Tophaceous gout of the lumbar spine: case report and review of the literature

Abstract

Tophaceous gout has classically been described as an affliction of the extremities. It has however been reported as early as 1947 to involve the spinal column. We report a 63-year-old male, previously scheduled for Anterior Cervical Discectomy and Fusion to correct an existing cervical myelopathy at the C3-C4 spinal level, who presented to the emergency room with progressive weakness of the lower extremities and inability to ambulate for three days. Physical examination suggested a possible worsening of his cervical myelopathy but magnetic resonance imaging (MRI) findings remained unchanged from comparison studies. On the day of surgery, he became febrile and complained of excruciating back pain and we therefore initiated an infectious etiology workup and obtained a lumbar spine MRI. Results of imaging suggested a lumbar epidural abscess with effacement of the thecal sac. Emergent L4-L5 decompression led to an evacuation of a "chalky" substance, which was sent for pathology evaluation. This patient was diagnosed with tophaceous gout of the lumbar spine upon final pathological review. We aim to present the management of this case and review the literature associated with this diagnosis with the goal of improving the approach taken to diagnose and treat this pathology. KeywOrds: Epidural abscess, Spinal gout, Spinal stenosis, Tophaceous gout, Spinal infection ÖZTofüslü gut, klasik olarak ekstremitelerin hastalığı olarak tanımlanmakla birlikte 1947 yılında omurganın da tutulumu rapor edilmiştir. Bu olgu sunumunda C3-C4 seviyesinde servikal miyelopati nedeniyle anterior servikal diskektomi ve füzyon planlanan ancak acil servise alt ekstremitelerde progresif güç kaybı ve 3 gündür yürüyememe şikayeti ile başvuran 63 yaşında erkek hastayı sunuyoruz. Fizik muayene hastanın servikal miyelopatisinde muhtemel bir ilerlemeyi işaret ediyordu ancak manyetik rezonans görüntüleme (MRG) bulgularında bir değişiklik olmadığı görüldü. Ameliyat günü hastanın ateşi çıktı ve bel ağrısı ön plana çıktı. Bunun üzerine hastada enfeksiyon kaynağı araştırılmaya başlandı ve lomber spinal MRG yapıldı. Görüntülemenin sonucunda lomber spinal epidural apse ve dural kesede bası tesbit edildi. Acil L4-L5 dekompresyon yapıldı ve tebeşir renkli materyal boşaltılarak patolojik inceleme için gönderildi. Patolojik inceleme sonucunda hastada lomber omurgada tofüslü gut tanısı konuldu. Makalemizde bu olgunun yönetimini sunmayı amaçladık ve ilgili literatürü tanı ve tedavideki yaklaşımı kolaylaştırmak için taradık.

Bone Cyst of Proximal Humerus after Local Betamethasone Injection (Case Report)

“…В некоторых научных статьях, посвященных внутрикостным подагрическим тофусам, описывалась манифестная клиника подагры с ее лабораторным подтверждением, и отсутствовала связь образования кист с инъекциями ГКС [41,42,43,44,45,46,47,48,49]. Статей, описывающих локализацию тофусов в проксимальном отделе плечевой кости, не было обнаружено.…”

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

“…It has been suggested that poor vascularization of spinal disc cells in patients with risk factors such as dyslipidemia, obesity, and a sedentary lifestyle, creates an environment for tophi deposition [6]. Furthermore, if a patient has degenerative joint disease of the spine it decreases oxygen and creates an acidic area with increased risk for deposition of monosodium urate crystals [6]. In fact, our patient had dyslipidemia and degenerative joint disease, both making him a candidate at risk for spinal tophi.…”

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

“…The exact mechanism of gouty tophi formation in the axial skeleton is not clear. Volkov et al 11 suggested that the poor vascularization within the area may be a contributing factor. The patient’s hyperlipidemic state, obese body habitus, and minimal physical activity can cause a small caliber vasculature in the axial skeleton, which can lead to inability to adequately filter the uric acid deposited in that area.…”

“…Their appearance can mimic neoplasm or abscess, or they can cause cervical neck pain and spinal instability, frequently seen in degenerative process disorders. 11 – 14 The most common symptom is back pain, accounting for 65.4%–68.5% of patients suffering from neurological deficits, including radiculopathy, loss of sensation, motor weakness, bowel/bladder dysfunction, and quadriparesis. 3 All segments of the spine could be affected by gout, and most of the gout tophi are located in the lumbar spine, followed by the cervical vertebrae.…”