Case Presentation: Acute calcific tendinitis of the Longus colli is a rare and likely underdiagnosed inflammatory response caused by deposition of calcium hydroxyapatite crystals in the Longus colli tendon, typically anterior to the C1-C2 vertebral bodies. This is a case of a 30-year-old Caucasian female with a past medical history of chronic back pain secondary to disc herniation employed as an accountant who presented with a 2-day history of abrupt onset of sharp worsening posterior cervical neck pain. She described the pain as severe and deep, radiating to her shoulders, and exacerbated by head rotation. She also reported limited range of motion of her neck, odynophagia, difficulty opening her jaw, and spasms of the neck muscles. There was no known antecedent trauma, unusual physical exertion or strain. The patient denied any fevers, speech difficulty, nausea, visual changes, or focal weakness. Her pain did not improve with over-the-counter ibuprofen and as a result presented first to urgent care. C-spine radiographs inconclusively showed only prevertebral soft tissue thickening. Upon hospital admission, CT neck demonstrated linear calcification anterior to the C2 level with elongated retropharyngeal effusion along the fascial plane. No abscess was noted. At this point, the differential diagnosis included cervical torticollis, retropharyngeal phlegmon, and acute calcific Longus colli tendinitis. The patient was started on IV clindamycin and dexamethasone 4 mg every 6 hours, ibuprofen, and cyclobenzaprine with some resulting improvement of symptoms. MRI verified a 7 mm calcification in the Longus colli tendon and prevertebral edema. The patient was evaluated by ENT who recommended continuing IV steroids and inpatient physical therapy. She was discharged after improvement of her symptoms on methylprednisone 4 mg by mouth for seven days and ibuprofen as needed. 3 days after discharge, the patient was doing well with unrestricted and painless neck motion and was able to tolerate a regular diet. She will follow up with ENT for possible repeat MRI.

Discussion: While unusual, such a diagnosis is important to consider. The classic presentation of odynophagia, low-grade fever, and neck pain can be easily suggestive of more life-threatening pathologies. Adjunctive imaging with CT or MRI is required to rule out severe disorders such as retropharyngeal abscess. Definitive diagnosis involves pin-pointing features of linear calcification along the Longus colli tendon. Management generally utilizes nonsteroidal anti-inflammatory medications, however in some severe cases corticosteroids and opiates may be indicated with most cases resolving a few weeks after beginning treatment.

Conclusions: The true incidence of acute calcific tendinitis of the Longus colli is difficult to estimate. As a self-limiting condition with subtle findings and vague symptoms, it is easily overlooked. We are presenting this case to raise awareness of the diagnosis, avoid unnecessary interventions, and promote high-value care.

IMAGE 1: A sagittal view of the calcification, indicated by the arrow, appears white on CT

IMAGE 2: The same calcification (yellow arrow) appears dark on this sagittal MRI image, with edema of the Longus colli indicated by the red arrow