Joseph Z. Levinson, MD
Resident Physician
University of Virginia, Department of Physical Medicine and Rehabilitation
Charlottesville, Virginia, United States
Susan Miller, MD
Associate Professor
University of Virginia School of Medicine
Charlottesville, Virginia, United States
A 77-year-old female presented to the Emergency Department (ED) with right sided neck and upper back pain without radiation, no traumatic mechanism. Her pain was refractory to opioids, oral prednisone and cyclobenzaprine, but responsive to ibuprofen. A cervical CT was ordered and showed, “mild calcification of the transverse ligament, likely due to CPPD.”
The patient re-presented to the ED with worsening neck pain, refractory to ketorolac and hydromorphone. CRP was elevated to 2.9. Outpatient examination by physiatry demonstrated right sided neck pain and limited cervical extension and rotation. Given this presentation, CT findings concerning for CPPD, and elevated CRP, colchicine was started with improvement in her pain.
Discussions:
CPPD disease is an inflammatory arthritis due to an immune response to calcium pyrophosphate deposits. Risk factors include aging, joint injury, metabolic disorders, and rarely, familial disease. Diagnosis requires presentation consistent with arthritis, and visualization of crystals in synovial fluid or imaging consistent with CPPD. CT is useful after negative initial X-ray or with concern for axial joint involvement. Crowned dens syndrome (CDS) should be considered with severe neck pain, decreased cervical rotation and elevated inflammatory labs. CT demonstrates calcific deposits in the transverse ligament of the atlas.
In acute flares, treatment includes high dose nonsteroidal anti-inflammatory drugs or corticosteroid, and colchicine. Chronic disease is treated with colchicine, hydroxychloroquine, or low dose methotrexate. Screening for secondary causes at onset should be pursued in younger patients.
Conclusions:
Our patient experienced excruciating neck pain refractory to neuropathic agents, opioids and oral steroids over two ED visits, while colchicine provided significant relief. This case illustrates the importance of keeping CDS in the differential when evaluating patients with severe neck pain and severely restricted range of motion, as well as close review of radiological reports and imaging.
