Dropped Head Syndrome – Isolated neck extensor myopathy

Ross Hauser, MD.

When your neck feels like it cannot keep your head up

In this article, we will discuss your problems of being able to keep your head upright. While there can be many causes for why your chin is in your chest, this article will focus on the cause as a mechanical problem coming from weakness and instability in your cervical spine, not only the neck muscles but the neck ligaments as well.  As some of you reading this article are probably aware through your own first-hand experience, and through an eventual diagnosis of Dropped Head Syndrome or Isolated neck extensor myopathy, there are many things that can cause this problem. In your own experience, you may have already been through a barrage of tests to rule out Lou Gehrig’s disease, Parkinson’s disease, head and neck cancer, myasthenia gravis among other neurological or hereditary disorders. Once all these things are ruled out, your Dropped Head Syndrome may become a diagnosis of isolated neck extensor myopathy. Sometimes you will carry both diagnoses. But simply stated, you cannot keep your head upright.

Medications, Cervical Collars, Physical Therapy, Chiropractic

You have probably tried all these treatments. You may be wearing a cervical collar right now. You may have a strong recommendation from a neurosurgeon to consider cervical spine fusion surgery. We are going to take a quick jump into a case history recently presented in the medical literature. Read what happens in this story.

A December 2020 case history was reported in the journal Clinical Medicine Insights-Arthritis and Musculoskeletal Disorders. (1) It will help explain some of the confusion surrounding the treatment and understanding of the dual diagnoses of Dropped Head Syndrome – Isolated neck extensor myopathy and give us an independent view that this problem can be caused by weakness and instability in your cervical spine. This is the view we hold and have seen clinical and empirical evidence at the Hauser Neck Center at Caring Medical that someone with their chin stuck in their chest who does not have the ability to hold their heads up, have a cervical spine ligament program. Further in this article, we will explain how to possibly treat this problem.

Here is the case history, explanatory notes have been added:

“Dropped head syndrome is manifested as the inability to maintain the head in an upright posture. It has been associated with a wide spectrum of myopathies and neurological conditions. Isolated neck extensor myopathy (INEM) is one of many potential causes of dropped head syndrome.

This is a case report of a 72-year-old man who presented with degenerative cervical spondylosis (cervical spine degenerative disc disease or degenerative arthritis) and dropped head syndrome for 2 years.

He had previously failed to achieve a positive outcome to medication, cervical collar, and exercise rehabilitation. However, he was able to regain his voluntary head control after a 4-month chiropractic program. It is believed that isolated neck extensor myopathy is caused by isolated myopathic (degenerative conditions) changes from chronic injury and overloading of the cervical muscles.”

Our note: What could cause overloading of the cervical muscles? What could cause painful muscle spasms in your neck? In many patients we see, it is cervical spine instability. The muscles are overworked because not only are they trying to do their own job as muscles, holding your head up for instance, but now they are trying to do the job of the neck ligaments, that is holding the vertebrae in place. The cervical ligaments are the connective tissues that hold the vertebrae to the vertebrae and help keep your cervical spine in proper alignment. If the ligaments are not holding the vertebrae in proper alignment, the muscles jump in and try to. That is why the neck muscles are spasming, it is too much work for them. Back to the case study.

“Cervical spondylosis has been attributed as the cause of dropped head syndrome secondary to denervation (something impacting the cervical spine nerves from relaying proper messages back and forth from the cervical spine muscles) of the cervical extensors. While Isolated neck extensor myopathy associated with degenerative spondylosis is not medically treatable, manipulative therapies may be adopted before considering surgical intervention.”

Our note: In this case history it was suggested that chiropractic treatments could help delay or prevent the need for cervical spine surgery, most likely an Anterior Cervical Discectomy and Fusion to help stabilize the neck. In our experience, almost all patients who respond favorably to chiropractic therapies will respond well to regenerative medicine type injections that help stabilize the cervical spine by strengthening the ligament and tendon attachments. This is going to be explained further in this article.

Chin-on-chest – the text neck position – when Dropped Head Syndrome is a problem of cervical instability

What are we seeing in this image?

What we are seeing is a progression of the text neck phenomena. That is over time, if you keep looking down at your smartphone, you will develop text-neck and you will eventually stretch out the ligaments of the cervical spine and this will cause neck instability and any number of dozens of possible symptoms not limited to simply neck pain. There is a very strong chance that if you are reading this article you are suffering from a few of these symptoms. We are going to share some stories with you from people who have multiple symptoms. You may recognize your own problems in these stories.

Look at the last image of the person to the right. That is the end of the text neck progression. This is the Chin-in-Chest position. When you do not have the strength to lift your head up. You are now in cervical instability caused by Dropped Head Syndrome.

What we are seeing is a progression of text neck phenomena. That is over time, if you keep looking down at your smartphone, you will eventually stretch out the ligaments of the cervical spine and this will cause neck instability and any number of dozens of possible symptoms not limited to simply neck pain.

Here we have a progression of tension on the neck and why you cannot lift your head up graphically displayed

  • Look at the first image of the progression
    • The weight of the head feels like 10-12 pounds on top of your neck
  • Look at the last image of the progression
    • The weight of the head feels like 60 pounds on top of your neck. This is why you have so much difficulty lifting your head up.

This is why you have so much difficulty lifting your head up

This problem of dropped head syndrome, text next, forward head posture is usually not limited problems to this one diagnosis. It is a diagnosis of many diagnoses, it displays not only symptoms of neck pain and head heaviness and your chin stuck in your chest. It can manifest itself as many symptoms. You may be suffering from many symptoms now. Here are sample stories of others like you:

I could not hold my head up

My story started when I could not focus on any electronic screens. TV, tablet, phone, or monitor. Even the menu displays in a fast-food restaurant or coffee and donut shop were a blur and they appeared to vibrate or move. (See our article Oscillopsia caused by cervical spine instability and neck pain). I was having vision problems, I could not focus on anything, my entire range of vision was blurry. I also become light sensitive. I developed terrible brain fog, neck pain, and cracking noises. On top of this and maybe worse of all was the anxiety and panic attacks I suddenly suffered from.

Then I could not hold my head up. This really set me off in a panic. I did not know if I was paralyzing myself out of fear, if this was all in my head, or something was really wrong with me. My vision problems became worse and I started to hallucinate. I bounced through a group of specialists and they all suggested one form of upper cervical spine instability or another. One doctor said it was my C0-C1, another doctor said C1-C2. My chiropractor said it was my whole neck. He put me in a cervical collar and that alleviated a lot of my problems, but I cannot live in a collar my whole life. I take the collar off, my chin sinks into my chest, the symptoms worsen.

Headaches, facial pain, and a heavy head

For me, it started with migraines and terrible headaches. Then the neck spasms, pain, and stiffness started. My neck felt like it was a clenched fist. Then I would get the sensation that my head was not balanced right on my head and I noticed I was looking down all the time. I could not get my chin up into the air. I could not hold my head up. I have been to many specialists, I got the Dropped Head Syndrome – Isolated neck extensor myopathy diagnosis. I also got a recommendation for fusion surgery and a warning that it may not help that much. I am on medications now for the headaches and nerve pain.

I cannot support my head

My head always feels heavy. When I am walking, if I can hold my shoulders and head back, I can move. It feels like I am a tight rope walker, I have to stay balanced. When I am sitting at a desk or table, I often have to use my hands to support my head. At home, I have taken to wearing a bigger neck brace. When I move my head my neck makes a lot of cracking, clicking, and popping sounds. I get the sensation that my bones are grinding together. X-ray of the cervical spine showed loss of my cervical curve. 

I have pain behind one eye and sometimes my vision in that eye starts to gray or whiteout. I am exhausted and tired. I am not sure if this is another symptom or the drain of trying to keep myself balanced and head up. My head feels clogged, my jaw makes noisy sounds and I have tinnitus.

One doctor now believes I have Ehlers-Danlos Syndrome (hEDS), because of my history of shoulder and elbow dislocations. There is a belief that this is why I cannot hold my head up.

Video summary and explanatory notes:

Dropped head syndrome:

  • You may have severe cervicothoracic kyphotic deformity (Hunchback deformity).
  • You have head and neck pain and a head-down position.
  • You may have severe declines in cervical range of motion.
  • You may have upper motor neuron signs when spinal cord myelopathy or compression is present.
    • Upper motor neuron signs or “upper motor neuron syndrome” symptoms include:
      • muscle weakness
      • loss of muscle control/spasms/tightness
      • clonus – involuntary muscle contractions
      • hyperreflexia (overactive or overresponsive reflexes)
      • difficulty swallowing
      • difficulty with speech
  • Progression may lead to:

When chiropractic manipulation will not work:

  • At 1:50 of the video, Dr. Hutcheson explains how chiropractic can help and how it may fail patients with Dropped Head Syndrome

In a case where traditional chiropractic care wouldn’t work for this would be where the chiropractor does a great job of addressing the bone alignment, activates the weak muscles, and you really start to see some changes in the patient’s posture, but then the patient hits a plateau, they can no longer get any better. Chiropractic has taken them as far as it can go. The problem now is one of cervical spine ligament instability and other interventions will be needed to address that. At Caring Medical, that intervention is Prolotherapy injections which are explained below.

Worsening case history and an answer in the curve of the cervical spine.

In many people that seek our services for their neck-related health problems, we see many people with abnormal cervical spine curvature. We tell many of these people that to help them alleviated the myriad of problems and symptoms they may suffer from, we have to restore a normal curve and reduce or eliminate the problems of pinched and herniated nerves and the problems of muscle, spine, and joint weakness.

Let’s look again at a published case history presented in the medical literature. It is presented by neurosurgeons in the Journal of Neurosurgery Spine. (2)

“The (surgeons of this study) present a rare case of cervical myelopathy caused by dropped head syndrome. This 68-year-old woman presented with her head hanging forward. After 1 month, she was admitted to the medical service because of head drop progression.

Examination of biopsy specimens from her cervical paraspinal muscles showed nonspecific myopathic features without inflammation (she did not have a neurologic disorder), and isolated neck extensor myopathy was diagnosed.

The patient’s condition did not respond to the administration of corticosteroids. (Note: She did not have inflammation, this would typically suggest cortisone would be ineffective).

During follow up as an outpatient, the patient’s head drop continued to gradually progress. At 1 year after onset, she developed bilateral weakness of the upper and lower extremities, clumsiness of the hands, and gait disturbance (her condition spread to the point where walking, balance, and coordination were now new issues.

A radiograph of the cervical spine obtained in a standing position showed a pronounced kyphotic deformity (a hunchback type deformity) and instability at the level of C4-5. Magnetic resonance imaging demonstrated spinal cord compression at C-3 and C-4. The patient underwent a C3-4 laminectomy and occipitocervicothoracic fixation. Gait and hand coordination gradually improved, and she was able to walk with no support at 1 month postoperative. Surgical fixation was beneficial in this patient with dropped head syndrome, myelopathy, and cervical instability.”

So what happened here?

  • This 68-year-old woman was suffering from worsening head forward problems that eventually became a Dropped Head Syndrome problem. Much like the person in the illustration above, her neck could not hold her head upright at the end stage of the progression.
  • For over a year her symptoms worsened to now include arm and leg weakness up to the point of impairing her ability to walk. Let’s remember that her gait abnormalities were coming from her cervical spine.
  • Finally, it was discovered that she had a significant spinal curve deformity at C4-C5 and this led to adjacent segment compression of the spinal cord at the C3-C4 area.
  • In the case of this patient, surgery was performed to alleviate the spinal cord progression.

At our center, we offer non-surgical options for tackling this problem including cervical spine realignment and Prolotherapy injections. In some instances, surgery will be needed. We hope to avoid that need.

Cervical spine realignment and Prolotherapy injections

In this segment, with the help of Brian Hutcheson, DC, I will explain non-surgical treatments and applications to restore normal cervical spine curvature in patients and help them with the alleviation of the myriad of problems and symptoms they may suffer from.

Treatments for cervical spine realignment – restoring the curve without surgery

When we start looking at the most recent research papers surrounding treatments for cervical spine realignment, we often find ourselves reading a lot of new research on cervical spine surgery procedures. Non-surgical treatments for cervical spine realignment are, for the most part, fewer and far between. There is a rush in medicine to surgically correct cervical spine abnormalities including the loss of the natural cervical spine curve.

The Horrific Progression of Neck Degeneration with Unresolved Cervical Instability

What if you were told surgery should be strongly considered? Or is it the only option?


Researchers say fusion surgery should not be considered for some kyphosis patients

Let’s look at a recurrent theme in medical research: Controversy in the surgical repair of cervical kyphosis. Let’s recall that the woman in the case history above had a pronounced kyphotic deformity, an outward curve at her spine at C4-C5. Let’s also remember that she had a successful surgery. There was no long term follow up to this case.

Let’s look at a June 2020 study from the Mayo Clinic. (3)

“Cervical kyphotic deformity can be quite debilitating. Most patients present with neck pain, but they can also present with radiculopathy, myelopathy, altered vertical gaze, swallowing problems, and even cosmetic issues (round back or hunchback) from the severe kyphotic deformity. After failing conservative management, surgery remains the only option for halting symptom progression.”

In some patients, fusion should be avoided as it is thought to lead to increased rates of adjacent segment degeneration

However, a March 2020 study in the Journal of Spine Surgery (4) with the title: “Sagittal alignment of the cervical spine: do we know enough for successful surgery?” suggested: “The relationship between sagittal cervical spine alignment and symptoms in patients prior to undergoing surgery remains imprecise, and the evidence for its influence on postoperative clinical outcomes is similarly mixed. It is generally accepted that in patients undergoing cervical fusion surgery for a variety of indications, fusion in kyphosis. . . should be avoided as it is thought to lead to increased rates of adjacent segment degeneration”

Treating cervical ligament weakness and starting the journey to restoring proper cervical curve.

In this video, Ross Hauser, MD, and Brian Hutcheson, DC describe a case of restoring the cervical spinal curve and alleviation of symptoms.

Summary transcript

At 0:15 of the video, Dr. Hauser and Dr. Hutcheson discuss a patient case. The patient was a family man. Very active and loved to lift weights

He started to develop symptoms of

  • vision blurriness
  • terrible headaches
  • neck pain
  • dizziness

His job also required him to be on the computer and his neck problems made it difficult for him to work.

  • Digital Motion X-Ray at 0:40 revealed a terrible problem with the curve in his neck and he had cervical spine neck instability especially focused on the C1-C2

We treated this patient with Prolotherapy injections. Prolotherapy is a non-surgical treatment designed to strengthen the cervical ligaments of the neck. The treatment is explained below.

  • Once the Prolotherapy treatments strengthen the ligaments significantly enough to handle the force of cervical spine curve correction, we put weights on him
  • The end result of the treatment at 1:00 a good cervical spine curve and we have not had to see the patient again.

In this image from the video, Dr. Hauser shows the end result of treatment, a restored cervical spinal curve.

In this image from the video, Dr. Hauser shows the end result of treatment, a restored cervical spinal curve.

In this image from the video, Dr. Hauser shows the end result of treatment, a restored cervical spinal curve.

At 1:28 of the video, Dr. Hutcheson explains


  • In patients like our case history, not only is tightening the ligaments with Prolotherapy injections important to help stabilize the neck, but just as important is that we are addressing the problems caused by cervical lordosis or loss of the natural cervical curve.
  • Helping a patient get the curve back in the neck is so important. Your head weighs 8 to 10 pounds, if your center of gravity (posture) is off, even a small amount, the pressure on the neck increases and degenerative problems accelerate.

The weight of your head, why it feels like you cannot hold your head up

In this image adapted from The Physiology of the Joints, volume III 6th Edition I. A. Kapandji MD, we see that if your have head forward of 2 inches of your center of gravity you head feels like it weights 32 pounds. Three inches forward your head feels like it weighs 42 pounds.

At 2:10 of the video: In this image adapted from The Physiology of the Joints, Volume III 6th Edition I. A. Kapandji MD, we see that if you have head forward changes of 2 inches off your center of gravity, your head feels like it weighs 32 pounds. Three inches forward your head feels like it weighs 42 pounds.

Prolotherapy treatment

Caring Medical has published dozens of papers on Prolotherapy injections as a treatment in difficult to treat musculoskeletal disorders. We are going to refer to our 2014 study where we published a comprehensive review of the problems related to weakened damaged cervical neck ligaments.

Prolotherapy is referred to as a regenerative injection technique (RIT) because it is based on the premise that the regenerative healing process can rebuild and repair damaged soft tissue structures. It is a simple injection treatment that addresses very complex issues.

This video jumps to 1:05 where the actual treatment begins.

This patient is having C1-C2 areas treated. Ross Hauser, MD, is giving the injections.

  • The patient was experiencing vertigo, tinnitus, severe neck pain, migraines, and other problems based around C1-C2 instability.

An individualized treatment protocol may include the following:

  • A certain number of Prolotherapy visits to resolve the instability.
  • Chiropractic consultation and treatment
  • An initial period of cervical immobilization with a cervical collar in order to limit neck forces while the ligaments regenerate.
  • Rescanning every two visits to ensure the Prolotherapy is resolving the instability.
  • When improved spinal stability is demonstrated, Caring Cervical Realignment Therapy using cervical weights will be started. In some severe spinal curves, CCRT using cervical weights is started immediately. Changing the spinal curve can take just minutes for some patients to several months in others.

The treatment regimen is continued until the person can do all desired activities with minimal symptoms and spinal curve kinematics (curve) are improved.

Our goal is to provide long-term solutions. Through extensive research and patient data analysis, it became clear that in order for patients to obtain long-term cures (approximately 90% relief of symptoms) the re-establishment of some lordosis, (the natural cervical spinal curve) in their cervical spine is necessary. Once spinal stabilization was achieved with Prolotherapy and the normalization of cervical forces by restoring some lordosis, lasting relief of symptoms was highly probable. As with any medical technique, the treatment will not work for everyone. We provide a detailed prescreening process to help assess the ideal candidates for treatment.

References

1 Chu EC, Wong AY, Lin AF. Isolated Neck Extensor Myopathy Associated With Cervical Spondylosis: A Case Report and Brief Review. Clinical Medicine Insights: Arthritis and Musculoskeletal Disorders. 2020 Nov;13:1179544120977844. [Google Scholar]
2 Nakanishi K, Taneda M, Sumii T, Yabuuchi T, Iwakura N. Cervical myelopathy caused by dropped head syndrome: case report and review of the literature. Journal of Neurosurgery: Spine. 2007 Feb 1;6(2):165-8. [Google Scholar]
3 Ebot J, Foskey S, Domingo R, Nottmeier E. Kyphosis Correction in Patients Undergoing a Four-Level Anterior Cervical Discectomy and Fusion. Cureus. 2020 Jun 25;12(6):e8826. doi: 10.7759/cureus.8826. PMID: 32742839; PMCID: PMC7384706. [Google Scholar]
4 Teo AQ, Thomas AC, Hey HW. Sagittal alignment of the cervical spine: do we know enough for successful surgery?. Journal of Spine Surgery. 2020 Mar;6(1):124. [Google Scholar]

This page was update January 4, 2021

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