Download Acute calcific tendinitis of the longus colli: an imaging diagnosis

Dentomaxillofacial Radiology (2008) 37, 121–124
’ 2008 The British Institute of Radiology
http://dmfr.birjournals.org
CASE REPORT
Acute calcific tendinitis of the longus colli: an imaging diagnosis
SK Ellika1, SC Payne2, SC Patel1 and R Jain*,1
1
Division of Neuroradiology, Department of Radiology, Henry Ford Hospital, Detroit, MI, USA; 2Department of Otolaryngology,
Henry Ford Hospital, Detroit, MI, USA
Acute calcific retropharyngeal tendinitis or longus colli tendinitis is an uncommon benign
condition presenting as acute neck pain. Clinically, it can be misdiagnosed as retropharyngeal
abscess, traumatic injury, or infectious spondylitis. The diagnosis is made radiographically by
calcification anterior to C1–C2 and prevertebral soft-tissue swelling. We present two cases of
this uncommon condition to illustrate the classic findings on CT and MRI. In addition to the
typical calcifications anterior to C1–C2, we detected a retropharyngeal effusion in both
patients and effusions involving both lateral atlantoaxial joints in one patient, which to our
knowledge has not been published in the literature. In both patients, the correct diagnosis
was established by prospective review of the radiographic studies. Recognition of the
pathognomonic imaging appearance allows for easy diagnosis preventing unnecessary tests
and treatment.
Dentomaxillofacial Radiology (2008) 37, 121–124. doi: 10.1259/dmfr/23211511
Keywords: calcific tendinitis; longus colli; retropharyngeal effusion; computed tomography;
magnetic resonance imaging
Introduction
Case reports
Acute calcific tendinitis of the longus colli muscle is an
inflammatory condition caused by deposition of
calcium hydroxyapatite crystals in the superior oblique
tendon of the longus colli muscle. It is an uncommon
cause of pain and stiffness in the neck associated with
odynophagia and retropharyngeal soft tissue swelling.
Imaging findings and clinical presentation should both
be used in differentiating acute calcific longus colli
tendinitis (LCT) from retropharyngeal abscess, infectious or inflammatory spondylitis, traumatic injury, or
foreign body aspiration. Plain radiographs, CT and
MRI can help make the correct diagnosis and help
prevent extensive work-up and surgical exploration. We
present here two cases in which an imaging diagnosis of
LCT was made. One of the patients also had reactive
effusion of the lateral atlantoaxial joints, which has not
been previously described in the literature.
Case 1
A 35-year-old man presented to an affiliated emergency
department with a 3 day history of neck pain that was
described as dull in nature and exacerbated by neck
movements. Recent onset of sore throat and odynophagia was also reported. No history of recent trauma,
diabetes or other medical history was elicited except that
he was a fork-lift operator and his work involved
repeated flexion and extension of the neck. Cervical
spine radiographs were obtained, revealing increased
thickness of the prevertebral soft tissues. The patient was
transferred to our institution with the possible diagnosis
of retropharyngeal abscess to be evaluated by crosssectional imaging. His temperature was 37.2˚C and other
vital signs were normal. On examination, he had limited
neck motion with tenderness but no lymphadenopathy.
Palatine tonsillar hypertrophy and mild pharyngeal
crowding with no overt oedema or erythema was noted
on oral examination. The white blood cell count (WBC)
was mildly elevated to 12 000 mm23 with no increase in
neutrophil or band counts. A contrast-enhanced CT scan
of the neck was obtained, which demonstrated prevertebral space oedema and effusion without obvious
abscess formation or rim enhancement. Amorphous
*Correspondence to: Rajan Jain, Senior Staff, Department of Radiology,
Division of Neuroradiology, Henry Ford Health Systems, 2799 West Grand
Blvd, Detroit 48202, MI, USA; Email: [email protected]
Received 23 February 2007; revised 11 April 2007; accepted 11 April 2007
Acute calcific tendinitis of the longus colli
SK Ellika et al
122
calcification was noted at the insertion of the superior
oblique tendon of the longus colli muscles anterior to the
anterior arch of C1. There were no imaging findings to
suggest infectious spondylitis or discitis osteomyelitis. A
diagnosis of acute calcific LCT was made and the patient
was discharged on non-steroidal anti-inflammatory
medication. His symptoms resolved completely in 3 days.
Case 2
A 41-year-old woman with a 2 day history of neck
stiffness, headache and dysphagia presented to the
emergency department. A past history of trauma,
diabetes or recent upper respiratory tract infection
was negative. On arrival her temperature was 37.4 ˚C
and she had a mildly elevated WBC of 11 600 mm23
with a differential count showing a very minimal
increase in neutrophil count. Endoscopic examination
was negative for erythema or exudate, but mild
symmetric oedema of the posterior pharyngeal wall
was noted. Lateral neck radiograph revealed prevertebral soft tissue swelling and a contrast-enhanced the CT
scan of the neck was performed. A fluid collection
smoothly expanding the retropharyngeal space without
rim enhancement extending from the C1 to C5 levels
was noted. Calcification was seen within the superior
oblique tendon of longus colli anterior to the C1 arch
(Figure 1). She had had another CT of the cervical
spine performed 2 years prior to the present event for
an unrelated motor vehicle accident and review of the
previous CT did not show any calcification at the
insertion of the superior oblique tendon of longus colli,
suggesting interval deposition of calcium hydroxyapatite crystals. Sagittal T2 weighted fast-spin echo MR
images (repetition time 3500/echo time 124) showed an
area of high signal intensity extending from the skull
base to the inferior border of C5 suggestive of
prevertebral oedema/effusion (Figure 2). T2 weighted
images also demonstrated joint effusion involving the
Figure 1 Axial CT scan showing dense calcification (long arrow)
within the superior oblique tendon of the left longus colli muscle at
the C1–C2 level; calcific deposits are also noted around the left side of
the odontoid process (short arrow)
Dentomaxillofacial Radiology
Figure 2 Sagittal T2 weighted MR image showing retropharyngeal
fluid (long arrows) with acute inferior margin (curved arrow)
extending from the skull base to the inferior border of C5 and
hypointense calcifications in the longus colli tendon (short arrow)
lateral atlantoaxial joints bilaterally in addition to
oedema of the longus colli muscle (Figure 3). The
calcification exhibited hypointense signal intensity on
the T2 weighted sequences (Figure 4). No enhancement
of prevertebral soft tissues or disc space was noted on
the post-contrast scans to suggest an infectious
spondylitis. She showed significant clinical improvement after 1 week of therapy with oral administration
of non-steroidal anti-inflammatory agents.
Discussion
The prevertebral space is limited anteriorly by the deep
layer of deep cervical fascia, which separates it from the
retropharyngeal space containing fat and lymph nodes.
Figure 3 T2 weighted axial MR image at the level of the atlantoaxial
joints shows bilateral joint effusions (long arrows) with the enlarged
and oedematous tendon of the left longus colli muscle noted anterior
to the body of the C2 vertebra (short arrow)
Acute calcific tendinitis of the longus colli
SK Ellika et al
Figure 4 T2 weighted axial MR image showing swelling and oedema
of the left longus colli muscle (long arrow) with hypointense
calcifications (short arrow)
The longus colli muscle is a paired neck muscle that
originates from the bodies of the C3–C7 and T1–T3
vertebrae, and inserts along bodies of the C2–C4 and
anterior tubercles of C1–C6 vertebrae. The muscle is
formed by vertical, inferior oblique and superior
oblique portions. The superior oblique portion, which
arises from the anterior tubercles of the transverse
processes of C3–C5 and inserts into the anterior
tubercle of the atlas, is the one that becomes involved
in acute LCT.1,2 LCT is a clinical syndrome that was
originally described by Hartley in 19643 and usually
affects patients who are mostly between 30 years and
60 years of age with no gender predilection.4 Ring et al
in 19945 showed this condition to be due to calcium
hydroxyapatite deposition in the longus colli tendon
and a foreign-body inflammatory response to the
crystals was demonstrated in the tissue specimen taken
from the prevertebral space.5 The most frequent
presentation is neck pain, neck rigidity, dysphagia,
odynophagia and headache. In some cases, there may
be a low-grade fever perhaps secondary to an inflammatory response. Laboratory data are usually normal,
but inflammatory changes may be observed with
elevated erythrocyte sedimentation rates and mildly
elevated white blood cell counts.6 Clinical presentation
can be confused with retropharyngeal abscess, infectious spondylitis, trauma, or foreign body aspiration;
however, awareness of acute LCT, particularly in the
emergency rooms, can be helpful. Cross-sectional
imaging with CT or MRI can be diagnostic in the
appropriate clinical setting. The pathognomonic radiographic findings consist of prevertebral soft tissue
swelling typically extending from C1 to C4 and
amorphous calcification anterior to C1–C2 at the
insertion of the superior oblique tendon of the
longus colli muscle.2,3,5,6–10 The appearance of
the calcification varies from punctate to densely
amorphous. The greater contrast resolution of CT
makes it a more sensitive technique than plain
123
radiography for the detection and localization of
calcification to the superior oblique fibres of the longus
colli muscle, thus differentiating it from other causes of
prevertebral densities such as fracture or extruded
calcified disc.2,11
MRI, which is a superior imaging technique for the
demonstration of soft tissue changes, may show
oedema of the longus colli tendon and muscle along
with retropharyngeal effusion and these are probably
secondary to local inflammatory mediators.12 T2
weighted MR images may demonstrate a prevertebral
high signal intensity which tends to extend beyond the
region of calcification, suggestive of oedema and
inflammatory changes of the muscle.13 On cursory
inspection, an effusion if present may be confused with
retropharyngeal abscess. Imaging features to distinguish this effusion from retropharyngeal abscess
include uniform expansion of the retropharyngeal space
by effusion, no peripheral enhancement around the
effusion and absence of suppurative retropharyngeal
lymphadenopathy associated with the effusion.12
CT and MRI can also help to rule out infectious
spondylitis as the cause for prevertebral space swelling.
Bone marrow signal abnormality in the adjacent C2
vertebra during an episode of longus colli tendinitis has,
however, been recently reported,14 but was found to
resolve completely on follow-up imaging suggesting an
inflammatory aetiology. These marrow signal changes
were thought to be due to direct continuity of the
periodontoidal venous plexus and the suboccipital
epidural sinuses with the pharyngovertebral veins which
may facilitate haematogenous spread of retropharyngeal
inflammation to the upper cervical vertebrae.14
Radiographic differential diagnostic considerations
include vertebral fracture, anteriorly bowed transverse
process, and calcified and protruded cervical disc. If
there is a coincidental history of recent trauma, CT can
rule out the possibility of an avulsed fracture since a
bone fragment can be easily distinguished from the
amorphous calcification associated with LCT. An
anteriorly bowed transverse process can project anterior to the vertebral body on a lateral view of the
cervical spine; however, careful evaluation of the lateral
and oblique views on the cervical spine should lead to
the correct diagnosis. CT is helpful in confirmation of
the location of the calcifications and to differentiate
them from other causes of prevertebral densities.11
One of the cases in the present study also showed
effusion in the adjacent lateral atlantoaxial joints
without any articular surface irregularity or joint
destruction, which to our knowledge has not been
described in the literature before with this entity. We
think this is probably due to contiguous spread of
prevertebral and retropharyngeal space inflammation
to the upper cervical joints causing reactive sympathetic
effusion, or could be due to intra-articular deposition of
hydroxyapatite crystals. This patient had also had a CT
scan for an unrelated reason 2 years prior to the present
event that did not show any calcification at the superior
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Acute calcific tendinitis of the longus colli
SK Ellika et al
124
oblique tendon insertion, suggesting interval deposition
of the crystals. Calcium hydroxyapatite deposition disease
(CHADD) typically involves the large joints, such as the
hip or shoulder; however, it can also be located around
the odontoid. The precise cause of CHADD is unknown.
It has been speculated that crystal deposition in and
around joints may be due to local or systemic metabolic
disturbances such as those following injury, tissue
necrosis, ischaemia, or repetitive trauma. A genetic
predisposition and metabolic factors have also been
suggested to play a role.11 These disturbances may raise
solute concentration, cause the loss of local inhibitors of
crystal growth and cause the presence of abnormal
surfaces, all of which may promote crystal nucleation.15
Symptoms of LCT usually improve spontaneously
over the course of 1–2 weeks. Conservative treatment
with a short course of non-steroidal anti-inflammatory
medications and avoidance of aggravating neck movements help to alleviate symptoms. Follow-up imaging is
usually not necessary due to the self-limiting nature of
this condition; however, if performed, this can be easily
achieved with plain films which might show resolution
of the characteristic findings of the amorphous
calcification and prevertebral soft tissue swelling.
Conclusion
The diagnosis of acute LCT can be made based on
characteristic imaging features in the appropriate
clinical setting of neck pain, rigidity, restricted movements and headache associated with odynophagia
without a history of trauma, particularly in an afebrile
patient. Lateral radiograph and CT scan of the soft
tissues of the neck may demonstrate characteristic
prevertebral calcification at the C1–C2 level. MRI can
better delineate prevertebral effusion and may also
show oedema in the muscle with calcification at the
tendinous insertion. Early diagnosis of this benign
condition is important to avoid inappropriate surgical
exploration to drain the fluid collection.
References
1. Som PM, Smoker WRK, Balboni A, Reidenberg JS, Hudgins P,
Weissman JL, et al. Embryology and anatomy of the neck. In:
Som PM, Curtin HD (eds). Head and neck imaging. St Louis,
MO: Mosby-Year Book, 2003, p 1792.
2. Artenian DJ, Lipman JK, Scidmore GK, Brant-Zawadzki M.
Acute neck pain due to tendinitis of the longus colli: CT and MRI
findings. Neuroradiology 1989; 31: 166–169.
3. Hartley J. Acute cervical pain associated with retropharyngeal
calcium deposit: A case report. J Bone Joint Surg 1964; 46-A:
1753–1754.
4. Kaplan MJ, Eavey RD. Calcific tendinitis of the longus colli
muscle. Ann Otol Rhinol Laryngol 1984; 93: 215–219.
5. Ring D, Vaccaro AR, Scuderi G, Pathria MN, Garfin SR. Acute
calcific retropharyngeal tendinitis. J Bone Joint Surg 1994; 76:
1636–1642.
6. Haun CL. Retropharyngeal tendinitis. AJR Am J Roentgenol
1978; 130: 1137–1140.
7. Newmark H 3rd, Forrester DM, Brown JC, Robinson A, Oiken
SM, Bledsoe R. Calcific tendinitis of the neck. Radiology 1978;
128: 355–358.
Dentomaxillofacial Radiology
8. Herwig SR, Gluckman JL. Acute calcific retropharyngeal
tendinitis. Arch Otolaryngol 1982; 108: 41–42.
9. Warington G, Palmer MK. Retropharyngeal tendonitis. Br J
Radiol 1983; 56: 52–54.
10. Hall FM, Docken WP, Curtis HW. Calcific tendinitis of the
longus colli: diagnosis by CT. AJR Am J Roentgenol 1986; 147:
742–743.
11. De Maeseneer M, Vreugde S, Laureys S, Sartoris DJ, De Ridder
F, Osteaux M. Calcific tendinitis of the longus colli muscle. Head
Neck 1997; 19: 545–548.
12. Eastwood JD, Hudgins PA, Malone D. Retropharyngeal effusion
in acute calcific prevertebral tendinitis: Diagnosis with CT and
MR imaging. Am J Neuroradiol 1998; 19: 1789–1792.
13. Ekbom K, Torhall J, Annell K, Traff J. Magnetic resonance imaging
in retropharyngeal tendinitis. Cephalalgia 1994; 14: 266–269.
14. Mihmanli I, Karaarslan E, Kanberoglu K. Inflammation of
vertebral bone associated with acute calcific tendinitis of the
longus colli muscle. Neuroradiology 2001; 43: 1098–1101.
15. Uri DS, Dalinka MK. Imaging of arthropathies. Crystal disease.
Radiol Clin North Am 1996; 34: 359–374.