1. LONGUS COLLI TENDONITIS: CLINICAL – RADIOLOGICAL CORRELATION IN RESORPTIVE PHASE
ASNR Annual Meeting 2015, Poster #: EE-10
Authors: S Mathur1, P Howard1, K Higgins2, P Jabehdar Maralani1
Institutional Affiliation : 1Division of Neuroradiology, Department of Medical Imaging, 2Department of Otolaryngology
Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON

2. DISCLOSURE INFORMATION
Authors have no financial relationships to disclose.
Authors will not discuss off label use and / or investigational use in this presentation.

3. PURPOSE
Awareness of typical clinical and imaging features of longus colli tendonitis can lead to timely and accurate diagnosis and appropriate management.
Our case demonstrates the imaging findings in the symptomatic resorptive phase of this condition with clinical correlation.

4. MATERIAL & METHODS (Case History)
44-year-old male
Presented with 1 day history of progressive neck pain, painful neck & jaw movements, odynophagia, hot potato voice
No history of trauma
Recent history of substance abuse
Past Medical History: Left submandibular space infection requiring incision & drainage 20 years ago

5. Examination Findings :
Painful neck and jaw movements
Several white small pustules on the soft palate, uvula and base of tongue which were concerning for infection
No fever / palpable neck mass / cervical adenopathy
Lab Investigations:
White blood cell (WBC) count : borderline high (11.2 x109/L)
Erythrocyte Sedimentation Rate (ESR) : High (38 mm/hr)
C-reactive protein (CRP) : High (208 mg/L)

6. Imaging findings: Lateral neck radiograph demonstrated prevertebral soft tissue widening and calcific density anterior to C1-2 vertebrae. Subsequent CT study confirmed the prevertebral effusion and calcific focus anterior to C1-2 with no abnormal enhancement.

7. drugs (NSAIDs) were started. The symptoms resolved over 5 days.
ON PRESENTATION
Based on the clinical, imaging and lab findings, a diagnosis of longus colli tendonitis was made and nonsteroidal anti-inflammatory
drugs (NSAIDs) were started. The symptoms resolved over 5 days. C5
C1-2
THREE DAYS LATER
CT study after 3 days of presentation demonstrated marked resolution of prevertebral effusion and significant resorption of tendinous calcification. C5
C1-2

8. DISCUSSION LONGUS COLLI TENDONITIS
(calcific prevertebral tendonitis / calcific retropharyngeal tendonitis / longus colli myositis)
Calcium hydroxyapatite deposition occurs at the superomedial insertion of the superior oblique portion of the longus colli muscle at the anterior tubercle of the atlas.
Etiology is not clear; repetitive trauma, tissue necrosis, inflammation, or ischemia may play a role. Genetic and metabolic factors have also been postulated.
Longus colli tendonitis is similar in histopathologic, clinical and radiological presentation to calcific tendonitis in other locations. Four stages of calcific tendonitis have been described and the third resorptive stage is usually symptomatic.

9. PRECALCIFIC / FORMATIVE STAGE
NORMAL TENDON
PRECALCIFIC / FORMATIVE STAGE
CALCIFIC STAGE
RESORPTIVE STAGE
POST CALCIFIC / REPARATIVE STAGE
(Fibroblasts restore the
normal tendon collagen pattern)
STAGES OF
CALCIFIC TENDONITIS
(SYMPTOMATIC PHASE: Increased vascularity at periphery,
phagocytic activity
of macrophages
and multinuclear giant cells, resorption of the calcium, associated inflammatory response)
(Fibrocartilaginous metaplasia, calcium hydroxyapatite crystal deposition, enlargement of calcification)
(Calcific deposit enters a resting period)

10. Clinical features of longus colli tendonitis :
No gender predilection. Wide age range (20-80 yrs).
Acute to subacute onset (usually 2-7 days history), possibly triggered by preceeding minor head and neck trauma
Neck pain and rigiditiy (due to involvement of longus colli muscle)
Odynophagia (effect on pharyngeal constrictors)
Less commonly ,
Torticollis (spasm of longus colli)
Choking sensation (prevertebral collection causing airway compromise)
Occipital headache (irritation of greater occipital nerve)
Mild fever, leukocytosis, elevation of the ESR & CRP (inflammatory response)
Usually treated with NSAIDs; occasionally immbolization with neck collar, steroids. Typically, resolution within 1-2 weeks of symptom onset. Recurrence possible (9months to 20 years).
Retropharyngeal abscess is a strong clinical mimic where antibiotics and incision & drainage is the standard care. CT/MRI is crucial to differentiate these two entities.

11. Imaging features of longus colli tendonitis :
Key features:
Tendinous calcifications within the longus colli, typically at C1-2, fluffy and amorphous.
Retropharyngeal fluid with no peripheral enhancement
Absence of retropharyngeal lymphadenopathy
Absence of bony destructive change to adjacent vertebra
Different patterns may arise from different resorption rates :
Simultaneous resolution of the calcification and prevertebral effusion.
Resorption of the calcification with persistence of effusion.
Persistence of the calcification but resorption of effusion.
CT is the imaging modality of choice and MRI is usually not necessary for the diagnosis.

12. RESULTS
Our case demonstrates typical imaging features of longus colli tendonitis on patient presentation with rapid change (within three days) in the tendinous calcification and prevertebral effusion.
There was significant resorption of tendinous calcification on sequential CT images over a span of just three days in our case. This provided a good imaging correlate to the rapid resolution of symptoms of the patient. It also supports the hypothesis that clinical syndrome in calcific tendinitis is associated with resorptive phase.

13. CONCLUSION
The clinical symptoms of longus colli tendonitis including acute neck pain and range-of-motion limitation and imaging findings including prevertebral effusion and calcification anterior to C1-2 are usually seen in the resorptive phase of this disease as seen in our case. Knowledge of these clinical and imaging features is essential to prevent delay in diagnosis and misdirected therapy.

14. REFERENCES:
Paik NC, Lim CS, Jang HS. Tendinitis of longus colli: computed tomography, magnetic resonance imaging, and clinical spectra of 9 cases. J Comput Assist Tomogr 2012 : 36(6) :
Eastwood JD, Hudgins PA, Malone D. Retropharyngeal effusion in acute calcific prevertebral tendinitis: diagnosis with CT and MR imaging. Am J Neuroradiol 1998 : 19 (9) :
Olivia F, Via AG, Maffulli N. Physiopathology of intratendinous calcific deposits. BMC Med : 10 : 95
Jiménez S, Millán JM. Calcific retropharyngeal tendinitis: a frequently missed diagnosis. J Neurosurg Spine 2007: 6:77–80
Artenian DJ, Lipman JK, Scidmore GK, et al. Acute neck pain due to tendonitis of the longus colli: CT and MRI findings. Neuroradiology 1989 : 31:
Hoang JK, Branstetter BF 4th, Eastwood JD, et al. Multiplanar CT and MRI of collections in the retropharyngeal space: is it an abscess? AJR Am J Roentgenol. 2011;196:
Offiah CE, Hall E. Acute calcific tendinitis of the longus colli muscle: spectrum of CT appearances and anatomical correlation. Br J Radiol. 2009;82:

15. THANKS