1. Case of the Week 94: Courtesy of Christoph Gorbach, DC, MD Zürich Very elderly lady presented with severe neck pain and restricted ROM

2. Here are her laboratory results over a few day period.

3. The next 4 slides are Bone Window CT slices focusing on her upper cervical spine. What are the abnormal findings? What is the diagnosis?

4. Parasagittal slice

6. Mid sagittal slice

7. Answers Abnormal findings: Abnormal findings: Amorphous calcific deposits are present surrounding the dens. Amorphous calcific deposits are present surrounding the dens. Calcification in the C5-6 disc is present with marked narrowing of the disc space and suggested ankylosis laterally. Calcification in the C5-6 disc is present with marked narrowing of the disc space and suggested ankylosis laterally. Diagnosis Diagnosis ‘Crowned Dens Syndrome’ ‘Crowned Dens Syndrome’

8. Is the diagnosis easy on her plain films? (See next 2 slides.)

10. Is the Diagnosis easy on the plain films? Answer No, due to overlying bony structures. Even on the lateral radiograph the mastoid air cells partially obscure the dens. No, due to overlying bony structures. Even on the lateral radiograph the mastoid air cells partially obscure the dens.

11. Note the CRP test. Why do you think it decreased so dramatically over a 4 day period? The patient was started on Corticosteroids for a short period of time. This brought down her CRP. The patient was started on Corticosteroids for a short period of time. This brought down her CRP.

12. Crowned Dens Syndrome Synopsis Typical patient presentation Typical patient presentation Most pts are over age 70. Most pts are over age 70. Markedly restricted neck ROM, particularly rotation. Markedly restricted neck ROM, particularly rotation. No history of trauma, exclusion of other inflammatory diseases and tumors. No history of trauma, exclusion of other inflammatory diseases and tumors. Laboratory features Laboratory features Almost all have positive inflammatory indicators (i.e. CRP) Almost all have positive inflammatory indicators (i.e. CRP) Imaging features Imaging features Calcium deposition around the odontoid process detected by CT, particularly behind the process Calcium deposition around the odontoid process detected by CT, particularly behind the process Treatment Treatment Corticosteroids and NSAIDs in combination are recommended. Corticosteroids and NSAIDs in combination are recommended. Reference: Goto S et al. Crowned Dens Syndrome. J Bone and Joint Surg (AM) 2007; 89:2732-2736. Reference: Goto S et al. Crowned Dens Syndrome. J Bone and Joint Surg (AM) 2007; 89:2732-2736.