with IM.
Practitioners from five IM networks were invited to report patients with IM suffering from DH/BS (without other known cause than IM). IM patients without DH/BS, randomly selected in each participating centre, were included as controls at a ratio of 2 to 1.
49 DH/BS-IM patients (DH: 57.1%, BS: 42.9%) were compared with 98 control-IM patients. DH/BS-IM patients were older (65 years vs 53 years, p<0.0001) and the diagnosis of IM was delayed (6 months vs 3 months, p=0.009). Weakness prevailing in the upper limbs (42.9% vs 15.3%), dysphagia (57.1% vs 25.5%), muscle atrophy (65.3% vs 34.7%), weight loss (61.2% vs 23.5%) and loss of the ability to walk (24.5% vs 5.1%) were hallmarks of DH/BS-IM (p≤0.0005), for which the patients more frequently received intravenous immunoglobulins (65.3% vs 34.7%, p=0.0004). Moreover, DH/BS-IM patients frequently featured signs and/or complications of systemic sclerosis (SSc), fulfilling the American College of Rheumatology/European Alliance of Associations for Rheumatology criteria for this disease in 40.8% of the cases (vs 5.1%, p<0.0001). Distribution of the myopathy, its severity and its association with SSc were independently associated with DH/BS (p<0.05). Mortality was higher in the DH/BS-IM patients and loss of walking ability was independently associated with survival (p<0.05).
In IM patients, DH/BS is a marker of severity and is associated with SSc (scleromyositis).

BACKGROUND: Dropped head syndrome (DHS) is a rare specific abnormal posture known to develop in Parkinson\'s disease (PD). This case series study aimed to characterize DHS by analyzing the characteristics of sagittal spinopelvic alignment in patients with PD/DHS.
METHODS: The study included eight patients with PD/DHS (men = 3, women = 5; mean age, 68.1 ± 6.4 years). Sagittal spinopelvic alignment was evaluated using 10 parameters on whole-spine lateral radiographs.
RESULTS: The time from the onset of PD to that of DHS varied among the patients from 0 to 15.3 years. In three patients, DHS appeared before the diagnosis of PD. The severity of motor symptoms at DHS onset varied from modified Hoehn and Yahr stage 1 to 4 among the patients. Although the spinopelvic parameters differed among PD/DHS individuals, all patients exhibited cervical kyphosis (cervical lordosis < 0˚). In patients with a larger T1 slope and greater thoracic kyphosis, anterocollis tended to be more severe. According to the assessment of the sagittal vertical axis (SVA), half of the patients showed a positive SVA (SVA ≥ 0 mm), whereas the other half showed a negative SVA (SVA < 0 mm).
CONCLUSIONS: DHS appeared regardless of the duration or severity of PD. Although all patients with PD/DHS exhibited cervical kyphosis, the C7 plumb line was shifted anteriorly in half of the patients and posteriorly in the other half.

BACKGROUND: Several reports exist on syndromic cervical kyphosis in the elderly, including dropped head syndrome, degenerative spondylosis, and neurological diseases; however, it is rarely reported in young patients especially with complications.
METHODS: We describe a case of a 25-year-old man who presented severe cervical kyphosis with dropped head syndrome, horizontal-gaze disorder, dysphagia, and myelopathy. The etiology of this cervical kyphosis was suspected to be as a result of a combination of an underlying developmental disorder and habitual, long-term cervical flexion postures while engaging in smartphone games. Combined anterior and posterior surgeries resulted in good outcomes and improved the patient\'s quality of life remarkably.
CONCLUSIONS: Cervical kyphosis awareness in young patients is crucial. Moreover, combined anterior and posterior approach provides secure, good results, and with less sequelae.

UNASSIGNED: Dropped head syndrome (DHS) is a relatively rare disease, and its potential relationship with drug exposure has been postulated but is poorly understood.
UNASSIGNED: This retrospective study evaluated the adverse event reports of DHS in the FDA adverse event reporting system （FAERS) between 1 January 2004, to 31 March 2021. Empirical Bayes Geometric Means (EBGM) and the lower 95% one-sided CI of EBGM were calculated to identify disproportionate reporting of DHS associated with drugs. In addition, published case reports were identified in the PubMed, Embase and Cochrane Library up to 5 August 2021.
UNASSIGNED: There were 193 reports of DHS in the FAERS, in which nervous system agents were most frequently reported, followed by antineoplastic and immunomodulating agents. Pramipexole, ropinirole, levodopa, pregabalin, rotigotine, cisplatin, imatinib and botulinum toxin showed disproportionality signal based each on more than 5 cases. Ten published DHS case reports were identified in the literature.
UNASSIGNED: Our study provides a more explicit profile on the occurrences and characteristics of DHS associated with drugs by analyzing the FAERS data and indicates that exposure of certain drug showed disproportionality signal with the increased DHS risk, which suggests the importance of further clinical and observational investigations.

A 68-year-old man with a 2-month history of progressive weakness and spontaneous pain in proximal limb muscles presented to our hospital with a dropped head. He started experiencing progressive dysphagia several days before admission. On admission, he had muscle weakness of the limbs and neck extensors with edema and induration in distal extremities. Laboratory tests showed elevation of muscle enzymes. FDG-PET/CT demonstrated multiple hypermetabolic lymph nodes, but the primary site was not identified; thus, metastatic carcinoma of unknown primary origin was considered. The patient was diagnosed with anti-nuclear matrix protein 2 antibody-positive paraneoplastic myopathy based on serum tests. Histological findings of the left biceps brachii muscle biopsy revealed severe variation in fiber size and perifascicular myofiber atrophy. Myofibers exhibited myxovirus resistance protein A expression predominantly in the perifascicular region. Following intravenous methylprednisolone pulse therapy and intravenous immunoglobulin, the patient\'s muscle strength improved with normalization of muscle enzyme levels. The dropped head was considered to have resulted from the preferential involvement of neck extensors based on the observed FDG-PET/CT uptake in neck extensors.

OBJECTIVE: Dropped head syndrome (DHS) is presumably caused by focal myopathy in the cervical posterior muscles; however, distinguishable radiological features of the cervical spine in DHS remain unidentified. This study investigated the radiological features of the cervical spine in dropped head syndrome.
METHODS: The records of DHS patients and age- and sex-matched cervical spondylotic myelopathy (CSM) patients were reviewed. Cervical spinal parameters (C2-7, C2-4, and C5-7 angles) were assessed on lateral cervical spine radiographs. Quantitative radiographic evaluation of cervical spine degeneration was performed using the cervical degenerative index (CDI), which consists of four elements: disk space narrowing (DSN), endplate sclerosis, osteophyte formation, and listhesis.
RESULTS: Forty-one DHS patients were included. Statistically significant differences were noted between the upper and lower cervical spine in the sagittal angle parameters on the neutral, flexion, and extension radiographs in DHS group, whereas no significant differences were observed in CSM group. CDI comparison showed significantly higher scores of DSN in C3/4, C4/5, C5/6, and C6/7; sclerosis in C5/6 and C6/7; and osteophyte formation in C4/5, C5/6, and C6/7 in DHS group than in CSM group. Comparison of listhesis scores revealed significant differences in the upper levels of the cervical spine (C2/3, C3/4, and C4/5) between two groups.
CONCLUSIONS: Our results demonstrated that the characteristic radiological features in the cervical spine of DHS include lower-level dominant severe degenerative change and upper-level dominant spondylolisthesis. These findings suggest that degenerative changes in the cervical spine may also play a role in the onset and progression of DHS.

Dropped head syndrome is a rare disease entity characterized by severe weakness of the cervical para-spinal muscles, resulting in a chin-on-chest deformity. Systemic sclerosis is one of the causes of dropped head syndrome, but its characteristics and prognosis remain unclear due to the extreme rarity of this condition. We present a case of dropped head which occurred in systemic sclerosis. He presented with severe dropped head and relatively mild weakness of the proximal limb muscles. Serum level of creatine kinase was elevated, myopathic change was observed in electromyography, and gadolinium enhancement was found in magnetic resonance imaging of his posterior neck muscles. Anti-topoisomerase I antibody was positive, while other autoantibodies such as anti-PM/Scl and anti-Ku antibodies were negative. Since his dropped head acutely progressed, high dose of glucocorticoid therapy was initiated, which successfully improved dropped head, serum level of creatine kinase, and gadolinium enhancement in magnetic resonance imaging. Our present case and literature review suggest that dropped head occurring in systemic sclerosis can be treatable with immunosuppressive therapy. It is important to recognize this rare but treatable involvement of systemic sclerosis because early diagnosis and treatment initiation are crucial to prevent the irreversible organ damage and the significant decrease of daily activities.

There have been a few reports on Dipeptidyl peptidase (DPP)-4 inhibitor-induced dropped head syndrome. However, there has been no known report on temporal changes in MRI findings. The patient described here was a 63-year-old man who was prescribed oral sitagliptin (50 mg/day) in February 2019. He experienced a dropped head from mid-January 2020, and in early April that year, he was admitted to our hospital for further evaluation. Weakness of the cervical extensor muscles (MMT 3) was noted, and MRI findings showed that the posterior cervical muscle group was hyperintense on short inversion time inversion recovery (STIR). We suspected sitagliptin to be the cause of his dropped head and discontinued it. On the 10th day of admission, his posture improved to the median position. One month after discontinuation of sitagliptin, MRI findings showed an improvement in the STIR hyperintensity of the posterior cervical muscle. In conclusion, if the initiation of a DPP-4 inhibitor results in dropped head syndrome, discontinuation of the drug should be considered.