CLINICAL VIGNETTE |
A typist with neck pain
Correspondence to: S. Hamdulay. E-mail: sh_hamdu{at}hotmail.com
A 27-yr-old office typist complained of a 6-month history of increasing neck pain. Symptoms were more pronounced later in the evening, exacerbated by movement, and occasionally interrupted her from sleep. There were no other symptoms and physical examination was entirely normal. Blood tests (including CRP and ESR) and a cervical spine radiograph (organized by her general practitioner 3 months previously) were reported normal by a senior, experienced radiologist. A diagnosis of mechanical neck pain was made. Eight weeks later, the patient described deterioration in symptoms; in particular, nocturnal symptoms were more pronounced. Physical examination and blood tests were again normal. A repeat cervical spine radiograph and MRI of the spine showed destruction of the third cervical vertebra with a soft tissue mass indenting the cord. A chest radiograph was normal. She was commenced on quadruple antituberculosis therapy. A CT-guided bone biopsy of the spinal lesion showed caseating granuloma, culture of which grew Mycobacterium tuberculosis.
Tuberculosis rarely affects the cervical spine. Typical symptoms include neck pain and spasm associated with restricted movements and localized spinal tenderness. Absence of these features led to a delay in this patient's diagnosis. In retrospect, persisting pain, nocturnal symptoms and poor response to symptomatic treatment indicated serious pathology. Furthermore, a normal plain spinal radiograph will not exclude sinister disease.
We would like to thank the Department of Medical Illustration at Wexham Park Hospital for providing photographs of X-rays and MRI.
The authors have declared no conflicts of interest.
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