The crowned dens syndrome as a cause of neck pain: clinical and computed tomography study in patients with calcium pyrophosphate dihydrate deposition disease.

OBJECTIVE: To investigate the association between articular chondrocalcinosis and calcification of the atlantoaxial region on a cervical computed tomography (CT) scan and to explore the relation between such calcifications and neck pain. MATERIALS AND METHODS: CT slices of the cervico-occipital junction were performed routinely in 49 consecutive patients (male/female ratio 28/21; mean age 70.4 yrs), diagnosed with calcium pyrophosphate dihydrate crystal deposition disease (CPPD). Of these, 35 met criteria for definite CPPD and 14 met the criteria for probable. The cervical CT scans were analyzed for the presence of periodontoid calcifications by 2 independent musculoskeletal radiologists. Both assessors were blinded to the disease status of the patients. Furthermore, conventional radiographs of the upper cervical spine were performed. An ad hoc designed protocol was used to register information at diagnosis, including age, sex, location of pain and stiffness, fever, presence of synovitis and its location. RESULTS: CT scan of the cervico-occipital junction showed periodontoid calcified deposits in 25 out of 49 patients (51%) with CPPD. In 10 of the 25 cases (40%) with periodontoid calcified deposits, CT scanning showed osseous abnormalities of the odontoid process, such as subchondral cysts or erosions. Conventional radiographs showed calcification behind the odontoid process in 17 patients (34.7%). Nine of CPPD cases (18.4%) presented with neck symptoms. In three patients, articular chondrocalcinosis was revealed only by an acute attack of neck pain with segmentary stiffness, fever, and an increased erythrocyte sedimentation rate; in one of them initial clinical examination found cervical stiffness with Kernig's and/or Brudzinski's sign. For the other two patients, impairment of general condition, occipito-temporal and mandible pain and weakness with inflammatory pain of the shoulder girdle was suggestive of giant cell arteritis (GCA) and/or polymyalgia rheumatica (PMR). In the six additional patients, questioning elicited a history of previous subacute or chronic neck pain, from one week to one year before their admission to our ambulatory or hospital. CONCLUSIONS: These results suggest that CPPD deposition disease frequently involves the cervical spine. Although such calcification often remains asymptomatic, it may be associated with attacks of acute neck pain with segmentary stiffness, fever, and an increased erythrocyte sedimentation rate, sometimes mimicking PMR and/or GCA or neurological symptoms.

[Echo Doppler in the characterization of thyroid nodular disease]. / L'eco Doppler nella caratterizzazione della patologia nodulare tiroidea.

This study was aimed at investigating role and efficacy of color-Doppler US in the characterization of thyroid nodules. Eight-three consecutive patients with only one solid thyroid nodule, not smaller than 0.8 cm, were examined. They were submitted to scintigraphy and laboratory tests first and then to color-Doppler US, to fine-needle biopsy and/or to histologic examinations. Color-Doppler US examinations were performed with a 7.5 MHZ linear probe, 5-MHz Doppler frequency, PRF = 0.8 KHz, 40-50 degrees insonation angle, wall filters at the lowest level, 2-5 mm sample volume, color and Doppler gains set at 30-50% and asynchronous data collection. The final diagnosis, made at cytology and/or histology, showed 43 follicular hyperplasias, 19 follicular adenomas and 21 carcinomas. The following US variables were considered: nodule size, site, margins and the possible presence of the "halo sign" pattern, with a special attention paid to micro-/macrocalcifications, signs of invasion of surrounding anatomic structures and possible adenopathies. With color-Doppler US, we studied presence and distribution of nodular vascularization, peak (Vp) and middle (Vm) velocity, resistive index (RI) and Doppler spectrum morphology. In agreement with the current literature, 3 patterns of nodular vascularization were considered: not apparent, or type I (3/83), which was found only in follicular hyperplasia; peripheral, or type II (46/83) and finally, peri- and intranodular, or type III (31/83). Hyperplasias exhibited a type I pattern rarely and exclusively and, if vascularized, they always exhibited Vp < 50 cm/s, Vm < or = 40 cm/s and mostly (39/40 RI < or = 0.75; adenomas were always vascularized, with Vp > 50 cm/s and mostly (18/19) RI < or = 0.75; primary or secondary tumors were always vascularized, with an extremely variable distribution, and if Vp < 50 cm/s, their RI > 0.75, while if Vp < 50 cm/s, their RI was independent of the threshold value of 0.75. These preliminary conclusions seem to confirm that vascular patterns alone are not particularly helpful, compared with B-mode US results, in distinguishing among thyroid nodules. Nevertheless, Vp and RI may be of great usefulness in the characterization of solid nodules and in the selection of the patients to submit to fine-needle biopsy.