Tophaceous gout of the spine: MR imaging features

Inaugural cervical spinal location of gout: A case report

Gout is a crystalline arthropathy associated with prolonged body overload with uric acid. The most common sites are the distal joints of the lower limbs and the spine is rare. We report a case of gout with an initial cervical location of spondylodiscitis with epiduritis in a 62-year-old patient.

Neoplastic and Non-neoplastic Soft Tissue Lesions Around the Knee

Neoplastic and non-neoplastic soft tissue masses around the knee are often incidental findings. Most of these lesions are benign with typical imaging characteristics that allow a confident diagnosis. However, some of these incidental neoplastic masses are characterized by morbidity and potential mortality. This review highlights the typical aspects of these lesions, facilitating a correct diagnosis.

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.

Lumbosacral Paravertebral Tophaceous Gout on an Adolescent Mimicking Malignant Neoplasm in 18 F-FDG PET/CT

ABSTRACT

Contrast-enhanced MRI was performed on a 17-year-old adolescent boy with chronic lumbar and lower-limb pain, which had worsened over the past 3 days. It revealed a suspicious malignant mass adjacent to right appendage of L5-S1 vertebrae, with mixed signals and heterogeneous and obvious enhancement. 18 F-FDG PET/CT was subsequently performed for staging. It showed an FDG-avid mass with mixed density in right psoas major muscle, involving adjacent appendage of L5-S1 vertebrae. Histopathological examination confirmed the mass to be gouty tophus, characterized by nodular homogeneous pink amorphous deposits around the cartilage tissue, surrounded by histiocytes and multinucleated giant cells.

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.

Imaging of Rheumatological Disorders

Early diagnosis and treatment of many rheumatological conditions has become crucial in order that drug therapies can be started before irreversible structural damage occurs. Both MR imaging and ultrasound play a valid role in the pathway of many of these conditions. The imaging findings as well as relative merits are described in this article as well as limitations that must be kept in mind when interpreting the imaging. Both conventional radiography and computed tomography also add important information in certain cases and should not be forgotten.

Intraspinal extradural gout tophus in the lumbar vertebral canal: Case reports

RATIONALE

Intraspinal gout tophus in the lumbar vertebral canal associated with gouty arthritis is rare. We present 2 cases with the first manifestations of a sequestrated intervertebral disc and an extradural tumor, and histopathologically proven to be gouty deposits in the lumbar vertebral canal.

PATIENT CONCERNS

The 2 patients presented with typical radiculopathy symptoms and a positive straight leg raise. In 1 case, there was weakness of the left toe extensors, with a positive left femoral nerve traction test. Additionally, the left patellar tendon reflex was weak. In the other patient who was unable to walk, there was a sensory deficit in the saddle distribution.

DIAGNOSIS

Histopathological examination of the specimens taken from the operation confirmed the presence of gouty deposits.

INTERVENTIONS

Posterior decompression was performed in these 2 cases, and chalky-white materials were identified in the lumbar vertebral canal.

OUTCOMES

No evidence of neoplasm, infection, or synovial cyst was found.

LESSONS

Definitive diagnosis of intraspinal extradural gout tophus, mimicking a sequestrated intervertebral disc or an extradural tumor, may be difficult. The initial suspicion of intraspinal gouty deposits, based on the diagnostic/management algorithm, may effectively avoid incorrect diagnosis via a less invasive procedure than explorative laminectomy.

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.

Chronic tophaceous gout mimicking widespread metastasis

Gout is a common crystal-induced arthropathy affecting mainly the joints of the appendicular skeleton; however, rarely this condition affects the axial skeleton as well. Spinal gout can cause radiculopathy, cord compression, canal stenosis and discitis. We describe a case of a 71-year-old woman where the initial presentation of destructive arthropathy and spinal masses secondary to axial gout was mistaken for a metastatic malignancy. Despite chronic polyarthropathy and bilateral subcutaneous gouty tophi, spinal gout was not considered a differential diagnosis during initial assessment.The patient was managed conservatively with pharmacological treatment resulting in improvement of her upper limb radiculopathy and systemic joint pain, although little improvement in mobility. Such extensive involvement is rare and the masses can mimic an underlying metastatic disease. Careful history and clinical examination recognising polyarthropathy and subcutaneous tophi can aid the clinician to make the right diagnosis and institute correct treatment. Delay in recognising gout as a differential diagnosis can lead to marked morbidity as illustrated in our case.

Chronic tophaceous gout causing lumbar spinal stenosis

Gout is a common cause of inflammatory arthritis, typically affecting the joints of the appendicular skeleton. In this report, we present the relatively less common scenario of chronic tophaceous gout affecting the lumbar spine and pelvis, complicated by compressive neuropathy, and notable for its advanced initial presentation in a young patient. We review the pathophysiology underlying gout and discuss its clinical and laboratory presentation. We also use our case as an example to present the radiographic, CT, and MR imaging features of gout affecting the lumbar spine, which can often present a diagnostic dilemma. Finally, we discuss therapeutic options for gout resulting in spinal canal compromise, which include interventions not commonly performed for gout elsewhere in the body.

Thoracic gout tophus with abdominal wall protrusion: A case report

RATIONALE

A patient presented the abdominal wall protrusion due to tophaceous gout of the spine. Similar cases were not reported in the literature. This study aimed to report a case of tophaceous gout of the spine with abdominal wall protrusion.

PATIENT CONCERNS

A 38-year-old male patient had a 10-year history of gout and hyperuricemia. He complained of back pain and abdominal wall protrusion.

DIAGNOSES

The patient was diagnosed with tophaceous gout of the spine with abdominal wall weakness caused by T11 nerve root compression.

INTERVENTIONS

A semi-lamina decompression was performed at T11-T12. The pathological examination of the specimen demonstrated tophaceous gout of the spine.

OUTCOMES

After the surgery, the patient's back pain was completely relieved and the abdominal wall weakness significant improved.

LESSONS

This case highlighted that axial gout could mimic thoracic disk herniation clinically. The abdominal wall weakness might also be due to single T11 nerve compression by the tophaceous gout of the spine. In patients with a history of gout, axial gout should be considered as one of the differential diagnoses.

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.

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

Tophaceous gout of the spine is an underappreciated source of back pain in patients with or without neurological decline. It has been reported to occur in the cervical, thoracic and lumbar spine. Rarely, does it occur at more than one region of the spine. Advanced imaging with magnetic resonance imaging and computed tomography are usually not helpful in differentiating between infection, malignancy and gout. Clinician should have a high suspicion of spinal gout in patients with history of gout who presents with renal insufficiency, presence of peripheral tophi on exam, with elevated serum uric acid and creatinine levels, erythrocyte sedimentation rate and C-reactive protein. Here we present a case of a 23-year-old male with history of gout and chronic renal disease with progressive weakness in his lower extremities with new urinary incontinence who was found to have spinal gout with epidural infection of both the cervical and thoracic spine. Our patient was successfully managed with surgical decompression followed by medical treatment with antibiotics and steroids.

Minimally Invasive Excision of Lumbar Tophaceous Gout: Case Report

Background

Symptomatic spinal gout is relatively rare. Open laminectomy, with or without fusion, has been so far the standard treatment for symptomatic spinal gout. We describe here the first case of spinal tophaceus gout treated with minimally invasive surgery.

Methods

A 60-year-old patient, morbidly obese, with no previous history of gout, presented with neurogenic claudication due to severe lumbar canal stenosis at L3/4. Surgery was performed through a minimally invasive approach, using tubular retractors. During surgery, an extradural mass with a thin capsule and containing white "chalky" partially calcified material, slightly adherent to and compressing the theca, was removed.

Results

There were no intra- or perioperative complications. Surgery successfully improved the functional status, with a significant increase in walking distance and no residual leg pain or neurogenic claudication. Histopathology confirmed the diagnosis of spinal tophaceous gout.

Conclusions/Level of evidence

Although spinal gout is usually responsive to medical treatment, surgery is often the first line treatment, particularly in patients with neurological deficits. Would surgery be indicated, we believe that minimally invasive surgery can be effective in treating symptomatic spinal tophaceous gout. Level of Evidence: Class IV.

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.

Gout: An old disease in new perspective - A review

Gout is a picturesque presentation of uric acid disturbance. It is the most well understood and described type of arthritis. Its epidemiology is studied. New insights into the pathophysiology of hyperuricemia and gouty arthritis; acute and chronic allow for an even better understanding of the disease. The role of genetic predisposition is becoming more evident. The clinical picture of gout is divided into asymptomatic hyperuricemia, acute gouty arthritis, intercritical period, and chronic tophaceous gout. Diagnosis is based on laboratory and radiological features. The gold standard of diagnosis is identification of characteristic MSU crystals in the synovial fluid using polarized light microscopy. Imaging modalities include conventional radiography, ultrasonography, conventional CT, Dual-Energy CT, Magnetic Resonance Imaging, nuclear scintigraphy, and positron emission tomography. There is remarkable progress in the application of ultrasonography and Dual-Energy CT which is bound to influence the diagnosis, staging, follow-up, and clinical research in the field. Management of gout includes management of flares, chronic gout and prevention of flares, as well as management of comorbidities. Newer drugs in the pharmacological armamentarium are proving successful and supplement older ones. Other important points in its management include patient education, diet and life style changes, as well as cessation of hyperuricemic drugs.

Spinal gout: A review with case illustration

AIM

To summarize clinical presentations and treatment options of spinal gout in the literature from 2000 to 2014, and present theories for possible mechanism of spinal gout formation.

METHODS

The authors reviewed 68 published cases of spinal gout, which were collected by searching “spinal gout” on PubMed from 2000 to 2014. The data were analyzed for clinical features, anatomical location of spinal gout, laboratory studies, imaging studies, and treatment choices.

RESULTS

Of the 68 patients reviewed, the most common clinical presentation was back or neck pain in 69.1% of patients. The most common laboratory study was elevated uric acid levels in 66.2% of patients. The most common diagnostic image finding was hypointense lesion of the gout tophi on the T1-weighted magnetic resonance imaging scan. The most common surgical treatment performed was a laminectomy in 51.5% and non-surgical treatment was performed in 29.4% of patients.

CONCLUSION

Spinal gout most commonly present as back or neck pain with majority of reported patients with elevated uric acid. The diagnosis of spinal gout is confirmed with the presence of negatively birefringent monosodium urate crystals in tissue. Treatment for spinal gout involves medication for the reduction of uric acid level and surgery if patient symptoms failed to respond to medical treatment.

Gout in the Spine: Imaging, Diagnosis, and Outcomes

Gout is characterized by the deposition of monosodium urate crystals and by acute and chronic inflammation in response to crystals so deposited. Multiple case reports and series describe the deposition of monosodium urate in the spine as a rare manifestation of gout, but the actual prevalence of spinal involvement is unknown and likely to be higher than generally anticipated. Here we review the characteristics of 131 previously reported cases of spinal involvement in gout. We focus in particular on the use of imaging modalities and the extent to which they correlate with presenting symptoms and tissue diagnoses. The recent innovation of using dual-energy computerized tomography to identify urate crystal deposition holds promise for reducing the need for surgical intervention and for establishing a true prevalence rate for spinal gout.

Thoracic spinal cord compression by extradural tophus: a case report and review of the literature

STUDY DESIGN

Case report and literature review.

OBJECTIVES

Gouty arthritis of the spine is rare. Gout presenting as back pain and quadriplegia may be difficult to distinguish from a spinal tumor. Symptoms vary, and the diagnosis is often delayed. We report an unusual case of thoracic spinal cord compression caused by extradural tophaceous deposits whose initial diagnosis had been lymphoid malignancy. To the best of our knowledge, this is only the second report of using single-photon emission computed tomography (SPECT) to diagnose spinal tophus.

METHODS

We retrospectively reviewed the medical records, operative reports and radiographic imaging studies of a single patient.

RESULTS

A 26-year-old man with severe tophaceous gout presented with a 4-month history of progressive weakness and dyschesia of both lower extremities. Coronal bone slices evaluated by SPECT indicated increased methylene diphosphonate uptake in the T9 and T10 pedicles. Pathology assessment revealed areas of amorphous substance containing urate crystals surrounded by inflammatory cells. The diagnosis was gouty tophus.

CONCLUSION

The position of the spinal tophus may be related to the 'S' type of spinal anatomical structure. Obesity and inactivity may be the two risk factors for spinal tophus. Every effort should be made to lower the serum uric acid level by maximizing the pharmacological regimen. We believe that laminectomy can effectively relieve spinal cord compression. It also improves the long-term prognosis for spinal gouty tophus. SPECT may be a viable method for differentiating spinal gout and a malignant tumor.

Thoracic cord compression due to ligamentum flavum gouty tophus: a case report and literature review

Study design:

Here we describe a patient who developed myelopathy due to gouty tophi of the ligamentum flavum in the thoracic spine. We also review similar cases previously reported in the literature.

Objective:

Our aim was to present a case of myelopathy due to thoracic spinal gouty tophus.

Methods:

We report the case of a 56-year-old male with history of peripheral gout and renal insufficiency. The patient complained of back pain and paraparesis of the left lower limb. Multiple tophi were noted over several interphalangeal and metatarsophalangeal joints. Neurological examination showed decreased left lower limb strength and a positive Babinski sign. Magnetic resonance imaging of the thoracic spine revealed hypertrophy of the ligamentum flavum at the level of T3/T4, T5/T6, T9/T10, T10/T11 and T11/T12.

Results:

A thoracic laminectomy at T1-T5 was performed. Chalky white granular material was found in the ligamentum flavum during surgery. Histological analysis of the specimen demonstrated a gouty tophus. The patient's back pain and paraparesis of the lower left limb improved.

Conclusion:

The clinician should include spinal gout in the differential diagnosis when dealing with patients with gout and axial pain with or without neurologic deficits. If this diagnosis is seriously entertained, then a CT scan or magnetic resonance imaging as well as tissue biopsy may be needed to establish the diagnosis.

Gout initially mimicking rheumatoid arthritis and later cervical spine involvement

Gout is clinically characterized by episodes of monoarthritis, but if not treated properly, it can lead to a chronic polyarthritis, which may eventually mimic rheumatoid arthritis (RA). We present the case of a 59-year-old man, with a history of symmetrical polyarthritis of the large and small joints with later development of subcutaneous nodules, which was initially misdiagnosed as RA, being treated with prednisone and methotrexate for a long period of time. He complained of occipital pain and paresthesia in his left upper limb, and computed tomography (CT) and magnetic resonance imaging (MRI) revealed the presence of an expansive formation in the cervical spine with compression of the medulla. He was admitted for spinal decompressive surgery and the biopsy specimen demonstrated a gouty tophus. Chronic gout can mimic RA and rarely involves the axial skeleton, and thus its correct diagnosis and the implementation of adequate therapy can halt the development of such damaging complications.

Gout in the spine

Axial gout can affect all segments of the spine. It is manifested as back pain, as pain associated with neurological symptoms, and as neurological impairment without pain in 17.9%, 75.8% and 4.2% of cases, respectively. These manifestations were the first presentation of gout in many patients. Although x-rays as well as computed tomography and especially magnetic resonance scans can be very suggestive, histopathological, cytological and crystal analyses are the diagnostic gold standard. In most cases involving neurological manifestations, the patient underwent surgery, leading to satisfactory results. There are, however, some reports of full recovery following the usual clinical treatment for gout, suggesting that such treatment may be the initial option for those subjects with a history of gout and radiological findings of axial involvement.

Advanced imaging in gout

OBJECTIVE

The purpose of this article is to describe the role of advanced imaging using ultrasound, CT, and MRI in the assessment and diagnosis of gout.

CONCLUSION

Dual-energy CT can quantitatively identify monosodium urate crystal deposits with high sensitivity and specificity within joints, tendons, and periarticular soft tissues. There are several characteristic ultrasound imaging findings, which include visualization of echogenic monosodium urate crystal deposition, tophus, and adjacent erosions. MRI is sensitive in showing soft-tissue and osseous abnormalities of gout, although the imaging findings are not specific. Gout commonly involves specific joints and anatomic structures, and knowledge of these sites and imaging appearances are clues to the correct diagnosis.

Tophaceous gout of the spine causing neural compression

Gout is a common metabolic disease in which monosodium urate crystals called tophi develop. Spinal involvement in gout resulting in neural compression is unusual. We describe a case of a 64-year-old man with a history of gouty arthritis of the knee. The patient presented with thoracic myelopathy and radiculopathy. Imaging of the spine revealed an extradural mass lesion with bony erosion of the thoracic spine. A decompressive operation was performed, and a chalky white material was found. Histopathological examination confirmed a gouty tophus. The symptoms of spinal gout vary and its radiological features are not sufficiently specific to provide a definite diagnosis. Therefore, in patients with a history of gouty arthritis who present with neural compressive symptoms of the spine, spinal gout should be strongly suspected.

When gout involves the spine: five patients including two inaugural cases

Spinal involvement is uncommon during gout and may raise diagnostic challenges. We describe five cases seen at a single center.

METHODS

We retrospectively reviewed the medical charts of the five patients with spinal gout seen over a 3-year period.

RESULTS

There were four men and one woman with an age range of 52 to 87 years. One patient presented with acute neck pain and visualization by imaging studies of a discovertebral tophus, another had febrile arthritis of a lumbar facet joint, and a third presented with a synovial cyst in a lumbar facet joint. The remaining two patients had acute febrile discitis confirmed by magnetic resonance imaging, at the cervical spine and lumbar spine, respectively. Laboratory tests showed systemic inflammation in four patients and marked serum uric acid elevation in two patients. Only three patients reported a previous history of peripheral acute gout attacks. Specimens of the spinal lesions were obtained in three patients and consistently showed monosodium urate crystals with tissue inflammation or a tophus. The outcome was rapidly favorable, either with colchicine therapy alone in four patients or after surgical resection of a facet joint cyst (during surgery to stabilize the lumbar spine) in the remaining patient. The patient with neck pain due to a tophus experienced nerve root pain at the acute phase. No other neurological manifestations were recorded.

CONCLUSION

These case reports illustrate the diagnostic challenges raised by spinal involvement due to gout. The spinal lesions can be inaugural, as seen in two of our five patients.

Imaging of gout: an overview

The diverse clinical states and sites of pathology in gout provide challenges when considering the features apparent on imaging. Ideally, an imaging modality should capture all aspects of disease including monosodium urate crystal deposition, acute inflammation, tophus, tissue remodelling and complications of disease. The modalities used in gout include conventional radiography, ultrasonography, magnetic resonance imaging, computed tomography and dual-energy computed tomography. This review discusses the role of each of these imaging modalities in gout, focussing on the imaging characteristics, role in gout diagnosis and role for disease monitoring. Ultrasonography and dual-energy computed tomography are particularly promising methods for both non-invasive diagnosis and monitoring of disease. The observation that ultrasonographic appearances of monosodium urate crystal deposition can be observed in patients with hyperuricaemia but no other clinical features of gout raises important questions about disease definitions.

MRI of spinal bone marrow: part 2, T1-weighted imaging-based differential diagnosis

OBJECTIVE

The purpose of this article is to review the structure of bone marrow and the differential diagnosis of bone marrow pathology on the basis of T1-weighted MRI patterns.

CONCLUSION

Bone marrow is an organ that is evaluated routinely during MRI of the spine, particularly lumbar spine evaluation. Thus, it is one of the most commonly performed MRI examinations. T1-weighted MRI is a fundamental sequence in evaluating spinal marrow, and an understanding of T1-weighted MR signal abnormalities is important for the practicing radiologist.

Magnetic Resonance Imaging Bone Edema Is Not a Major Feature of Gout Unless There Is Concomitant Osteomyelitis: 10-year Findings from a High-prevalence Population

Objective.

Magnetic resonance imaging (MRI) is commonly used in autoimmune inflammatory arthritis to define disease activity and damage, but its role in gout remains unclear. The aim of our study was to identify and describe the MRI features of gout.

Methods.

Over a 10-year period we identified patients with gout who underwent MRI scanning of the hands or feet. Scans were reviewed for erosions, synovitis, tenosynovitis, tendinosis, bone edema, and tophi by a musculoskeletal radiologist and 2 rheumatologists in a blinded manner. MRI features in patients with uncomplicated gout were compared with features where concomitant osteomyelitis was diagnosed.

Results.

A total of 47 patients with gout (51 scans) were included: 33 (70%) had uncomplicated gout and 14 (30%) had gout complicated by osteomyelitis. MRI features included tophi in 36 scans (71%), erosions in 35 (69%), bone edema in 27 (53%), synovitis in 15 (29%), tenosynovitis in 8 (16%), and tendinosis in 2 (4%). Uncomplicated gout and gout plus osteomyelitis did not differ for most MRI features. However, “severe bone marrow edema” was much more common in gout plus osteomyelitis, occurring in 14/15 scans (93%) compared with 3/36 scans (8%) in uncomplicated gout (OR 154.0, 95% CI 14.7–1612, p < 0.0001). Sensitivity and specificity of “severe bone edema” for concomitant osteomyelitis were 0.93 (95% CI 0.68–0.99) and 0.92 (95% CI 0.78–0.98), respectively.

Conclusion.

MRI reveals that gout affects the joints, bones, and tendons. Bone edema in patients with chronic tophaceous gout is frequently mild and this contrasts with the “severe bone edema” observed in patients with concomitant osteomyelitis.

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

Tophaceous gout of the spine is rare. We report here the case of a 68-year-old man with long-standing peripheral gouty arthritis who developed a progressive and painful weakness of the lower extremities. Radiological and histopathological findings confirmed the presence of tophaceous gout of the spine. Also presented is the case history, including the radiological and histopathological findings, and a discussion of the literature.

Spinal gout tophus: a very rare cause of radiculopathy

Gout is a common metabolic disease characterized by the development of arthritis and nephropathy related to the deposition of monosodium urate crystals within the joints, periarticular tissues, skin and kidneys. Tophus formation seen around the spinal column is very rare, while occurrences of spinal gout tophus without systemic gout disease are much more unique. In our study, we report a spinal gout case that presented with right sciatica without previous history of systemic gout disease.

Tophaceous gout of the knee: revisiting MRI patterns in 30 patients

OBJECTIVE

To evaluate the locations and associated erosions of tophaceous gout in the knee and to reevaluate its characteristic magnetic resonance imaging features.

MATERIALS AND METHODS

We performed a retrospective review of the magnetic resonance (MR) images of the knees of 30 patients with histopathologically confirmed gouty tophi. Each tophaceous lesion was evaluated for location, morphology, signal intensity, and associated bone erosion or intraosseous involvement.

RESULTS

The tophaceous masses were commonly located on the medial aspect of the infrapatellar fat pad and anterior joint recess (n = 28, 87%), the space adjacent to the lateral rim of the lateral femoral condyle (n = 25, 78%), and the intercondylar fossae (n = 22, 69%). All tophaceous lesions showed similar signal characteristics (low-intermediate signal intensities on T1-weighted images, with heterogeneous signal intensities on T2-weighted images), and 3 morphologic patterns were observed: amorphous masses (n = 27), linear crystalline-like deposits (n = 6), and cystic lesions of the bursae around the knee (n = 3). Associated bone erosions occurred in the lateral rim of the lateral femoral condyle (n = 8), the roof of the intercondylar notch (n = 7), the tibial eminence (n = 5), and the medial and lateral rim of the tibial plateau (n = 3). Intraosseous tophi were seen in the tibial plateau (n = 3) and patella (n = 1).

CONCLUSION

Knowledge of the common locations and associated erosions of tophaceous gout and its characteristic MR appearance may facilitate its correct diagnosis with magnetic resonance imaging, particularly in patients with no clinical symptom or only an isolated lesion on MR images.

Tumoural calcinosis of the cervical spine: case report, pathogenesis and differential diagnosis

A rare case of tumoural calcinosis of the cervical spine is presented. Tumoural calcinosis presents with masses of dystrophic calcification in juxta-articular areas. It is very rare in the cervical spine with few cases described in the literature so far. It remains part of the differential diagnosis for any calcified spinal compressive lesion.

Gout in the Axial Skeleton

Objective.

Gout typically affects the peripheral joints of the appendicular skeleton and rarely involves the axial joints. The literature on axial gout is limited to case reports and case series. This preliminary study was conducted to identify the frequency and characteristics of axial gout.

Methods.

Six hundred thirty medical records with ICD codes 274.0, 274.82, and 274.9 for peripheral gout were reviewed. Ninety-two patients had clinical or crystal-proven gout, of which 64 had prior computed tomography (CT) images of the spine performed for various medical reasons. These CT images were reviewed for features of axial gout, which include vertebral erosions mainly at the discovertebral junction and the facet joints, deposits of tophi, and erosions in the vertebral body, epidural space, ligamentum flavum and pars interarticularis.

Results.

Nine of the 64 patients had radiographic changes suggestive of axial gout. Lumbar vertebrae were most commonly involved, with facet joint erosions being the most common finding. Isolated involvement of the sacroiliac joints was seen in 2 patients. Axial gout had been diagnosed clinically in only one patient.

Conclusion.

Radiologic changes of axial gout were more common than recognized clinically, with a frequency of 14%. Since not all patients had CT images, it is possible that the frequency of axial involvement was even greater. A prospective study is needed to further define this process.

Bacteremia coexisting with tophaceous gout of the spine mimicking spondylodiscitis: a case report

STUDY DESIGN

A case report and review of the literature.

OBJECTIVE

To report a rare case of bacteremia coexisting with spinal gout initially suspected as pyogenic spondylodiscitis.

SUMMARY OF BACKGROUND DATA

Gouty spine is a rare disease. It is even rare when coexisting with bacteremia. The presentation as pain, fever, and positive blood culture will make it more difficult to distinguish from spinal infection.

METHODS

A 64-year-old woman with type II diabetes mellitus and chronic renal insufficiency was admitted to the emergency department with a fever of 39 degrees C, chills, and back pain. Laboratory studies revealed an elevated white count and neutrophils; her serum glucose level was 279 mg/dL. The C-reactive protein level was 25.55 mg/dL and serum uric acid was in the upper range of normal. Blood cultures revealed Escherichia coli, Klebsiella pneumoniae, and Enterococcus faecalis. Urine culture revealed 3 separate gram-negative bacilli. Magnetic resonance imaging of the spine revealed contrast enhancement in the L4-L5 and T5-T9 vertebral bodies. Infective spondylodiscitis of the lumbar and thoracic spine was suspected.

RESULTS

Because antibiotic treatment had failed, surgical debridement with diskectomy, partial corpectomy, and allogenous strut graft reconstruction (T8-T9) was performed. During the operation, 600 cc of pleural effusion was drained. Chalky white material was noted at the T8-T9 disc and the adjacent vertebral bodies. Cultures for bacteria, tuberculosis, and fungus were all negative. Histologic examination revealed deposition of eosinophilic crystal-like material, and a diagnosis of tophaceous gout of the spine was established.

CONCLUSION

This is, to our knowledge, the first case of bacteremia coexisting with multiple areas of tophaceous gout of the spine. Although uncommon, gouty spine should be added into the differential diagnosis of patients with back pain and bacteremia.

Crystal arthropathy of the lumbar spine: a report of 4 cases

Gout or pseudogout, caused by deposition of crystals, rarely affects the spine. We report 4 cases with gout or pseudogout in the lumbar spine. Two had cauda equina syndrome and another 2 had spinal stenosis. To avoid unnecessary surgery, this should be considered in the differential diagnosis when treating patients with histories of gout or pseudogout for spinal problems.

A rare cause of spinal cord compression: imaging appearances of gout of the cervical spine

Gout is a metabolic disorder typically affecting the peripheral joints, more commonly in males. Spinal involvement is uncommon and is usually associated with hyperuricemia. We present the imaging findings of a case of spinal gout in a female patient with no previous history of hyperuricaemia, involving multiple spinal segments.

Spinal gout in a renal transplant patient: a case report and literature review

BACKGROUND

Gout in the axial spine is rare. We present a case report on a renal transplant patient who developed fever and acute back pain at the L5 through S1 level secondary to sodium urate deposits. We review the literature on this rare disease and propose a management algorithm based on a resulting analysis.

CASE DESCRIPTION

A 37-year-old man with a history of gout and a renal transplant for IgA nephropathy presented with acute back pain and fever without evidence of neurological deficits. Magnetic resonance imaging revealed a uniformly contrast-enhancing infiltrative process involving the right pedicle, lamina, and inferior facet of the L5 vertebra. Computed tomography-guided needle biopsy revealed a friable white tissue consistent with sodium urate crystals. Conservative treatment with steroids and narcotics was used with good symptomatic relief.

CONCLUSION

Although few cases of gout involving the spine have been reported, its prevalence is likely grossly underestimated. Most patients have a history of gout and have elevated levels of serum urate level on presentation. The disease most commonly involves the lumbar spine. Patients usually have neurological deficits on presentation, and surgical decompression produces favorable outcomes. However, conservative medical management is appropriate for those with back pain only. Aggressive control of hyperuricemia is essential regardless of the method of treatment.