Catastrophic Dropped Head Syndrome Requiring Multiple Reconstruction Surgeries after Cervical Laminoplasty

INTRODUCTION: Dropped head syndrome (DHS) after cervical laminoplasty (LAMP) is a rare complication, and no etiologies or surgical strategies have been reported. We present a patient who developed catastrophic DHS after LAMP despite having preoperative cervical lordosis that is known to be suitable for LAMP. We describe a hypothesis concerning the possible mechanism responsible for the DHS and a surgical strategy for relieving it. CASE REPORT: A 76-year-old woman underwent LAMP for cervical spondylotic myelopathy. She achieved satisfactory improvement of neurological symptoms immediately after surgery. However, her neurological symptoms began to gradually deteriorate. She exhibited a dropped head and complained of difficulty maintaining horizontal gaze. Postoperative images showed a focal cervical kyphotic deformity causing anterior shift of the head, and recurrence of spinal cord compression was observed. She underwent additional surgeries for three times, but none of them restored her to baseline status. Retrospectively, the preoperative loading axis of the head existed anteriorly, and she also had a high T1 slope because of rigid thoracic kyphosis. Her preoperative hyper cervical lordosis was compensation for the global spinal malalignment. After LAMP, in accordance with decreases in her cervical lordosis, her head shifted anteriorly. The abnormal lever arm acting on the neck put further stress on the neck extensors, and the overstretched neck extensors possibly no longer generated enough power to raise the head. Uncompensated very high T1 slope because of marked thoracic kyphosis plus invasion of the posterior extensor mechanism by LAMP may have contributed to her catastrophic DHS development. CONCLUSIONS: In the treatment of cervical myelopathy, posterior decompression alone should be applied carefully to elderly patients with cervical sagittal imbalance even if they have apparent cervical lordosis. Once DHS occurs because of cervical sagittal imbalance, normalization of global spinal balance through corrective osteotomy may be indispensable for a successful outcome.