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Acute Calcific Prevertebral Tendinitis
The tendons of the longus colli, longus capitis, anterior rectus capitis, and rectus muscles lie in the anterior cervical space and are prone to the development of tendinitis.
Tendinitis of these muscles is usually caused either by repetitive trauma to the musculotendinous apparatus or by the deposition of calcium hydroxyapatite crystals. This crystal deposition usually occurs in the superior fibers of the musculotendinous apparatus and is easily identified on a lateral plain radiograph of the neck.
The onset of calcific prevertebral tendinitis is generally acute, and it is often misdiagnosed as acute pharyngitis or retropharyngeal abscess because the acute onset of retropharyngeal pain is frequently accompanied by a mild elevation in temperature and leukocytosis.
The longus colli muscle is most often affected. Calcific prevertebral tendinitis is most often seen in the third to sixth decades of life.
What are the Symptoms of Acute Calcific Prevertebral Tendinitis
The pain of calcific prevertebral tendinitis is constant and severe and is localized to the retropharyngeal area. It is made worse by swallowing.
The patient may complain of acute anterior neck pain in addition to the pain on swallowing. Referred pain from the inflamed muscles into the anterior and posterior neck often occurs. A mild fever is often present, as is mild leukocytosis.
Intraoral palpation of the superior attachment of the muscles usually reproduces the symptoms. Thickening of the affected muscles may also be appreciated.
How is Acute Calcific Prevertebral Tendinitis diagnosed?
Plain radiographs are indicated for all patients who present with retropharyngeal pain. Characteristic amorphous calcification of the superior attachment of the musculotendinous unit just below the anterior arch of atlas is highly suggestive of calcific prevertebral tendinitis.
Computed tomographic scanning, magnetic resonance imaging, and/or ultrasound imaging may further delineate the problem.
The finding of a smooth, linear prevertebral fluid collection is considered pathognomonic for this disease. Unlike in a retropharyngeal or prevertebral abscess, the wall of the fluid-containing structure does not enhance with contrast administration.
Additional testing may be indicated, including a complete blood count, erythrocyte sedimentation rate, and complete blood chemistry tests, in patients suspected of suffering from calcific prevertebral tendinitis.
Differential Diagnosis
Acute calcific prevertebral tendinitis is often misdiagnosed as acute pharyngitis or retropharyngeal abscess. Occasionally, the patient is diagnosed with an early peritonsillar abscess.
This delay in diagnosis can often subject the patient to unnecessary antibiotic therapy and occasionally surgical drainage of the suspected “abscess.” In some clinical situations, consideration should be given to primary or secondary tumors involving this anatomical region.
Treatment
Initial treatment of the pain and functional disability associated with acute calcific prevertebral tendinitis should include nonsteroidal antiinflammatory drugs (NSAIDs) or cyclooxygenase-2 inhibitors.
Local application of heat and cold and deep sedative massage may also be beneficial. For patients who do not respond to these treatment modalities, injection of the superior portion of the affected musculotendinous units with local anesthetic and steroid is a reasonable next step. Such injection should be considered only if the clinician is certain that no occult infection in this anatomical region exists.
Ultrasound needle guidance may simplify needle placement and avoid injury to surrounding structures, including the thyroid gland, carotid artery, jugular vein, and exiting cervical nerve roots.
Complications
The main pitfalls in the treatment of longus colli tendinitis are failure to diagnose this painful condition in a timely manner and mistaking it for a disease requiring more intensive treatment (e.g., retropharyngeal abscess or peritonsillar abscess).
Rapid institution of treatment with NSAIDs and reassurance is often all that is required. For more recalcitrant cases, injection with local anesthetic and steroid almost always results in prompt resolution of symptoms. Use of this injection technique is safe if careful attention is paid to the clinically relevant anatomy. Sterile technique must be used to avoid infection, along with universal precautions to minimize any risk to the operator.
The incidence of ecchymosis and hematoma formation can be decreased if pressure is applied to the injection site immediately after injection. Trauma to the tendon from the injection itself is also a possibility. Tendons that are highly inflamed or previously damaged are subject to rupture if they are injected directly. This complication can often be avoided if the clinician uses a gentle technique and stops injecting immediately on encountering significant resistance. Approximately 25% of patients complain of a transient increase in pain after injection, and patients should be warned of this possibility.
Clinical Pearls
The musculotendinous unit of the muscles are susceptible to the development of tendinitis. Also known as crowned dens syndrome and retropharyngeal calcific tendinitis, calcific prevertebral tendinitis is often misdiagnosed as retropharyngeal abscess.
Calcium hydroxyapatite deposition around the tendon may occur, thus making subsequent treatment more difficult. NSAIDs usually provide excellent palliation of the patient’s pain. If they do not, properly performed injection of the affected inflamed musculotendinous units with local anesthetic and steroid is a reasonable next step.
