A thirty-five year-old woman sought help from several physicians for pain in the right side of her neck. It had started insidiously as a mild discomfort but over a nine-month period had increased to the point where she was taking strong pain medicine several times a day.
Her primary care physician (PCP) had ordered neck X-rays that showed only very early degenerative changes in her spine – typical of what one would see in someone her age. Not knowing what to make of this pain, her PCP referred her to a specialist in pain management. The consultant physician had started her career as a physiatrist – specialist in physical medicine and rehabilitation – but had taken on more and more responsibility in managing chronic pain, as other physicians referred her cases they did not wish to manage because narcotics were involved.
The pain management doctor (PMD) examined the lady and found slight asymmetry in the neck exam: the right side of the neck seemed to bulge a bit. She attributed this to muscle spasm and prescribed a muscle relaxant. This strategy provided some pain relief but the swelling did not improve. She next injected the area with a steroid medication designed to reduce the swelling associated with the muscle spasm. There was no objective benefit and only brief pain relief. After about four months, when the pain had failed to resolve, she ordered at CT scan because the asymmetry persisted and might even have become more prominent.
The radiologist on call the day of the scan looked at the requisition and noticed that the PMD had not specified that the scan be done with intravenous iodinated contrast. When looking at the soft tissues of the neck, iodine contrast can help bring out subtle abnormalities because tumors and areas of inflammation will preferentially take up the iodine, and the area in question will then stand out from surrounding structures. The radiologist called the office of the PMD but failed to reach her because it was her day off.