IntroductionThe cervical spine is a crucial anatomical structure protecting neurologic elements and is fundamental in preserving horizontal gaze. Maintaining normal alignment of the cervical spine, especially in the sagittal plane, is essential for proper physiological functioning and minimizing muscle energy expenditure.(1)Cervical kyphosis is the most prevalent deformity impacting the cervical spine, disrupting its physiology and resulting in considerable disability for the affected individual. This deformity may manifest as either regional or global, and multiple studies have shown its correlation with a diminished quality of life.(2)Dropped Head Syndrome (DHS), also known as floppy head syndrome, is a rare medical disorder characterized by weakness in the neck extensor muscles against gravity. Consequently, a passively correctable chin-on-chest deformity develops.(3)DHS is most commonly associated with various neuromuscular conditions, including mitochondrial myopathy, congenital myopathy, myasthenia gravis, motor neuron disease, chronic inflammatory demyelinating polyneuropathy (CIDP), and cervical myelopathy.(4)In this study, we present an intriguing and previously undocumented case of DHS. Unlike commonly reported causes of DHS, such as neuromuscular disorders or structural abnormalities, our case diverges from these conventional etiologies. This unique presentation challenges existing paradigms and underscores the importance of further investigation into less conventional pathways leading to DHS. By thoroughly examining the patient’s medical history, clinical presentation, and diagnostic findings, we aim to contribute insights that broaden our understanding of the etiological spectrum of DHS.Case History:A 23-year-old male with a progressive cervical spine deformity and dropped head, ongoing for the past 15 months, presented to the neurosurgery outpatient clinic. The patient is experiencing chronic neck pain and upper limb paresthesia. He appears to have a slight build and exhibits a pronounced forward-bending head posture. Additionally, there is markedly restricted range of motion (ROM) in the cervical spine, with the chin nearly in contact with the sternum manubrium. He has no history of severe neck trauma or neck surgery, and the kyphosis is not passively correctible.The patient, hailing from a socioeconomically disadvantaged background, has a significant medical history of major depressive disorder and substance abuse, including addiction to heroin, opium, and amphetamines. After every episode of amphetamine use, the patient consistently maintained a fixed kyphotic neck position for extended periods, leading to a progressive alteration in his cervical alignment. Prior to this history of addiction, there was no malalignment in his neck.During physical examination, inspection and palpation of the cervical spine revealed a pronounced kyphoscoliosis deformity. Cranial nerve testing yielded normal results. Muscle strength assessment indicated a rating of 4/5 in the upper limbs and 5/5 in the lower limbs. Upper limb paresthesia was observed, with unspecified sensory level. Deep tendon reflexes (DTRs) in the upper limbs were within normal limits, while those in the lower limbs showed a slight exaggeration. Autonomic functions were normal, and there was no evidence of sphincter dysfunction. The patient had tried various traditional and herbal remedies, but none had alleviated his symptoms.As described above, due to the severe deformity of the neck, he was admitted to our department at Al-Zahra hospital in Isfahan city, Isfahan, Iran (figure 1).The cervical CT scan revealed a severe kyphoscoliosis deformity affecting C3, C4, and C5, accompanied by degenerative joint disease (DJD) changes in the anterior aspect of these vertebrae. No evidence of canal stenosis or fractures was observed. Subsequent MRI confirmed cervical kyphoscoliosis with unremarkable cervical cord features. Following comprehensive clinical and radiological assessment and considering the severity of the cervical spine deformity, a decision was made to proceed with a three-stage surgical intervention during a single anesthesia session.