802 - Compromised Kyphosis: Delayed Onset of Dropped-Head Syndrome after Bilateral Multilevel Cervical Radiofrequency Ablations

Case Diagnosis: Dropped-Head Syndrome

Case Description: A 68-year-old Veteran and practicing orthopedic surgeon presented to VA Physiatry clinic for chronic cervicalgia. MRI showed multilevel cervical spondylosis with cord flattening, multilevel foraminal stenosis, and lack of lordotic curve. After two positive diagnostic medial branch blocks, left and right radiofrequency ablations were performed on the third occipital nerve and C3/C4 medial branches without immediate complications. The left and right RFAs were performed 2 weeks apart. 4 weeks post-RFAs, he reported weakness in neck extension that resulted in a chin-on-chest posture. As a result, he was unable to function as an operating surgeon. Examination revealed neck extensor weakness with rapid fatigability, and new bilateral ankle myoclonus. He was prescribed a soft cervical collar for comfort and support as well as referral to PT for strengthening exercises. He has scheduled follow up with his spine surgeon to consider decompression and fusion.


Discussions: Dropped-head syndrome, characterized by severe weakness of the cervical extensor muscles leading to chin-on-chest posture, is a rare yet significant complication of cervical neurotomies. In this case, the patient's underlying severe multilevel cervical degeneration likely amplified biomechanical vulnerability, accentuating extensor weakness and kyphosis. Given the timing of onset of these new symptoms post-RFA and the finding of new bilateral myoclonus, spine surgeon evaluation took precedence over further investigations of the etiology of the dropped-head syndrome. Importantly, the Veteran had premorbid kyphosis that became accentuated post-RFA and limited his function as a surgeon.

Conclusions: This case illustrates a rare but functionally limiting complication of cervical neurotomy. The uniqueness of this case is in the context of pre-existing severe cervical degeneration with lack of normal lordotic curvature. Physiatrists engaged in interventional pain management should anticipate potential post-RFA kyphosis exacerbation and incorporate current function in their assessment when deciding to pursue treatment.