Prevertebral soft tissue swelling on MRI, now what?

1 Mar

RAGING HYPOTHETCAL:

Your next patient is a 62 year old female without significant past medical history with 2 weeks of neck pain, progressively worsening over past 5 days.

Denies trauma, recent infections, dental problems, or surgeries.

Reports pain worse with movements and swallowing and not relieved with Tylenol.

Afebrile, well appearing, normal vital signs, decreased range of motion of neck in all directions. Normal ENT exam; Normal Neuro exam; no loss of bladder/bowel function.

worst case neck badness DDx: osteomyelitis, spinal/epidural abscess, retropharyngeal abscess, spinal stenosis, etc.

So someone orders an MRI: “Prevertebral soft tissue swelling from C2 through C6 levels. The findings could be due to infectious etiology.”  

But no abscess/surgical lesion on the MRI.  hmmmm…..

 

Now what?

XR C-Spine: Upper cervical prevertebral soft tissue swelling associated with amorphous calcification anterior to C2 vertebral body

Boom! Acute Calcific Tendinitis

Prevertebral acute calcific tendinitis was originally described in 1964 by Hartley and subsequently shown to be due to hydroxyapatite deposition by Ring and colleagues in 1994. Longus colli are bilateral neck flexors which make up bulk of prevertebral space along with longus capitus. Divided from retropharyngeal space, composed of fatty tissue and lymph nodes, by middle layer of deep cervical fascia.

Retropharyngeal space is prone to infections in children, immunocompromised, and patients with penetrating neck injuries.  Causes of acute calcific tendinitis are still unclear.

Importance: Aggressive management, often involving surgery and long-term antibiotics, of retropharyngeal and spinal abscesses is required as they still carry significant morbidity and mortality.

XR as compared to MRI can help differentiate acute calcific tendinitis (due to the calcium deposition) from other inflammatory processes.

Criteria for diagnosing prevertebral acute calcific tendinitis is as follows:

  • Fluid smoothly expands retropharyngeal space in all directions
  • Absence of enhancing wall around fluid
  • Absence of purative retropharyngeal space lymph nodes with low-attenuation centers
  • Pathognomonic tendinous calcifications within the longus colli

Submitted by K. Dabrowski.

References: Eastwood JD, Hudgins PA, Malone D. Retropharyngeal effusion in acute calcific prevertebral tendonitis: Diagnosis with CT and MR imaging. AJNR Am J Neuroradiol. 1998;19:1789-1792.; picture

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