A 37 year old man presents to the emergency room with an 8 day history of low grade fevers, neck stiffness, and odynophagia. His medical history is otherwise unremarkable. Physical examination reveals an uncomfortable appearing young man who holds his head in semi-flexion; there is decreased cervical range of motion upon flexion and extension, with marked paraspinous muscle spasm. There is no spinal tenderness or meningismus. Laboratory evaluation reveals a WBC of 8.3 and an ESR of 56. An X-ray of the cervical spine is obtained.
X-Ray of the cervical spine (Film 1) reveals amorphous calcification anterior to the C1 and C2 vertebrae (yellow arrow) with marked prevertebral soft tissue swelling (red arrow). This is seen with higher magnification in Film 2. There is no evidence of fracture. A confirmatory CT scan (not shown) often reveals calcification of the longus colli tendon at its insertion site.
Diagnosis and Discussion
Correct Diagnosis: Acute Calcific Retropharyngeal Tendinitis (Longus Colli tendinitis)
Acute calcific retropharyngeal tendinitis, caused by hydroxyapatite crystal deposition in the tendinous insertion of the longus colli muscle, is an often unrecognized cause of acute to subacute neck pain. It typically occurs in the 3rd through 6th decades of life, and usually presents as the triad of neck pain, odynophagia, and fevers. Laboratory evaluation often reveals a low-grade leukocytosis and an elevated sedimentation rate, raising the specter of more ominous diagnoses such as retropharyngeal abscess and malignancy. The diagnosis is readily made radiographically, with characteristic prevertebral calcifications and soft tissue swelling. The diagnosis can be confirmed by CT scan in cases where retropharyngeal tendinitis is strongly considered and cacifications are not obvious on the plain films. Accessory ossicles are fairly common just inferior to the anterior arch of C1, and can have a similar appearance on plain films. However, they are not associated with the soft tissue swelling and neck pain characteristic of tendinitis.
Treatment is usually conservative; most cases are self-limiting and resolve within several weeks of the onset of symptoms. A short trial of NSAIDs such as Indomethacin, Ibuprofen, or Naproxen is usually sufficient, however some patients may require a short course of corticosteroids if the symptoms are severe.
- Ring D, Vaccaro AR, Scuderi G, Pathria MN, Garfin SR. Acute calcific retropharyngeal tendinitis. Clinical presentation and pathological characterization. Bone Joint Surg Am 76(11):1636-42, 1994.
- Artenian DJ, Lipman JK, Scidmore GK, Brant-Zawadzki M. Acute neck pain due to tendonitis of the longus colli: CT and MRI findings. Neuroradiology 31(2):166-9, 1989.