Imaging Original Article
Imaging Case Challenge
Michelle A Wessely (1) and Timothy J Mick (2)
(1) Director of Radiology (Paris/Toulouse), Department of Radiology, Institut Franco-Europeen de Chiropratique (IFEC), 24 Boulevard Paul Vaillant Couturier, 94200 Ivry Sur Seine, France email@example.com
(2) Center for Diagnostic Imaging (CDI), and Imaging Consultants, Inc.565 Arlington Avenue West, St Paul 55117, Minnesota, USA firstname.lastname@example.org
Journal of the Academy of Chiropractic Orthopedists
March 2011, Volume 8, Issue 1
Received: March, 2011
Accepted: March, 2011
© 2011 Wessely/Mick and the Academy of Chiropractic Orthopedists. This is an Open Access article which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
A 37 year old male patient presented to the chiropractor with severe left sided suboccipital/neck pain for one week, with no report of trauma. The patient was currently on a course of antibiotics for a “severe strep infection,” diagnosed by his medical doctor. A cervical radiographic exam, to include a lateral cervical neutral view (Figure 1) was obtained by the chiropractor, who did not notice the key radiographic finding, an oval calcification inferior to the C1 anterior tubercle. On the basis of the clinical presentation, because of the severity of the pain and concern for the possibility of disc space infection or herniation, the chiropractor ordered MR imaging of the cervical spine. (Figure 2a and 2b).
Figure 1. Lateral cervical neutral radiograph showing homogeneous, ovoid calcification inferior to the C1 anterior tubercle, the classic radiographic finding of longus colli calcific tendinitis. As in this case, there is often related widening of the pre-cervical soft tissues. Also, as in this case, these radiographic findings are often overlooked.
Figure 2a. Sagittal T1-weighted image the cervical spine, demonstrating markedly low signal of the globular calcification inferior to the anterior tubercle of C1 and fullness of the adjacent pre-cervical soft tissues.
Figure 2b. Sagittal fluid –sensitive STIR image of the cervical spine shows extensive bright signal in the pre-cervical soft tissues from the sphenoid bone to C4, characteristic of soft tissue edema, in a pattern typical for longus colli calcific tendinitis. Note lack of abnormal signal extension from a disc or vertebral body, an important sign to distinguish this entity from disc space infection/osteomyelitis or soft tissue extension of neoplasm from a vertebral body.
Pertinent Imaging Findings
A fairly well circumscribed, ovoid region of low signal inferior to the C1 anterior tubercle, best seen on T1-weighted MR images, corresponds to the globular opacity seen on radiographs, typical of calcium hydroxyapatite deposition at the longus colli tendon attachment site. There is associated extensive precervical/retropharyngeal soft tissue edema from C4 to the sphenoid bone. These findings are diagnostic of acute longus colli calcific tendinitis with active inflammation involving the longus colli muscle and retropharyngeal soft tissues.
P ertinent Conclusions
Findings of acute longus colli calcific tendinitis. This condition is typically self-limiting, but with the history of strep infection, consultation with ENT may be warranted. In this case, one should question the diagnosis of “strep throat,” as longus colli calcific tendinitis may mimic other causes of pharyngitis and streptococci may be part of the normal flora, potentially producing a false positive throat culture.
Most clinicians who see patients for musculoskeletal conditions are familiar with calcific tendinitis (calcium hydroxyapatite deposition disease or HADD) involving the peripheral joint regions, such as the rotator cuff of the shoulder. Among the less common sites of calcific tendinitis or HADD is the longus colli tendon. This entity was first described in 1964 by Hartley (1) and in 1994, Ring et al, showed that the cause was that of crystal deposition (4). It is important that those who assess patients with neck pain and related complaints are familiar with longus colli calcific tendonitis, with its unique imaging and clinical findings, often overlooked or confused with other abnormalities. We present a case in a young adult male with history, clinical course and imaging findings not unlike those that are often encountered with this entity. While the literature emphasizes a relationship to hyperflexion-hyperextension injury, there is often no significant trauma. This condition is probably more common than the literature and experience might suggest, owing to under-diagnosis, which may largely relate to a lack of general awareness of the condition.
The typical patient with longus colli calcific tendonitis is between 30 and 60 years old, will present with persistent neck pain following hyperflexion-hyperextension injury, most often from motor vehicle accident or sports trauma (2, 3). There may be sense of fullness in the throat, dysphagia and/or pharyngitis, with significant muscle guarding, as was seen in this patient (4). The throat symptoms are due to the close proximity of the retropharyngeal space to the adjacent pharyngeal constrictors. Uniquely, this patient had no history of significant trauma over the past six weeks and presented to the chiropractor with neck pain for one week, having been diagnosed by his medical doctor with strep throat, for which he was on a course of antibiotics. The chiropractor did a thorough history, physical exam and radiographs, although the images were not reviewed by a radiologist. The characteristic globular calcific density inferior to the C1 anterior tubercle had not been noted on the radiographs, but this clinician with 30+ years of practice experience did not feel comfortable adjusting the patient without further imaging and, therefore, ordered MRI.
The MRI reveals the typical findings of active/acute longus colli calcific tendinitis. In addition to confirming the presence of the globular calcification inferior to the C1 anterior tubercle, the MR images show extensive pre-vertebral (retropharyngeal) edema with bright STIR signal extending from the C2-3 level, cephalically to the clivus of the skull. This finding often corresponds to a widening of the precervical soft tissues on radiographs, a non-specific finding which may also be created by hematoma, prevertebral extension of tumor, such as metastasis, lymphoma or myeloma or discitis (disc space infection) (5). Importantly, there is no evidence of focal disc space narrowing, endplate erosion or other findings to suggest that the precervical abnormality has arisen from a disc or vertebral body.
Longus colli calcific tendinitis is considered to be a self-limiting condition, much like HADD involving peripheral sites, such as the rotator cuff. The symptoms may subside some time before the calcification resorbs and in some instances, the calcification persists and may even convert to organized bone, with no ongoing related symptoms. As with other forms of calcific tendinitis, both imaging and clinical findings may recur, typically after re-injury (6).
- Hartley J: Acute cervical pain associated with retropharyngeal calcium deposit: a case report. J Bone Joint Surg Am 1964,46:1753-4.
- Chung T, Rebello R, Gooden EA: Retropharyngeal calcific tendinitis: case report and review of literature. Emerg Radiol 2005,11:375-80.
- Bladt O, Vanhoenacker R, Bevernage C, Van Orshoven M, Van Hoe L, D'Haenens P: Acute calcific prevertebral tendinitis. JBR-BTR 2008,91:158-9.
- Ring D, Vaccaro AR, Scuderi G, Pathria MN, Garfin SR: Acute calcific retropharyngeal tendinitis: clinical presentation and pathological characterization. J Bone Joint Surg Am 1994,76:1636-42.
- Razon RV, Nasir A, Wu GS, Soliman M, Trilling J: Retropharyngeal calcific tendonitis: report of two cases. J Am Board Fam Med 2009,22:84-8.
- De Maeseneer M, Vreugde S, Laureys S, Sartoris DJ, DeRidder F, Osteaux M: Calcific tendinitis of the longus colli muscle. Head Neck 1997,19:545-8.