Sergio Mosquera Limas, DO
Resident Physcian
Yale New Haven Hospital
New Haven, Connecticut, United States
Charles A. Odonkor, MD
Assistant Professor of Orthopaedics & Rehabilitation
Yale School of Medicine
New Haven, Connecticut, United States
A 69-year-old female presented with worsening neck stiffness and radiating occipital pain following a recent C4-C7 anterior discectomy and fusion. The dull, achy pain extends ipsilaterally to the vertex and is exacerbated by cervical movement, suggesting but not confirming crowned dens syndrome (CPPD in the transverse ligament of the dens). She underwent multiple rounds of physical therapy and right C3-C4 medial branch blocks with lidocaine without relief. A five-week course of colchicine and prednisone provided temporary improvement, with increased neck fluidity lasting a month before stiffness recurred. Due to persistent symptoms, she was advised to obtain another CT scan and pursue additional prednisone therapy along with trigger point injections.
Discussions:
Crowded dens syndrome is characterized by calcium pyrophosphate crystals on imaging, causing severe occipital pain, neck stiffness, and reduced lateral flexion. These crystals induce inflammation, leading to pain, swelling, and in severe cases, joint erosion. Rarely, inflammation erodes atlantoaxial ligaments and the dens, causing instability, cord compression, and tetraparesis. Exacerbations often occur after trauma, illness, or surgery, with chronic relapsing neck pain and stiffness. Risk factors include age over 60, hypomagnesemia, and hyperparathyroidism. Her case is complicated by surgical screws and worsening peri-prosthetic osteoarthritis, obscuring the true pain source. The combination therapy of NSAIDs and glucocorticoids appears to be the most effective treatment approach in reducing inflammation and symptoms in patients with crowded dens syndrome.
Conclusions:
In conclusion, this case highlights the difficulty in treating crowded dens syndrome, particularly in patients with prior surgical interventions. Despite the patient having initial therapeutic responses, the recurrence of symptoms highlights the need for ongoing monitoring and tailored treatments. This includes NSAIDs and glucocorticoids to effectively manage this challenging condition.
