The dropped head sign in parkinsonism

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Abstract

We describe seven patients who exhibited the dropped head sign in parkinsonism. These included six females and one male between the ages of 53 and 74. Three patients were clinically diagnosed as probable Parkinson’s disease and four were diagnosed with probable multiple system atrophy. None had weakness in the posterior neck muscles or spasms in the anterior neck muscles. When the patients attempted to extend the head voluntarily or passively muscle contraction that was not seen in the dropped-head condition appeared. Surface electromyography of the neck indicated that the anterior neck muscles had rigidity. A γ-block of the SCM muscles reduced the muscle activity when the head was elevated and improved the dropped-head condition slightly. These findings seem to indicate that the dropped head sign in parkinsonism could be associated with anterior neck muscle rigidity. Although the severity of the dropped head condition was affected by medication or by the clinical course in three patients, there was no clear relationship between the severity of the dropped head condition and the parkinsonism. We suspected that unbalanced muscle rigidity between the anterior and the posterior neck muscles could cause the dropped head sign.

Introduction

The peculiar neck flexion posture alternatively called ‘dropped head syndrome’ [1], ‘disproportionate antecollis’ [2], or ‘progressive head drooping’ [3], in which the head assumes an attitude of looking at the ground, is occasionally seen in some neurological diseases. It is known that this symptom can accompany two different conditions, neck extensor muscle weakness or parkinsonism. The former condition occurs in myasthenia gravis, motor neuron disease, polymyositis, dermatomyositis, facioscapulohumeral dystrophy, congenital myopathy, carnitine deficiency, chronic inflammatory demyelinating polyneuropathy, and isolated neck extensor myopathy [4]. The latter occurs in multiple system atrophy, diffuse Lewy body disease [5], and Parkinson’s disease [5], [6]. The pathophysiology of the dropped head sign in parkinsonism has not yet been made clear. Here, we here reviewed seven patients with parkinsonism who exhibited the dropped head sign.

Section snippets

Patients and methods

The seven patients with parkinsonism studied here presented extreme flexion of the neck (Fig. 1). They included six females and one male ranging in age from 53 to 74 (Table 1). We investigated the relationship between the dropped head sign and their clinical courses, drug treatments, and other clinical symptoms. Surface EMG of the neck, in which electrodes were placed on the bilateral trapezius and sternocleidomastoid (SCM) muscles, was performed on three of the patients. The diagnoses of all

Clinical diagnosis and findings

Three patients were clinically diagnosed with Parkinson’s disease and the other four patients were diagnosed with multiple system atrophy (Table 1).

All patients had moderate to severe neck rigidity which was stronger than limb rigidity in all but patient 3. Anterior neck muscle spasms were not observed, but extensor muscle contractions were obvious in all cases. When patients attempted to extend the head voluntarily or passively muscle contraction of the SCM, which was not seen in the

Discussion

The dropped head sign in parkinsonism, which seems not to be caused by neck extensor muscle weakness, was reported by Quinn [2] under the name of ‘disproportionate antecollis.’ In that report, he suggested that the dropped head sign might be a relatively characteristic symptom of multiple system atrophy. Subsequently, additional reports were made of the dropped head sign in association with Parkinson’s disease and diffuse Lewy body disease [5], [6]. In keeping with these reports, our present

References (8)

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