Spinal gout: A review with case illustration

Single photon emission computed tomography/computed tomography imaging of gouty arthritis: A new voice

Gouty arthritis, often referred to simply as gout, is a disorder of purine metabolism characterized by the deposition of monosodium urate monohydrate (MSU) crystals in multiple systems and organs, especially in joints and their surrounding soft tissue. Gout is a treatable chronic disease, and the main strategy for effective management is to reverse the deposition of MSU crystals by uric acid reduction, and to prevent gout attacks, tophi deposition and complications, and thereby improve the quality of life. However, the frequent association of gout with other conditions such as hypertension, obesity, cardiovascular disease, diabetes, dyslipidemia, chronic kidney disease (CKD) and kidney stones can complicate the treatment of gout and lead to premature death. Here, we review the use of medical imaging techniques for studying gouty arthritis with special interest in the potential role of single photon emission computed tomography (SPECT)/computed tomography (CT) in the clinical management of gout and complications (e.g., chronic kidney disease and cardiovascular disease).

Understanding spinal gout: A comprehensive study of 88 cases and their clinical implications

Background

Spinal gout, a rare and often underdiagnosed condition, significantly impacts patients' quality of life. Therefore, the aim of the research is to analyze cases of spinal gout, including clinical features, anatomical location of spinal gout, laboratory studies, imaging studies, treatment choices, and outcomes from various cases of spinal gout.

Methods

The author conducted a systematic literature search in the PUBMED and Science Direct databases from 2013 to 2023. We included clinical case presentations of spinal cases in adults, published in English. The three researchers independently reviewed the title and abstract of each article, and any differences in opinions were resolved through consensus. The extracted data were subsequently analyzed descriptively.

Results

A total of 88 cases of spinal gout were obtained and studied. Out of the total reviewed cases of spinal gout, 89.77% of the subjects were male, with an average age of 51.9 years (age range 16-87 years). Common symptoms include back/neck pain (78.41%) and lower extremity weakness (37.50%). The lumbar spine is the most frequently affected region (62.50%), diagnosed primarily through magnetic resonance imaging (MRI) scans. Surgery, performed in 61.36% of cases, commonly involves decompressive laminectomy. Posttreatment, symptoms resolve in 87.50% of cases.

Conclusion

Cases of spinal gout present with a variety of symptoms, including back pain and weakness. Diagnosis typically involves an MRI examination and synovial fluid analysis for confirmation. Treatment varies and includes medication therapy and surgical interventions. A deeper understanding of these cases can assist healthcare practitioners in the management and diagnosis of spinal gout cases.

False-Positive Metastatic Bone Disease on FDG PET/CT Due to Multilevel Tophaceous Gout of the Spine

ABSTRACT

A 74-year-old woman was referred for 18 F-FDG PET/CT for the evaluation of incidental CT finding of expansile destruction of left L4/5 facet joint with associated soft tissue mass concerning for a metastatic deposit. The FDG PET/CT revealed variable abnormally increased FDG activity involving multiple facet joints in all regions of the spine with corresponding expansile "punched-out" lytic lesions with sclerotic rims and overhanging margins on CT, raising the possibility of inflammatory polyarthropathy, including gout, as a differential diagnosis. Dual-energy CT of lumbar spine and CT-guided biopsy and culture of the left L4/5 facet joint demonstrated the presence of urate crystal deposition with no evidence of malignancy or infection, confirming the diagnosis of multilevel tophaceous gout of the spine.

Spinal gout with intervertebral foramen infiltration: A rare case perfectly mimicking degenerative lumbar disc disease

Spinal gout is a relatively rare disease characterized by significant clinical symptoms. In the current study, the first case of spinal gout with tophus in the intervertebral foramen, which perfectly mimicked degenerative lumbar disc disorders, was presented. The patient was a 57-year-old man with a medical history of gout who had suffered from progressive neurological deterioration for the last 12 months. Imaging examination revealed bilateral stenosis in the L5/S1 intervertebral foramen, mimicking degenerative lumbar disc disease. Nerve root radiculography and blocking were performed and the neurological symptoms were completely relieved. Open surgery was further performed and unexpectedly, the intra-operative findings were amorphous chalky white lesions. Histopathology confirmed the diagnosis of spinal gout. After surgery, the patient was prescribed a medication and achieved complete remission of clinical symptoms. No deterioration was found at the 1-year follow-up. To the best of our knowledge, this is the first report of spinal gout tophus in intervertebral foramen in the literature. It was concluded that, although intraspinal tophaceous gout is relatively rare, orthopedic surgeons should take it into consideration as a differential diagnosis, particularly if the patient has a medical history of gout. Early diagnosis and timely medical management may possibly be able to avoid neurological compromise and the need for surgery.

Gout-Induced Cervical Deformity and Progressive Myelopathy Mimicking Infection Requiring Cervical Reconstruction

BACKGROUND

This study describes a rare case where gout, a condition primarily associated with joint inflammation, initially manifested as a progressive cervical kyphotic deformity, mimicking infection and causing myelopathy. The patient, a previously healthy 56-year-old woman, presented with severe jaw pain and a temporomandibular joint abscess, alongside 2 months of worsening balance and arm/hand tingling. Extensive clinical and radiographic assessments revealed a severe cervical kyphotic deformity with bony erosion at multiple vertebral levels, raising suspicion of an infectious cause of compressive myelopathy.

METHODS

The patient underwent an urgent staged surgical intervention involving multilevel cervical decompression and fusion, coupled with cervical deformity correction.

RESULTS

Post surgery, she received antibiotics for 7 days, during which pathologic analysis unveiled collections of macrophages reacting to urate crystal deposition in a pattern consistent with gouty tophus. This unexpected diagnosis marked a novel case of undiagnosed gout-induced severe cervical deformity presenting with myelopathic symptoms and successfully managed through cervical spine deformity correction.

CONCLUSIONS

This report underscores the significance of considering gout as a potential cause when encountering unusual spinal pathologies, especially in cases where gout-related symptoms are atypical. The presented 540-degree surgical approach effectively addressed both the cervical deformity and gout-induced myelopathic symptoms. To the best of our knowledge, this study represents the first documented instance of a patient with undiagnosed gout-induced severe cervical deformity successfully treated through cervical spine deformity correction, emphasizing the importance of vigilance and innovative management approaches in such rare clinical scenarios. As of the 2-year follow-up, the patient exhibited significant symptom improvement and overall well-being.

Spinal Gout: An Unusual Cause of Low Back Pain

Low back pain is the most common musculoskeletal complaint accounting for over 30 million visits to primary care physicians annually. Serious pathology is found in less than 1% of these visits. Therefore it is often a challenge to distinguish worrisome findings requiring further workup and treatment from common complaints of pain. Gout is an inflammatory arthritis that most commonly affects the appendicular skeleton. It is characterized by the saturation of uric acid and deposition of monosodium urate crystals in joints and tissues. Spinal involvement is rare and is not typically considered on the differential diagnosis for a patient presenting with acute low back pain. We present such a case of a 35-year-old male who presented with intractable back pain, highlighting the need to recognize signs and symptoms that raise suspicion for spinal gout.

Foraminal stenosis and radiculopathy secondary to tophaceous gout: illustrative case

BACKGROUND

Tophaceous gout is a severe form of gout that results in the formation of large nodules, or tophi, in the affected joints and surrounding tissues. Gouty tophi in the spine have a constellation of presentations that often mimic other pathologies and may not be easily discernable from more common pathologic processes.

OBSERVATIONS

A 47-year-old female with a history of chronic renal disease, obesity, gout, inflammatory polyarthritis, and multiple sclerosis presented with 6 months of low-back pain and lumbar radiculopathy affecting the right lower extremity. A lumbar magnetic resonance imaging study revealed right foraminal stenosis and spondylolisthesis at levels L4-5. An intraspinal extradural mass was noted adjacent to the traversing right L5 and exiting right L4 nerve roots. A bilateral decompressive laminectomy, facetectomy, and foraminotomy of L4-5 was performed. A calcific, chalky-white mass was discovered in the foramen, and pathology determined the specimen to be a gout tophus. Postoperatively, the patient endorsed the resolution of her preoperative symptoms, which have not returned on follow-up.

LESSONS

Reports of gouty depositions compressing the spinal cord in the current literature are relatively rare. Although the diagnosis of gouty tophi can only be confirmed histologically, patient history may serve as a helpful diagnostic tool.

A unique presentation of acute tophaceous gout in the lumbar spine causing cauda equina syndrome

Gout is a common metabolic disease characterized by the deposition of monosodium urate (MSU) crystals and typically affects the peripheral joint, rarely involving the axial skeleton. We present a rare case of acute tophaceous gout in the lumbar spine causing cauda equina syndrome. A 60-year-old man with a history of gout and prior admissions for polyarticular gout flare presented with acute onset of bilateral lower limb numbness and weakness. He underwent surgical decompression with drainage of the epidural collection, with histology consistent with tophaceous gout. The patient made a full recovery postoperatively and was discharged uneventfully. Due to the high initial suspicion for gout, early spinal decompression surgery was performed, and the patient was started on medical therapy. Spinal tophaceous should be considered in the list of different diagnoses of spinal epidural masses especially in the context of a history of gouty arthritis.

Case of lumbar spinal stenosis and chronic tophaceous gout

Background

Rarely, chronic tophaceous gout can result in lumbar spinal stenosis and neural compression.

Case Description

A 67-year-old male presented with the radiographic and magnetic resonance findings of gout involving and causing compression of the lumbar spine that responded to surgical decompression.

Conclusion

It is difficult to diagnose lumbar spinal stenosis secondary to tophaceous gout. Notably, the treatment, based on the clinical presentation, may include both medication and surgical decompression.

Tophaceous spinal gout in a young man with complete spinal cord injury

Gout is a common inflammatory arthritis, caused by monosodium urate crystal deposition in the joints. Gout typically affects peripheral joints but less commonly it affects the spine. We report a case of a man in his 30s with chronic gout who presented acutely with thoracic back pain and flaccid paralysis of his lower limbs. CT showed abnormal facet joints at T8/9 with lucency suggestive of septic arthritis and MRI showed signal changes suggestive of epidural collection. The patient underwent emergency spinal surgery to evacuate the collection, followed by broad-spectrum antibiotic treatment. Cultures were negative; however, histopathology was suggestive of gout tophi. The patient was subsequently treated for spinal gout with prednisolone, allopurinol and colchicine and saw significant improvement in symptoms though he sustained a complete spinal cord injury. This case demonstrates that spinal gout is an important differential to consider in patients with chronic gout, presenting with acute back pain.

99mTc-methylene diphosphonate SPECT/CT imaging of gout spondylitis: a case report

Single-photon emission computed tomography (SPECT)/computed tomography (CT) imaging of the gouty spine is rare. We describe a 66-year-old man who presented with pain and numbness in the right lower leg; he reported a 2-month history of intermittent low back pain. Imaging revealed neoplastic lesions of the spine, which were initially regarded as tumors. Thus, the patient underwent surgical removal of the lumbar lesion. However, the postoperative pathological diagnosis was gout spondylitis. In this report, we show multimodal images of advanced gout spondylitis. The metabolic information provided by SPECT/CT, combined with the microscopic changes in bone structure revealed by dual-source thin-layer CT and the anatomical localization information provided by magnetic resonance imaging, can help clinicians to more fully understand the pathophysiological mechanisms and imaging manifestations of gout from multiple perspectives, thereby reducing the rate of misdiagnosis.

Relationship between hyperuricemia with deposition and sexual dysfunction in males and females

PURPOSE

The association between gout, the most common crystal arthropathy, and sexual dysfunctions has often been investigated by studies in the last decades. Despite the presence of shared risk factors and comorbidities and the possible effects on sexual health of long-term gout complications, awareness of this association is severely lacking and the pathogenetic mechanisms have only partially been identified. In the present review, we aimed to investigate the current evidence regarding the potential mechanisms linking sexual dysfunctions and gout.

METHODS

A comprehensive literature search within PubMed was performed to provide a summary of currently available evidence regarding the association between gout and sexual dysfunctions.

RESULTS

Gout and sexual dysfunctions share several risk factors, including diabesity, chronic kidney disease, hypertension, metabolic syndrome, and peripheral vascular disease. Gout flares triggered by intense inflammatory responses feature severe pain and disability, resulting in worse sexual function, and some, but not all, treatments can also impair sexual health. Long-term gout complications can result in persistent pain and disability due to joint deformity, fractures, or nerve compression, with negative bearing on sexual function. The presence of low-grade inflammation impairs both sex steroids synthesis and endothelial function, further advancing sexual dysfunctions. The psychological burden of gout is another issue negatively affecting sexual health.

CONCLUSIONS

According to currently available evidence, several biological and psychological mechanisms link sexual dysfunctions and gout. Addressing risk factors and providing adequate treatment could potentially have beneficial effects on both conditions. Appropriate clinical evaluation and multidisciplinary approach are recommended to improve patient care.

A Case of Spinal Infectious Osteomyelitis Versus Gout: Advanced Imaging with Dual Energy CT

A 67-year-old male presented to the hospital for lower back pain and left lower extremity radiculopathy. Although the patient was afebrile and white blood cell count was normal, MRI was concerning for discitis/osteomyelitis at L4-L5. Subsequently, the patient developed a right knee joint effusion and underwent an arthrocentesis that was notable for the presence of urate crystals. A systemic urate crystal arthropathy was proposed as a potential etiology for the patient's back pain and radiculopathy. Dual energy CT of the lumbar spine was performed, a technique which determines material composition by comparing the photon attenuation of the substance from two different x-ray energy levels. Results revealed the presence of monosodium urate crystals in the intervertebral discs. This technique is proposed as a noninvasive way to evaluate for gout in atypical locations or those difficult to sample and may replace an invasive intervertebral disc/endplate aspiration and/or biopsy. Dual energy CT should be considered in patients with elevated serum uric acid and concern for spinal involvement of gout.

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

Imaging of facet joint diseases

Facet joints are the important articular pillars of the spine. Several pathologies can occur in and around the facet joint, including extra ossicles, traumatic dislocation, osteoarthritis, synovial cyst, axial spondyloarthritis, rheumatoid arthritis, calcium pyrophosphate deposition disease, septic arthritis, and malignant and benign neoplasms. Imaging is the mainstay to detect and characterize these diseases. In this review, we discuss the anatomy and function of facet joints, imaging techniques, and the imaging findings of several facet joint diseases. This information may be helpful to radiologists to make the correct diagnosis and optimize the management of patients with facet joint diseases.

Spinal gouty tophus presenting as an epidural mass lesion - A case report

Introduction

Gout is a metabolic disease secondary to an increased body pool of urate with hyperuricemia. Gout typically affects the peripheral joints and rarely involves the intra-spinal area.

Case presentation

A 43-year-old man, who had metabolic syndrome s/p bariatric surgery and gout suffered from severe left low back pain with radiation to the lateral side of his left thigh and anterior side of his left leg for more than 7 days. His L-spine MRI showed an abnormal posterior epidural space occupying lesion at L4-L5 level. For tissue diagnosis and neural structures decompression, he underwent surgical removal of the epidural mass lesion. The surgical specimen showed a picture of gout and he got a good recovery after operation.

Discussion

The differential diagnoses of an epidural mass includes synovial cysts, ligament cyst, cystic neuromas, tumors, hematomas and abscesses. Gout in the spinal canal is difficult to diagnosis before surgery because it is rare and its clinical presentation and radiologic findings mimic tumor, abscess, tuberculosis, and degenerative spinal diseases. Patients with spinal gout may present with axial pain and a variety of neurological symptoms.

Conclusion

Spinal gouty tophus should be considered in the different diagnoses of spinal epidural masses especially in patients with systemic gout. Surgery is needed for final diagnosis. If spinal gouty tophus is highly suspected during the surgery, the specimen should not be preserved with Formalin because birefringent crystals under polarized light is a unique feature for gouty tophus but they dissolve in Formalin.

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Gout rarely involves the intra-spinal area.

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Surgery is needed for the final diagnosis of spinal gouty tophus.

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Birefringent crystals under polarized light is an unique feature for gouty tophus

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Birefringent crystals dissolve in Formalin.

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.

Percutaneous transforaminal endoscopic decompression for the treatment of intraspinal tophaceous gout: A case report

RATIONALE

Intraspinal tophaceous gout is relatively rare condition presenting with major clinical manifestations, such as spinal cord or nerve roots compressions (radiculopathy). It is usually difficult to differentiate intraspinal tophaceous gout, lumbar disc herniation, stenosis of spinal canal, ossification of ligamentum flavum, and other degenerative spinal disorders from each other.

PATIENT CONCERNS

A 64-year-old man was admitted with a history of progressive low back pain for 11 months. He also presented with radiculopathy and numbness of his left lower extremity.

DIAGNOSES

Preoperative computed tomography (CT) and magnetic resonance imaging (MRI) showed L4/5 disc herniation and lateral recess stenosis on the left side. During the operation of percutaneous transforaminal endoscopic decompression, intraspinal chalky white material was seen. Post-operative pathologic results confirmed the diagnosis of gouty tophi.

INTERVENTIONS

Percutaneous transforaminal endoscopic decompression was performed as treatment. Intraspinal chalky white material was seen. We removed most of the chalky white material and extruded nucleus.

OUTCOMES

His symptom subsided rapidly and no deterioration was noted 1 year post-operatively.

LESSONS

Although intraspinal tophaceous gout is not commonly seen, clinicians should take it into consideration as a possible differential diagnosis when the patient exhibits axial pain or neurological deficits with risk factors of gout. We identified and treated this case with percutaneous transforaminal endoscopic decompression for the first time and got an excellent outcome. Percutaneous transforaminal endoscopic surgery proved to be an effective and minimally invasive alternative for identifying and treating intraspinal tophaceous gout.

FDG PET/CT of Cervical Gout With Spinal Cord Compression

We report FDG PET/CT images of a 63-year-old woman referred for characterization of osteolytic lesions of the cervical spine. This patient with chronic renal failure had a history of follicular thyroid carcinoma with undifferentiated cells, treated by a total thyroidectomy, completed by radioactive iodine in 2017. Because of cancer history, a FDG PET/CT was performed and showed multiple moderately hypermetabolic osteolytic lesions of the spine from C3 to T1, with joint erosion on CT. A laminectomy was performed for cervical spinal cord decompression and revealed a gouty tophus.

A rare cause of back pain and radiculopathy - spinal tophi: a case report

Background

Gout is a monosodium urate deposition disease which is prevalent worldwide. The usual manifestations are crystal arthropathy and tophi deposition in the soft tissues. Spinal tophi may also occur and are rarely reported, resulting in various clinical manifestations such as back pain, spinal cord compression, radiculopathy, and even mimicking epidural abscess and spondylodiscitis.

Case presentation

We report a case of a 42-year-old Chinese man with underlying gout who presented with back pain and radiculopathy. The diagnosis of spinal tophi was unsuspected and he was initially treated for epidural abscess and spondylodiscitis. He underwent a laminectomy and posterolateral fusion during which tophus material was discovered. He recovered and medications for gout were started.

Conclusion

Spinal tophi are rare. The diagnosis is difficult and spinal tophi may be mistaken for epidural abscess, spondylodiscitis, or neoplasm.

Spinal Manifestations of Systemic Disease

The spine is frequently involved in systemic diseases, including those with neuropathic, infectious, inflammatory, rheumatologic, metabolic, and neoplastic etiologies. This article provides an overview of systemic disorders that may affect the spine, which can be subdivided into disorders predominantly involving the musculoskeletal system (including bones, joints, disks, muscles, and tendons) versus those predominantly involving the nervous system. By identifying the predominant pattern of spine involvement, a succinct, appropriate differential diagnosis can be generated. The importance of reviewing the medical record, as well as prior medical imaging (including nonspine imaging), which may confer greater specificity to the differential diagnosis, is stressed.

Spinal gout causing reversible quadriparesis: a case report and literature review

Gout commonly affects peripheral joints and is rarely found in axial joints, such as the spine and sacroiliac joints. We report a case of a patient that presented with quadriparesis who was empirically treated for spinal gout and a review of relevant literature. A 77-year-old male presented with new-onset quadriparesis that developed over 3 days. MRI imaging was suggestive of tophaceous gout of the cervical spine, but our patient refused a spinal biopsy. He was empirically treated with high-dose steroids and his upper and lower extremities weakness started improving within 3 days and resolved completely. Although spinal gout is uncommon, this case indirectly suggests that gout should be kept as a differential diagnosis when faced with back pain or quadriparesis. This case implies that empiric treatment should be considered when radiographic evidence is suggestive of tophaceous gout of the spine.

Spinal tophaceous gout presenting in a young adult without pain

A 26-year-old man with a medical history of gout and morbid obesity presented with a 7-day history of decreased sensation to light touch and temperature from the feet to the level of the nipples. He also noted incomplete voiding. Laboratory investigations showed an elevated serum uric acid level (10.4 mg/dL, reference range: 3.8-8.7 mg/dL) as well as negative rapid plasma reagin and rheumatoid factor. MRI showed inflammatory changes on multiple spinal levels. Laminectomy was performed, with follow-up biopsy revealing multiple multinucleated giant cells and monosodium urate (MSU) crystals. He was ultimately diagnosed with spinal gout. Patient's symptoms did not resolve immediately after surgery. Yet with the administration of intravenous glucocorticoids and a course of non-steroidal anti-inflammatory drugs, he slowly regained sensation, leaving the hospital with complete resolution of symptoms.

Lumbar spinal stenosis attributable to tophaceous gout: case report and review of the literature

Objectives

Tophaceous gout seldom affects the axial skeleton. Symptoms vary according to the differential localization of urate deposits and the diagnosis is often delayed. Here, we report an unusual case of lumbar spinal stenosis caused by extradural tophaceous deposits.

Methods

We retrospectively reviewed a case of a patient with tophaceous gout of the lumbar spine and reviewed the relevant literature.

Results

A 62-year-old man with a 2-year history of lower back pain and a 3-month history of lower limb radiation pain and intermittent claudication was admitted. After laboratory and imaging investigations he underwent surgical decompression and stabilization. Histological analysis of the extracted specimen confirmed that it was gouty tophus. The patient’s symptoms improved progressively after the operation. He recovered very well with no complications.

Conclusion

The mechanism associated with axial gout is not yet clear. Obesity, inactivity, and previous degenerative disc disease may be the risk factors for spinal tophus. The clinical symptoms are diverse according to the differential localization of urate deposits. It is not easy to diagnose this disease radiographically by routine radiological examination. Analysis of a biopsy specimen is definitely the only way to confirm diagnosis. Surgical treatment should be considered in patients with spinal gout who are experiencing neurological deterioration.

Tophaceous Gout of the Lumbar Spine Mimicking Malignancy on FDG PET/CT

A 46-year-old man with over a 10-year history of gout complained of progressive bilateral buttock pain with numbness of legs for 4 months. Serum uric acid level was elevated. Lumbar radiographs showed decreased density of the bilateral L4-L5 facet joints. CT showed lytic lesions of the facet joints with hyperdense periarticular lesions. Enhanced MRI showed marked enhancement of these lesions. FDG PET/CT showed avid FDG uptake of the bony and periarticular lesions with SUVmax of 16.8. A decompressive posterior lumbar laminectomy with periarticular lesion resection was performed. Histopathologic findings of the periarticular lesions were consistent with tophaceous gout.

Tophaceous Gout in the Lumbar Spinal Canal Mimicking Epidural Spinal Tumor

Gout is an inflammatory arthritis characterized by deposition of monosodium urate crystals in joints. Though gout frequently involves the big toe or other extremities, it rarely occurs in the spinal canal. A 35-year-old man presented with left L5 radiculopathy. He had leg pain for 8 months and received several epidural steroid injections. Magnetic resonance imaging revealed a 1.7×1.1-cm ovoid contrast-enhancing mass, causing pressure erosion of the left L5 pedicle. Microscopic laminotomy was performed at the left L5 lamina. White chalky materials, identified at the left lateral recess of the spinal canal, were removed in a piecemeal manner. The histopathologic diagnosis was tophaceous gout. Although the patient’s radiating pain did not resolve postoperatively, it was dramatically relieved with uric acid-lowering medications. If a mass effect is suspected, surgical removal of gouty tophi might aid in symptom release and definite diagnosis. Medical treatment after rheumatology consultation is crucial.

[Tophaceous gout of the lumbar spine in a patient without systemic gout or normouricaemia]

Gout is a common metabolic disorder typically diagnosed in peripheral joints. Tophaceous deposits in the lumbar spine is a very rare condition with very few cases reported in the literature. We present a case of tophaceous gout that originated in the lumbar spine in a patient with normal uric acid blood levels. The following case report concerns a 52-year-old patient with low back pain, left sciatica and numbness in the left leg. Serum uric acid levels were within normal range. MRI and bone scan images suggested an inflammatory-infectious process focussed at L4. After an L4-L5 decompressive laminectomy, histological examination revealed tissue infiltrated with mature plasma cells with negatively birefringent crystals using polarised light consistent with urate deposits.