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Three-dimensional gait analysis reveals dynamic alignment change in a patient with dropped head syndrome: A case report
Journal of Clinical Neuroscience xxx (2017) xxx–xxx
Contents lists available at ScienceDirect
Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn
Case report
Three-dimensional gait analysis reveals dynamic alignment change in a patient with dropped head syndrome: A case report Kousei Miura a,⇑, Hideki Kadone b, Masao Koda a, Hiroshi Kumagai a, Katsuya Nagashima a, Kengo Fujii a, Hiroshi Noguchi a, Toru Funayama a, Tetsuya Abe a, Takeo Furuya c, Masashi Yamazaki a a b c
Department of Orthopaedic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki 305-8575, Japan Center for Innovative Medicine and Engineering, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, Japan Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba 260-8677, Japan
a r t i c l e
i n f o
Article history: Received 12 June 2017 Accepted 23 October 2017 Available online xxxx Keywords: Three-dimensional gait analysis Electromyography Dropped head syndrome Dynamic spinal alignment Cervical sagittal imbalance
a b s t r a c t Dropped head syndrome (DHS) is a cervical kyphotic deformity caused by apparent weakness of the neck extensor muscles. We often encounter patients whose symptoms, including impaired forward vision and neck pain, deteriorate while walking. This is the first report of a case of dynamic spinal alignment change in a patient with DHS during walking using three-dimensional gait analysis. A 78-year-old Japanese woman complained of impaired forward vision and neck pain while walking. Her radiograph showed severe cervical kyphosis. C2–C7 SVA was +74 mm and C7–S1 SVA was 18.4 mm. The patient attempted to compensate to improve forward vision through lumbar hyperlordosis. We analyzed the gait motion of the patient by using three-dimensional (3D) motion and wireless surface electromyographic analysis systems to measure two systems synchronously. The patient walked continuously for as long as possible. We calculated dynamic SVA from the 3D motion analysis. Her head drop deformity gradually progressed and interfered with her forward vision while walking. Cervical SVA gradually increased from 75 to 85 mm. Thoracic SVA, Lumbar SVA and Whole spine SVA were initially decreased because of compensatory lumbar hyperlordosis, but ultimately increased, suggesting decompensation by the time she had finished walking. EMG activity of the bilateral trapezius muscles gradually reduced, which reflected the disturbance of maintaining her posture. Previous static evaluation could not prove the dynamic change of spinal alignment and EMG activity during walking. By introducing 3D gait analysis, we could evaluate dynamic spinal alignment of a patient with DHS. Ó 2017 Elsevier Ltd. All rights reserved.
1. Background Dropped head syndrome (DHS) is a cervical kyphotic deformity caused by apparent weakness of the neck extensor muscles and often results in passively correctable chin-on-chest deformity. Patients suffer from impaired forward vision and neck pain. DHS occurs in a variety of disease backgrounds [1–5]. However, the pathology of DHS remains unclear. We developed a new system for three-dimensional (3D) gait analysis to evaluate dynamic spinal alignment. To our knowledge, ⇑ Corresponding author. E-mail addresses: [email protected] (K. Miura), [email protected] (H. Kadone), [email protected] (M. Koda), [email protected] (H. Kumagai), [email protected] (K. Nagashima), [email protected] (K. Fujii), [email protected] (H. Noguchi), [email protected] (T. Funayama), [email protected] (T. Abe), [email protected] (T. Furuya), [email protected] (M. Yamazaki).
this is the first case report of dynamic spinal alignment change in a patient with DHS using 3D gait analysis.
2. Case presentation A 78-year-old Japanese woman complained of impaired forward vision and neck pain while walking. A whole spine lateral radiograph of the patient in a standing position showed severe cervical kyphosis. C2–C7 sagittal vertical axis (SVA), which was measured as the distance between the perpendicular line from the center of the C2 vertebral body and posterosuperior corner of the C7 vertebra, was +74 mm; and C7–S1 SVA, which was measured as the distance between the perpendicular line from the center of the C7 vertebral body and posterosuperior corner of sacrum, was 18.4 mm. C2–C7 angle was 43.5°, T1 slope was 58°, thoracic kyphosis was 41.9°, lumbar lordosis was 52°, pelvic incidence was 56°, and pelvic tilt was 32°. Those radiographic parameters
https://doi.org/10.1016/j.jocn.2017.10.075 0967-5868/Ó 2017 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Miura K et al. Three-dimensional gait analysis reveals dynamic alignment change in a patient with dropped head syndrome: A case report. J Clin Neurosci (2017), https://doi.org/10.1016/j.jocn.2017.10.075
2
Case report / Journal of Clinical Neuroscience xxx (2017) xxx–xxx
suggested that the patient attempted to compensate to improve forward vision through lumbar hyperlordosis. Three-dimensional motion analysis was performed using an VICON MX system (Vicon, Oxford, UK), which consisted of 16 cameras set in and 38 reflective markers attached on her head, spine, pelvis, and upper and lower limbs, including seventeen markers attached to her spinous processes. Wireless surface electromyogram analyses were performed using a Delsys Tringo Lab System (Delsys, Boston, MA, USA), which consisted of 12 EMG sensors attached to her bilateral muscles including the sternocleidomastoid, trapezius, latissimus dorsi, erector spinae, abdominal rectus, and quadriceps. Three-dimensional motion analysis and EMG analysis were interconnected to achieve synchronous measurement. The patient was asked to walk continuously for as long as possible at a comfortable pace around a rotary walkway. We calculated dynamic SVA from VICON. Obtained parameters were defined as follows: cervical SVA was the sagittal distance between reflective marker on the C2 and C7 spinous processes, thoracic SVA was the sagittal distance between reflective markers on the T1 and T12 spinous processes, lumbar SVA was sagittal distance between reflective markers on the L1 and S1 spinous processes, and whole spine SVA was defined as the sagittal distance between reflective markers on the C2 and S1 spinous processes. Her head drop deformity gradually progressed and interfered with her forward vision and ultimately showed chin-on-chest deformity while walking (Fig. 1). Cervical SVA gradually increased from 75 to 85 mm. Thoracic SVA initially decreased from 65 to 61 mm, but ultimately increased to 75 mm. Lumbar SVA initially decreased from 7.4 to 8.9 mm, but ultimately increased to 6.8 mm. Whole spine SVA initially decreased from 140 to 133 mm, but ultimately increased to 160 mm (Fig. 2). EMG activity of
the bilateral trapezius muscles gradually reduced, whereas the EMG activity of other muscles did not show significant change.
3. Discussion The present analysis found a gradual increase of the cervical kyphosis in the patient while walking and an initial decrease of thoracic kyphosis because of compensatory lumbar hyperlordosis followed by an ultimate increase of kyphosis, suggesting decompensation by the time she had finished walking. By contrast, lumbar dynamic change was only slight compared with cervical and thoracic change. Together with the results of dynamic alignment change, we speculate that EMG activity reduction of bilateral trapezius muscles reflects the disturbance of maintaining her posture. Previous static evaluation could not prove this dynamic change. Static spinal sagittal balance parameters measured by radiography are widely used as a criterion standard for diagnosis, as prognostic values, and as surrogate outcome measures after surgery. However, we often encounter patients whose symptoms deteriorate while walking. This phenomenon suggests that static evaluation alone might be insufficient for understanding the pathology of DHS. Thus, we performed 3D gait analysis, which enabled us to analyze the dynamic change of spinal alignment at least in the present case. Previous studies have used 3D gait analysis for patients with idiopathic scoliosis [6,7]. However, to our knowledge, no investigators have reported 3D gait analysis of patients with DHS. In light of the limitations of static measures, we recommend considering dynamic change of spinal alignment to evaluate patients with DHS. Our 3D gait motion analysis system shows potential utility for understanding the pathophysiology of DHS
Fig. 1. (a) Lateral plain radiograph of the whole spine showing severe cervical kyphosis. (b) Lateral posture on standing. (c) Lateral posture during gait analysis immediately after start. (d) Lateral posture during gait analysis just before the patient finished walking showing progression of cervical kyphosis.
Please cite this article in press as: Miura K et al. Three-dimensional gait analysis reveals dynamic alignment change in a patient with dropped head syndrome: A case report. J Clin Neurosci (2017), https://doi.org/10.1016/j.jocn.2017.10.075
Case report / Journal of Clinical Neuroscience xxx (2017) xxx–xxx
3
Fig. 2. Dynamic sagittal vertical axis (SVA) from the Vicon MX system: cervical, thoracic, lumber, and whole spine SVA.
and determining the optimal degree of surgical correction, although further investigation in various kinds of patients is needed to confirm this. 4. Conclusion By introducing 3D gait analysis, we could evaluate dynamic spinal alignment of a patient with DHS. Conflicts of interest/disclosures This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
[2] Zenmyo M, Abematsu M, Yamamoto T, Ishidou Y, Komiya S, Ijiri K. Dropped head syndrome due to myogenic atrophy –- a case report of surgical treatment. Diagn Pathol 2011;6:9. https://doi.org/10.1186/1746-1596-6-9. [3] Nakanishi K, Taneda M, Sumii T, Yabuuchi T, Iwakura N. Cervical myelopathy caused by dropped head syndrome. Case report and review of the literature. J Neurosurg Spine 2007;6:165–8. [4] Eguchi Y, Toyoguchi T, Koda M, Suzuki M, Yamanaka H, Tamai H, et al. The influence of sarcopenia in dropped head syndrome in older women. Scoliosis Spinal Disord 2017;12:5. https://doi.org/10.1186/s13013-017-0110-6. [5] Koda M, Furuya T, Inada T, Kamiya K, Ota M, Maki S, et al. Resolution of low back symptoms after corrective surgery for dropped-head syndrome: a report of two cases. BMC Res Notes 2015;8:545. https://doi.org/10.1186/s13104-015-1430-3. [6] Syczewska M, Graff K, Kalinowska M, Szczerbik E, Domaniecki J. Influence of the structural deformity of the spine on the gait pathology in scoliotic patients. Gait Posture 2012;35:209–13. [7] Kramers-De Quervain IA, Müller R, Stacoff A, Grob D, Stüssi E. Gait analysis in patients with idiopathic scoliosis. Eur Spine J 2004;13:449–56.
References [1] Sharan AD, Kaye D, Charles Malveaux WM, Riew KD. Dropped head syndrome: etiology and management. J Am Acad Orthop Surg 2012;20:766–74.
Please cite this article in press as: Miura K et al. Three-dimensional gait analysis reveals dynamic alignment change in a patient with dropped head syndrome: A case report. J Clin Neurosci (2017), https://doi.org/10.1016/j.jocn.2017.10.075
Contents lists available at ScienceDirect
Journal of Clinical Neuroscience journal homepage: www.elsevier.com/locate/jocn
Case report
Three-dimensional gait analysis reveals dynamic alignment change in a patient with dropped head syndrome: A case report Kousei Miura a,⇑, Hideki Kadone b, Masao Koda a, Hiroshi Kumagai a, Katsuya Nagashima a, Kengo Fujii a, Hiroshi Noguchi a, Toru Funayama a, Tetsuya Abe a, Takeo Furuya c, Masashi Yamazaki a a b c
Department of Orthopaedic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki 305-8575, Japan Center for Innovative Medicine and Engineering, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, Japan Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba 260-8677, Japan
a r t i c l e
i n f o
Article history: Received 12 June 2017 Accepted 23 October 2017 Available online xxxx Keywords: Three-dimensional gait analysis Electromyography Dropped head syndrome Dynamic spinal alignment Cervical sagittal imbalance
a b s t r a c t Dropped head syndrome (DHS) is a cervical kyphotic deformity caused by apparent weakness of the neck extensor muscles. We often encounter patients whose symptoms, including impaired forward vision and neck pain, deteriorate while walking. This is the first report of a case of dynamic spinal alignment change in a patient with DHS during walking using three-dimensional gait analysis. A 78-year-old Japanese woman complained of impaired forward vision and neck pain while walking. Her radiograph showed severe cervical kyphosis. C2–C7 SVA was +74 mm and C7–S1 SVA was 18.4 mm. The patient attempted to compensate to improve forward vision through lumbar hyperlordosis. We analyzed the gait motion of the patient by using three-dimensional (3D) motion and wireless surface electromyographic analysis systems to measure two systems synchronously. The patient walked continuously for as long as possible. We calculated dynamic SVA from the 3D motion analysis. Her head drop deformity gradually progressed and interfered with her forward vision while walking. Cervical SVA gradually increased from 75 to 85 mm. Thoracic SVA, Lumbar SVA and Whole spine SVA were initially decreased because of compensatory lumbar hyperlordosis, but ultimately increased, suggesting decompensation by the time she had finished walking. EMG activity of the bilateral trapezius muscles gradually reduced, which reflected the disturbance of maintaining her posture. Previous static evaluation could not prove the dynamic change of spinal alignment and EMG activity during walking. By introducing 3D gait analysis, we could evaluate dynamic spinal alignment of a patient with DHS. Ó 2017 Elsevier Ltd. All rights reserved.
1. Background Dropped head syndrome (DHS) is a cervical kyphotic deformity caused by apparent weakness of the neck extensor muscles and often results in passively correctable chin-on-chest deformity. Patients suffer from impaired forward vision and neck pain. DHS occurs in a variety of disease backgrounds [1–5]. However, the pathology of DHS remains unclear. We developed a new system for three-dimensional (3D) gait analysis to evaluate dynamic spinal alignment. To our knowledge, ⇑ Corresponding author. E-mail addresses: [email protected] (K. Miura), [email protected] (H. Kadone), [email protected] (M. Koda), [email protected] (H. Kumagai), [email protected] (K. Nagashima), [email protected] (K. Fujii), [email protected] (H. Noguchi), [email protected] (T. Funayama), [email protected] (T. Abe), [email protected] (T. Furuya), [email protected] (M. Yamazaki).
this is the first case report of dynamic spinal alignment change in a patient with DHS using 3D gait analysis.
2. Case presentation A 78-year-old Japanese woman complained of impaired forward vision and neck pain while walking. A whole spine lateral radiograph of the patient in a standing position showed severe cervical kyphosis. C2–C7 sagittal vertical axis (SVA), which was measured as the distance between the perpendicular line from the center of the C2 vertebral body and posterosuperior corner of the C7 vertebra, was +74 mm; and C7–S1 SVA, which was measured as the distance between the perpendicular line from the center of the C7 vertebral body and posterosuperior corner of sacrum, was 18.4 mm. C2–C7 angle was 43.5°, T1 slope was 58°, thoracic kyphosis was 41.9°, lumbar lordosis was 52°, pelvic incidence was 56°, and pelvic tilt was 32°. Those radiographic parameters
https://doi.org/10.1016/j.jocn.2017.10.075 0967-5868/Ó 2017 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Miura K et al. Three-dimensional gait analysis reveals dynamic alignment change in a patient with dropped head syndrome: A case report. J Clin Neurosci (2017), https://doi.org/10.1016/j.jocn.2017.10.075
2
Case report / Journal of Clinical Neuroscience xxx (2017) xxx–xxx
suggested that the patient attempted to compensate to improve forward vision through lumbar hyperlordosis. Three-dimensional motion analysis was performed using an VICON MX system (Vicon, Oxford, UK), which consisted of 16 cameras set in and 38 reflective markers attached on her head, spine, pelvis, and upper and lower limbs, including seventeen markers attached to her spinous processes. Wireless surface electromyogram analyses were performed using a Delsys Tringo Lab System (Delsys, Boston, MA, USA), which consisted of 12 EMG sensors attached to her bilateral muscles including the sternocleidomastoid, trapezius, latissimus dorsi, erector spinae, abdominal rectus, and quadriceps. Three-dimensional motion analysis and EMG analysis were interconnected to achieve synchronous measurement. The patient was asked to walk continuously for as long as possible at a comfortable pace around a rotary walkway. We calculated dynamic SVA from VICON. Obtained parameters were defined as follows: cervical SVA was the sagittal distance between reflective marker on the C2 and C7 spinous processes, thoracic SVA was the sagittal distance between reflective markers on the T1 and T12 spinous processes, lumbar SVA was sagittal distance between reflective markers on the L1 and S1 spinous processes, and whole spine SVA was defined as the sagittal distance between reflective markers on the C2 and S1 spinous processes. Her head drop deformity gradually progressed and interfered with her forward vision and ultimately showed chin-on-chest deformity while walking (Fig. 1). Cervical SVA gradually increased from 75 to 85 mm. Thoracic SVA initially decreased from 65 to 61 mm, but ultimately increased to 75 mm. Lumbar SVA initially decreased from 7.4 to 8.9 mm, but ultimately increased to 6.8 mm. Whole spine SVA initially decreased from 140 to 133 mm, but ultimately increased to 160 mm (Fig. 2). EMG activity of
the bilateral trapezius muscles gradually reduced, whereas the EMG activity of other muscles did not show significant change.
3. Discussion The present analysis found a gradual increase of the cervical kyphosis in the patient while walking and an initial decrease of thoracic kyphosis because of compensatory lumbar hyperlordosis followed by an ultimate increase of kyphosis, suggesting decompensation by the time she had finished walking. By contrast, lumbar dynamic change was only slight compared with cervical and thoracic change. Together with the results of dynamic alignment change, we speculate that EMG activity reduction of bilateral trapezius muscles reflects the disturbance of maintaining her posture. Previous static evaluation could not prove this dynamic change. Static spinal sagittal balance parameters measured by radiography are widely used as a criterion standard for diagnosis, as prognostic values, and as surrogate outcome measures after surgery. However, we often encounter patients whose symptoms deteriorate while walking. This phenomenon suggests that static evaluation alone might be insufficient for understanding the pathology of DHS. Thus, we performed 3D gait analysis, which enabled us to analyze the dynamic change of spinal alignment at least in the present case. Previous studies have used 3D gait analysis for patients with idiopathic scoliosis [6,7]. However, to our knowledge, no investigators have reported 3D gait analysis of patients with DHS. In light of the limitations of static measures, we recommend considering dynamic change of spinal alignment to evaluate patients with DHS. Our 3D gait motion analysis system shows potential utility for understanding the pathophysiology of DHS
Fig. 1. (a) Lateral plain radiograph of the whole spine showing severe cervical kyphosis. (b) Lateral posture on standing. (c) Lateral posture during gait analysis immediately after start. (d) Lateral posture during gait analysis just before the patient finished walking showing progression of cervical kyphosis.
Please cite this article in press as: Miura K et al. Three-dimensional gait analysis reveals dynamic alignment change in a patient with dropped head syndrome: A case report. J Clin Neurosci (2017), https://doi.org/10.1016/j.jocn.2017.10.075
Case report / Journal of Clinical Neuroscience xxx (2017) xxx–xxx
3
Fig. 2. Dynamic sagittal vertical axis (SVA) from the Vicon MX system: cervical, thoracic, lumber, and whole spine SVA.
and determining the optimal degree of surgical correction, although further investigation in various kinds of patients is needed to confirm this. 4. Conclusion By introducing 3D gait analysis, we could evaluate dynamic spinal alignment of a patient with DHS. Conflicts of interest/disclosures This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
[2] Zenmyo M, Abematsu M, Yamamoto T, Ishidou Y, Komiya S, Ijiri K. Dropped head syndrome due to myogenic atrophy –- a case report of surgical treatment. Diagn Pathol 2011;6:9. https://doi.org/10.1186/1746-1596-6-9. [3] Nakanishi K, Taneda M, Sumii T, Yabuuchi T, Iwakura N. Cervical myelopathy caused by dropped head syndrome. Case report and review of the literature. J Neurosurg Spine 2007;6:165–8. [4] Eguchi Y, Toyoguchi T, Koda M, Suzuki M, Yamanaka H, Tamai H, et al. The influence of sarcopenia in dropped head syndrome in older women. Scoliosis Spinal Disord 2017;12:5. https://doi.org/10.1186/s13013-017-0110-6. [5] Koda M, Furuya T, Inada T, Kamiya K, Ota M, Maki S, et al. Resolution of low back symptoms after corrective surgery for dropped-head syndrome: a report of two cases. BMC Res Notes 2015;8:545. https://doi.org/10.1186/s13104-015-1430-3. [6] Syczewska M, Graff K, Kalinowska M, Szczerbik E, Domaniecki J. Influence of the structural deformity of the spine on the gait pathology in scoliotic patients. Gait Posture 2012;35:209–13. [7] Kramers-De Quervain IA, Müller R, Stacoff A, Grob D, Stüssi E. Gait analysis in patients with idiopathic scoliosis. Eur Spine J 2004;13:449–56.
References [1] Sharan AD, Kaye D, Charles Malveaux WM, Riew KD. Dropped head syndrome: etiology and management. J Am Acad Orthop Surg 2012;20:766–74.
Please cite this article in press as: Miura K et al. Three-dimensional gait analysis reveals dynamic alignment change in a patient with dropped head syndrome: A case report. J Clin Neurosci (2017), https://doi.org/10.1016/j.jocn.2017.10.075