Case Description or Program Description: We present a 74 y.o. M with PMHx of DM, hypothyroidism, HTN, HLD, OSA, and prior cervical myelopathy s/p C3-4 discectomy/fusion (2018). He was referred to PM&R for chronic axial neck pain persisting for a year. The patient described left-sided neck pain radiating to the shoulder, worsened by left rotation, with mild balance issues. Neurologic exam showed reduced sensation over the left C5 dermatome, brisk upper extremity reflexes, and limited cervical rotation. CT/MRI revealed pannus formation and erosive C1-C2 changes with retro-odontoid calcifications, suggestive of CPPD-associated Crowned Dens Syndrome. Neurosurgery was consulted and they did not recommend surgery.
Setting: KC-VA outpatient PM&R clinic
Assessment/Results: Given Crowned Dens Syndrome (CDS) diagnosis, patient was prescribed naproxen for symptom control. Rheumatology ruled out RA and other inflammatory arthritides as potential etiology. Physical therapy tailored to CDS diagnosis improved ROM and pain over follow-up.
Discussion (relevance): CDS is a rare and often underdiagnosed cause of cervical pain accounting for approximately 2% of acute neck pain. It is caused by calcium pyrophosphate dihydrate deposition around the C2 odontoid process, leading to inflammation and pannus formation. This case places emphasis on the imaging findings, particularly retro-odontoid calcifications, in distinguishing CDS from rheumatoid arthritis (RA). While RA causes synovial inflammation and erosions, CDS uniquely presents with crown-like calcifications. Recognizing this pattern is crucial to prevent misdiagnosis and unnecessary interventions. Conservative management with NSAIDs and physical therapy effectively improved symptoms in this case, emphasizing a non-surgical approach for most patients.
Conclusions: This case highlights the importance of considering CDS in the differential diagnosis of axial neck pain and demonstrates the effectiveness of conservative management with NSAIDs and physical therapy. Early recognition and appropriate non-surgical management can lead to significant symptom relief and prevent unnecessary interventions.
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