Presentation
Diabetic patient with severe neck pain for 2 months not responding to analgesics.
Patient Data
On lateral view, there is increased prevertebral soft tissue thickness at the level of C1 and C2 reaching 9 mm (normal <6 mm), suggestive of retropharyngeal pathology.
Normal prevertebral soft tissue thickness from C3 downwards (5 mm at C3 and C4 levels).
Very limited flexion and extension. Stability cannot be assessed.
Linear high T2 fluid signal at the prevertebral space, suggestive of retropharyngeal infection.
Diffuse soft tissue thickening around C2 vertebra with avid postcontrast enhancement and cortical erosions of the odontoid process, suggestive of retropharyngeal infection with periodontal soft tissue involvement and C2 vertebral osteomyelitis with pathological fracture. The posterior epidural component mildly indenting the craniocervical junction, with no signs of compressive myelopathy or syrinx formation.
Spondylodegenerative changes are also noted.
Preivertebral soft tissue swelling, at the level of C1 and C2 vertebrae with bone erosions of the odontoid process complicated by a pathological fracture.
Soft tissue swelling around the dens exerts a mass effect upon the cervicomedullary junction.
Case Discussion
Prevertebral soft tissue thickness is one of the important items to look in lateral radiographs of the cervical spine, as retropharyngeal infections can have a variable and non-specific presentation. In this case, the infection has a late presentation with osteomyelitis of the dens complicated by a pathological fracture. The odontoid process pathological changes were not seen on plain radiographs as it is masked by the atlas vertebra.
Erosion of the odontoid process can result from a number of pathological entities (see article).
Flexion and extension lateral radiographs are used to assess stability however patients experiencing pain are often unable to flex and extend the cervical spine and compensate with movement of the body which tilts the cervical spine and head as a unit.
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