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298.2.Full.Pdf 290 J Neurol Neurosurg Psychiatry 2005;76:290–300 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.2004.047357 on 14 January 2005. Downloaded from PostScript.............................................................................................. of the small muscles of the left hand since impaired pain and temperature sensations in LETTERS August 1998. This deficit stabilised after a both upper limbs and in the shoulder girdle period of one year. At the onset of illness, he region. Magnetic resonance imaging of the had also developed mild difficulty in using spine and brain revealed a septate intrinsic cord ‘‘Dropped head syndrome’’ in his right hand for performing fine work but hypointensity in T1 weighted images, becom- this symptom remained stable. He noticed ing hyperintense in T2 weighted images syringomyelia: report of two occasional fasciculations over the arms for extending from the C2 to C7 (fig 1) levels, cases one year. After two years and nine months he associated with low lying cerebellar tonsils and ‘‘Dropped head syndrome’’ is characterised developed rapidly progressive head drop and brainstem reaching the lower border of C1. by weakness of the extensor muscles of the required assistance of the hand to maintain Brain images revealed evidence of hydrocepha- neck, with or without involvement of the the head in an erect posture, and he also lus. There was no evidence of myelomeningo- neck flexors, and is commonly caused by a had mild difficulty in lifting his head off the cele. Electromyography of the distal muscles in variety of neuromuscular disorders, including bed while rising from the supine position. the upper limbs showed fibrillation and fasci- myasthenia gravis, polymyositis, amyotrophic There was no history of impaired sensation culation potentials. Motor and sensory conduc- lateral sclerosis, facio–scapulo–humeral dys- to touch, pain, or temperature, or inadvertent tion studies were normal. Investigations trophy, nemaline myopathy, carnitine defi- burns over the hands or shoulders. There including serum chemistry and haemogram ciency, spinal muscular atrophy, and isolated were no features to suggest Horner’s syn- were normal. neck extensor myopathy.12There are isolated drome or symptoms referring to the cranial reports of dropped head syndrome occurring nerves, lower limbs, cerebellar system, or Case report 2 sphincters. There was no nuchal pain, res- in cervical spondylitis and ankylosing spon- A 30 year old man presented in December dylitis.3 In this report, we describe the clinical tricted neck movements, or symptoms of raised intracranial pressure. 2003 with progressive weakness and atrophy and imaging findings of two patients who of the right shoulder girdle muscles with a Examination revealed mild cerebellar dys- had dropped head syndrome as a rare duration of one year, followed by similar arthria and fasciculations over the tongue. neurological sign secondary to syringomyelia. symptoms on the left side for 10 months; at There were no features of Horner’s syndrome presentation he was unable to raise his arms. and the eye movements, facial sensations, In the last six months he had developed head palatal reflexes, and pharyngeal reflexes were Case report 1 drop, with difficulty in maintaining the head normal. Occasional fasciculations were pre- A 46 year old right handed man presented in the erect posture, and since this time he sent over the arms. There was Medical during May 2002 with insidious onset, had noticed weakness and atrophy of the Research Council grade 2 weakness of the gradually progressive weakness and wasting hand muscles. There were no symptoms of neck extensor muscles with head drop and pain or restricted neck movements, and there grade 4 weakness of the neck flexors. There was no sensory impairment, sphincter dis- was mild wasting of the erector spinae copyright. turbance, or cerebellar ataxia. Neurological muscles in the neck and asymmetric wasting deficits were present in the form of thoracic of the small muscles of the hand, including kyphoscoliosis and wasting of the extensor the thenar, hypothenar, and interossei mus- muscles of the neck, resulting in severe cles bilaterally, with the left side being weakness and dropped head (fig 2). Power affected more severely. Power in the lower in the neck flexors was grade 4. Severe limbs was normal. Deep tendon reflexes were asymmetric wasting of the shoulder girdle sluggish in the upper limbs and exaggerated muscles, in addition to moderate wasting of in the lower limbs, with a bilateral flexor the arm, forearm, and hand muscles was plantar response. The sensory system noted, with bilateral clawing. There was revealed bilateral C2 hypoesthesia, with grade 2 power in the proximal muscles, including the arm, and grade 3 in the small muscles. Deep tendon reflexes were absent in the upper limbs and exaggerated in the lower limbs, with a bilateral extensor plantar res- http://jnnp.bmj.com/ ponse. Temperature sensation was impaired in the entire body except for the face. Posterior column and spinothalamic sensa- tions were normal. Contrast magnetic reso- nance imaging of the spine, including T1 weighted and T2 weighted images, revealed a cerebrospinal fluid signal intensity lesion involving the entire cord, with expansion of the cord, and no evidence of abnormal on September 26, 2021 by guest. Protected contrast enhancement, suggestive of holo- cord syringomyelia. Discussion Dropped head syndrome is a well known feature in a variety of neuromuscular disorders, and is also described in diseases of the bone and joints, such as ankylosing spondylitis and cervical spondylitis.3 Neck flexion weakness is typical in most conditions, but prominent neck extensor weakness has been described in several reports. In the recent review article on dropped head syndrome in amyotrophic lateral sclerosis, 19 different conditions are listed as Figure 1 Sagittal T2 weighted image showing Figure 2 Clinical feature of dropped head causes for dropped head syndrome, but syr- the hyperintense lesion in the cervicodorsal with severe wasting and weakness of neck ingomyelia is not mentioned as a cause.4 Our cord with multiple haustrations and associated extensor muscles. This photograph is patients presented with classic features of tonsillar herniation. reproduced with the full consent of the patient. cervical intrinsic cord lesion suggestive of www.jnnp.com PostScript 291 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.2004.047357 on 14 January 2005. Downloaded from syringomyelia and had the typical features of score was calculated. As previously, we correlation with IQ scores on the same test dropped head syndrome. included only participants with mini-mental given 68 years previously. This is a similar state examination scores greater than 23 and situation to that with blood pressure.2 This A Nalini, S Ravishankar no history of dementia, to exclude patholo- further emphasises the importance of inter- National Institute of Mental Health and Neurosciences, gical cognitive decline as far as possible.4 preting associations between cognition and Bangalore, India None of the participants had a history of other variables in older people in the context head trauma or ongoing CNS affecting of ‘‘pre-morbid’’ mental ability. The effect Correspondence to: Dr A Nalini, National Institute of disease. The resultant sample comprised 470 size of vitamin B-12 is smaller than those Mental Health and Neurosciences (NIMHANS), Hosur participants (194 men, 276 women). found with more domain specific cognitive Road, Bangalore 560 029, India; nalini@nimhans. tests,3 contributing less than 1% of total kar.nic.in; [email protected] Mean (SD) serum vitamin B-12 was 390 (161) ng/l (n = 422) and mean serum folate variance in age 79 IQ. It is unlikely to be doi: 10.1136/jnnp.2004.040428 was 337 (155) mg/l (n = 391). Pearson corre- clinically apparent. However, the effect was lation coefficients with age 11 IQ were: more significant in the small subsample with Received 4 March 2004 laboratory defined deficiency. Revised form received 2 June 2004 r = 0.04 (p = 0.42) for B-12 and r = 0.13 Accepted 8 June 2004 (p = 0.010) for folate; and with age 79 IQ, Inspection of the relation between vitamin r = 0.12 (p = 0.018) for B-12 and r = 0.12 B-12 and the standardised residual score of Competing interests: none declared (p = 0.016) for folate. Linear regression of age age 79 IQ regressed on age 11 IQ (fig 1) 79 IQ controlling for age 11 IQ confirmed a suggests that the overall correlation is The patient gave consent for reproduction of the accounted for by a subgroup that is cogni- photograph. significant effect on age 79 IQ for B-12 (b = 0.092, p = 0.016, R2 improvement = tively vulnerable to vitamin B-12 deficiency. 0.008) but not for folate (b = 0.038, Moreover, this vulnerability occurs at levels References p = 0.33). Only two participants had folate within the normal laboratory range. An IQ levels below the normal range (,5 mg/l) and decline of .1 SD occurred in seven of 18 1 Suarez GA, Kelly JJ. The dropped head omitting these did not affect correlation participants (39%) with a serum vitamin B- syndrome. Neurology 1992;42:1625–7. coefficients with age 11 and age 79 IQ scores. 12 of ,200 ng/l, 19 of 84 (23%) with levels of 2 Lomen-Hoerth C, Simmons ML, DeArmond SJ, 200–299 ng/l, 21 of 103 (20%) with levels of et al. Adult-onset nemaline myopathy: another Twenty five participants had vitamin B-12 cause of dropped head. Muscle Nerve levels below the normal range (,200 ng/l) 300–399 ng/l, and 21 of 149 (14%) with levels 1999;22:1146–9. and there was a stronger correlation with age of .399 ng/l. Further work is required to 3 Swash M. Dropped-head and bent-spine 79 IQ in this group (r = 0.57, p,0.001) than confirm this and ascertain what makes these syndromes; axial myopathies? Lancet in those well within the normal range individuals vulnerable.
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