Tophaceous gout of the cervical and thoracic spine with concomitant epidural infection

Crystal Diseases of the Spine

Gout, calcium pyrophosphate deposition disease, and apatite calcifications, the three main crystal disorders, may involve the spine. These disorders can be completely asymptomatic or associated with various clinical symptoms, such as acute flares and more chronic manifestations. This article presents the typical and more unusual imaging features encountered in these disorders.

Gout Storm

Patient: Male, 55-year-old

Final Diagnosis: Gout • spinal gout

Symptoms: Back pain • fever • incontinence • pain • paresthesia of extremities • tachycardia

Medication: —

Clinical Procedure: Antibiotics • arthrocentesis • biopsy • CT scan • surgery • ultrasonography

Specialty: General and Internal Medicine

Tophaceous gout of the atlantoaxial joint: a case report

Background

To report the occurrence of tophaceous gout in the cervical spine and to review the literature on spinal gout.

Case presentation

This report details the occurrence of a large and clinically significant finding of tophaceous gout in the atlantoaxial joint of the cervical spine in an 82-year-old Caucasian man with a 40-year history of crystal-proven gout and a 3-month history of new-onset progressive myelopathy. The patient's American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) criteria score was 15.0.

Conclusion

Spinal gout is more common than previously thought, and it should be considered in patients who present with symptoms of myelopathy. Diagnosis can be made without a tissue sample of the affected joint(s) with tools like the ACR/EULAR criteria and the use of the “diagnostic clinical rule” for determining the likelihood of gout. Early conservative management with neck immobilization and medical management can avoid the need for surgical intervention.

Beyond Medical Treatment: Surgical Treatment of Gout

PURPOSE OF REVIEW

Medical treatment with urate-lowering therapy (ULT) is efficacious. A recent publication suggested that surgery in gout is more prevalent than previously reported. This revelation led us to review what is known about surgical treatment of gout.

RECENT FINDINGS

The Google Scholar database (January 1, 2014-January 1, 2020) found 104 publications with a total of 169 gout patients, with an average disease duration of 6.7 years. Most (68%) were not on ULT. The mean pre-operative serum urate levels were 9.19 mg/dL. One hundred thirteen patients underwent tophi excision, while in 33 patients, tophi were found during surgery. The majority of the surgeries were performed in Asia and Europe. Most patients were not taking ULT at the time of surgery, leading to hyperuricemia. This can result in tophi reformation post-surgery. The role of surgery should be a last-line treatment and until recently has only been demonstrated through case reports.

Gout involved the cervical disc and adjacent vertebral endplates misdiagnosed infectious spondylodiscitis on imaging: case report and literature review

Background

Gout in spine is rare and commonly mimics some infectious or tumoral lesions, the differentiation of spinal gout from other diseases is not always easy. We report a case of gout involved cervical disc and adjacent vertebral endplates whose etiology was initially not determined. Compared with the previous published 10 similar cases, this case displayed a complete and continuous image data with higher image quality and resolution than before. So we give a brief literature review for concerning cervical gout, with the emphasis on the discussion of radiological findings.

Case presentation

A 50-year-old male with a 5-year history of neck and shoulder pain had muscle atrophy and weakness in both arms. Physical examination revealed multiple tophi were seen in left wrist, both feet and knee; bilateral superficial sensory declined below level of mastoid portion and the muscle strengths of limbs decreased. Laboratory findings showed hyperuricemia and the C-reactive protein level was very high. Imaging studies including Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) showed abnormality of the C5–6 intervertebral disc and irregular osteolytic destruction of both adjacent C5–6 endplates, narrowing of C5–6 disc space and swelling of prevertebral soft tissue. Under the circumstance of the lesions being not determined and nerve root symptoms, surgical treatment was performed and pathological examination of the specimen revealed deposited uric acid crystals surrounded by granulomatous inflammation. After surgery combined with pharmaceutical and rehabilitation treatment, the muscle strengths of limbs, the pain of neck and shoulder and the level of serum uric acid were all improved.

Conclusions

Cervical spinal gout involving the disc and adjacent vertebral endplates is uncommon and may misunderstand infectious spondylodiscitis. Physician and radiologist should take the gouty spondylitis into account with a combination with previous history and clinical manifestations when encountering with such this condition.