Neck pain: an unusual presentation of a common disease

Abstract

A 68-year-old man presented with 1 month history of neck pain, progressively worsening sensory dysfunction in the right hand, weakness of both hands and difficulty walking. On clinical examination he was found to have reduced power in both upper and lower limbs, with upgoing plantar reflexes. MRI was performed using a Philips Gyroscan 1.5 T machine using sagittal T1 weighted turbo spin echo (TSE; repetition time (TR) 400/echo time (TE) 10, matrix 512, field of view (FOV) 2556255, slice thickness 3.0 mm/ 0.3 mm, number of signal averages (NSA) 4), T2 weighted TSE (TR 3500/TE 120, matrix 512, FOV 2556255, slice thickness 3.0 mm/0.3 mm, NSA 4) and axial T2 weighted turbo field echo (TFE, TR 7.8/TE 3.9, flip angle 45 , matrix 512, FOV 2256225, slice thickness 3.5 mm/21.8 mm, NSA 3) sequences. Post-contrast sagittal (as above) and axial T1 weighted TFE (TR 9.4/ TE 4.6, flip angle 25 , matrix 512, FOV 24562.4, slice thickness 4.0 mm/22.0 mm, NSA 4) sequences were also performed from C3 to D1 level. MRI demonstrated a destructive lesion involving the right facet joint of C4/5 associated with a medially placed extradural mass of intermediate signal on T1 weighted images, intermediate heterogeneous signal on T2 weighted images which showed peripheral contrast enhancement postgadolinium (Figure 1). Enhancement was also present in the joint and surrounding soft tissues. The soft tissue mass was compressing and displacing the spinal cord and intrinsic high signal was present in the cord on T2 weighted sequences. Similar but less severe changes were also present in the right C2/C3 facet joint. A CT scan performed to look for bony changes revealed subtle eggshell calcification noted around the extradural mass and well-defined erosive changes involving the facets of C2/C3, C3/C4 and C4/C5 (Figure 2). What is the differential diagnosis? Address correspondence to: Dr Tufail Patankar, 30 Windy Hill Drive, Bolton BL3 4TH, UK. The British Journal of Radiology, 79 (2006), 537–539