Diagnostic challenges of spinal gout

Abstract

Introduction: Spinal gout is rarely encountered in clinical practice, is easily misdiagnosed, and often remains undiagnosed. This paper aims to provide some clues that are the salient diagnostic features of spinal gout, particularly axial pain, radiculopathy, and myelopathy, as determined on the basis of our experience with a few cases as well as a literature review. Methods: We retrospectively reviewed the clinical data of 5 patients that were treated for axial pain and neurological symptoms associated with spinal gout between 2014 and 2017 in our hospital. Herein, we systematically describe the clinical characteristics of 5 patients with spinal gout. The 5 patients included 4 men and 1 woman, aged between 24 and 75 years. The most common clinical presentation included spinal pain, radiculopathy, and myelopathy. Four of the 5 patients had a history of gout and elevated serum uric acid levels. Results: Four patients underwent surgery, while the remaining patient underwent conservative treatment and biopsy due to poor general condition. Pathological examination of the surgical samples in the 4 surgical cases and the biopsy sample in the remaining case confirmed the presence of spinal gout tophi. The neurological symptoms of all 5 patients were relieved after treatment. Conclusion: Due to its rarity and lack of typical defining criteria, the diagnosis of spinal gout is quite difficult. We recommend that patients presenting with axial pain; radicular pain or myelopathy; and especially high uric acid levels, with or without a history of gout, should be evaluated for spinal gout. Timely pathological examination of surgical or biopsy samples would help confirm the diagnosis and enable practitioners to provide the appropriate treatment to prevent disease progression.

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

“…The most commonly affected level of the spinal gout is the lumbar level followed by the cervical and the thoracic levels [ 5 , 9 , 10 ]. Patients with spinal gout may present with axial pain, a variety of neurological symptoms such as radiculopathy, myelopathy, cauda equina syndrome, and claudication secondary to cord or root compression [ 4 , [8] , [9] , [10] , [11] ]. Spine plain films cannot provide diagnostic value [ 4 , 8 , 10 ].…”

“…Patients with spinal gout may present with axial pain, a variety of neurological symptoms such as radiculopathy, myelopathy, cauda equina syndrome, and claudication secondary to cord or root compression [ 4 , [8] , [9] , [10] , [11] ]. Spine plain films cannot provide diagnostic value [ 4 , 8 , 10 ]. Magnetic resonance imaging is still the most important tool of diagnosis; from the previous reports, spinal gout tophi may show isointensity, low or intermediate signal intensity on T1- weighted images and homogenous low intensity to homogenous high intensity or heterogeneous intensity on T2-weighted images.…”

“…After gadolinium administration, spinal gout tophi may show homogeneous enhancement or heterogeneous peripheral enhancement. The former may reflect vascularized reactive tissue within the tophi, while the latter may result from hypervascular granulation tissue surrounding the tophi [ 2 , 4 , 5 , [8] , [9] , [10] , [11] , [12] ]. Back to our patient, on MRI, his spinal gouty tophus demonstrated as a lobulated lesion at the posterior epidural space at the level of L4/5 manifesting non-specific low intensity on T1WI, heterogeneous high intensity on T2WI with marginal enhancement after gadolinium injection.…”

“…Back to our patient, on MRI, his spinal gouty tophus demonstrated as a lobulated lesion at the posterior epidural space at the level of L4/5 manifesting non-specific low intensity on T1WI, heterogeneous high intensity on T2WI with marginal enhancement after gadolinium injection. CT is very helpful to detect the tiny erosions caused by tophi [ 4 , 5 ]. Gout in the spinal canal is difficult to diagnosis before surgery because it is rare and its clinical presentations as well as radiologic findings mimic tumor, abscess, tuberculosis, and degenerative spinal diseases [ 5 ].…”

“…Hyperuricemia, defined as a serum uric acid level > 7.0 mg/dL, is the most dominant factor in gout development [ 1 ]. Gout is an inflammatory disease characterized by the deposition of monosodium urate crystals in joints, cartilage, synovial bursa, tendons or soft tissues with resultant nodules called tophi [ [1] , [2] , [3] , [4] ]. Crystallization is caused by poor solubility of the synovial fluid compared to the plasma and the lower temperatures exacerbate the phenomenon, so gout usually involves the peripheral joints such as hands, wrists, elbows, feet, ankles and knees [ 5 ].…”