Image Quiz
Neck Pain and Torticollis in an Eleven-Year-Old Boy1
An eleven-year-old boy had neck pain for two weeks followed by the development of persistent torticollis. The neck pain gradually increased, and the symptoms did not improve after the administration of antipyretic drugs. Two weeks after treatment was begun, magnetic resonance imaging showed a destructive process within the lateral mass of C1, and the patient was referred to our hospital. The medical history was otherwise unremarkable.
Four weeks after the onset of symptoms, the boy required walking aids because of severe neck pain and persistent torticollis; the neck was bent to the left side and slightly rotated to the right side. Physical examination revealed stiffness, pain upon motion of the cervical spine, and tenderness of the left upper cervical spine. There were no neurological deficits. Blood tests showed a slightly increased C-reactive protein level of 0.5 mg/dL (5 mg/L) (normal, 0.0 to 0.4 mg/dL [0 to 4 mg/L]) and alkaline phosphatase of 414 U/L (normal range for an adult, 90 to 340 U/L), while the white blood-cell counts were within the normal range.
Cervical radiographs showed torticollis of the cervical spine, and computed tomography demonstrated an osteolytic lesion in the left lateral mass of the atlas (Fig. 1). Magnetic resonance imaging confirmed a mass that was isointensive on the T1-weighted image and high-intensity on the T2-weighted image (Fig. 2). The mass was shown to be expanding to the outside of the atlas on the left side.
Fig. 1 |
Fig. 2 |
Fig. 1 Axial computed tomography scan showing an osteolytic lesion in the left lateral mass of the atlas.
Fig. 2 Axial magnetic resonance imaging scans showing an isointensive mass on the T1-weighted image (A) and a high-intensity mass on the T2-weighted image (B).
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With the patient under local anesthesia and in a prone position, a percutaneous needle biopsy was performed with computed tomography guidance (Fig. 3, A and B). The biopsy needle was inserted posterolaterally to the lesion.
Fig. 3 |
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