The Journal of Bone and Joint Surgery

Image Quiz
Neck Pain in a Forty-Six-Year-Old Woman¹
A forty-six-year-old woman was seen because of a nine-month history of neck pain. She had no history of trauma, paresthesias, loss of motor, bowel, or bladder control, or constitutional symptoms. The pain was exacerbated with flexion and extension movements of the neck as well as during bouts of sneezing or coughing. Anti-inflammatory medications provided minimal pain relief.
On physical examination, she could extend her neck only 20° to 30°. Neurological examination showed normal motor and sensory findings, with reflexes bilaterally symmetrical, and a normal gait.
Radiographs of the neck showed a lytic lesion that had destroyed the joint between the right lateral masses of the first and second cervical vertebrae and had extended into the second cervical vertebral body. A thin sclerotic margin bordered the lesion. No central stenosis was present. A computed tomographic scan (Fig. 1) and a magnetic resonance image (Fig. 2) were acquired.
Fig. 1	Fig. 2	For larger view, click on image


What is the differential diagnosis?