Presentation

A 50-year-old female with a 5-year history of well-controlled seropositive rheumatoid arthritis on methotrexate 15 mg weekly presented to the emergency department with a 3-day history of right-sided retropharyngeal and neck “knifelike” pain when swallowing. Labs including a complete blood count and inflammatory markers were unremarkable. She underwent a computed tomography (CT) scan of the neck (Fig. 1A, C) showing a prevertebral fluid collection from C1 to C6 with calcification just anterior to the dens and inferior to the anterior ring of C1, corresponding to the proximal longus colli tendon insertion. Due to concern for an abscess, the patient underwent a magnetic resonance imaging (MRI) scan (Fig. 1B) showing significant prevertebral edema in the right longus colli and longus capitis muscles. She responded within 24 hours to 10 mg dexamethasone and was discharged on a 10-day prednisone taper with complete resolution and without recurrence.

Fig. 1
figure 1

A Sagittal CT image demonstrating a prevertebral fluid collection seen from C1 to C6 with calcification just anterior to the dens and inferior to anterior ring of C1 corresponding to the proximal longus colli tendon insertion and along the longus colli tendon. B Sagittal MRI image demonstrating diffuse prevertebral edema in the longus colli and longus capitis muscles. C Axial, coronal, and sagittal CT images showing calcification anterior to the odontoid process

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Discussion

Acute longus colli calcific tendinitis, also known as retropharyngeal calcific tendonitis, is a rare cause of neck pain that can mimic spondylodiscitis, meningitis, or retropharyngeal abscess. It is important to diagnose early to avoid unnecessary antibiotics or surgical procedures but is often missed due to being unrecognized by both radiologists and clinicians. It is thought to be related to hydroxyapatite crystal deposition along the longus colli tendon with risk factors including repetitive trauma, recent injury including the common “whiplash” injury, degenerative cervical disorders, osteoarthritis, tissue necrosis, renal failure, or vascular disease. Typically, it presents with acute severe neck pain and can be accompanied by dysphagia, odynophagia, and headache. A CT scan can establish the diagnosis with pathognomonic findings including amorphic calcifications in the longus colli muscle with retropharyngeal edema and is more specific than MRI due to its ability to detect calcifications. In general, it is a self-limited disease which will respond similarly to other aseptic inflammatory crystal disease processes with a short course of steroids showing better efficacy and quicker symptom control than oral NSAIDs [1,2,3,4].