Gout in the spine

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Axial gouty arthropathy.
Saketkoo LA, Robertson HJ, Dyer HR, Virk ZU, Ferreyro HR, Espinoza LR.
Am J Med Sci. 2009 Aug;338(2):140-6. (http://journals.lww.com/amjmedsci/pages/articleviewer.aspx?year=2009&issue=08000&article=00012&type=abstract)
Gouty involvement of the spinal column is not as rare as generally perceived. Tophaceous gout involving the spinal column is a well-documented cause of myelopathy and frank cord compression. It takes several years of gout before bony destruction is radiologically apparent. If erosive or tophaceous gout is present, magnetic resonance imaging signal enhancement offers diagnostic guidance. Non-tophaceous gout of the spine may also show signal enhancement consistent with inflammation. The sequelae of cord compression can be reversed with timely surgical intervention and maintenance of uric acid-lowering therapy; in some cases, medical therapy alone can reverse the findings of radiculopathy. Growing evidence suggests that the tangled web of hypertension, diabetes, and atherosclerotic disease are risk factors for gout and hyperuricemia and may, in fact, be the result of higher than physiologically tolerable levels of uric acid in humans. Here, 52 additional cases to the 73 collated by Hou et al (Surg Neurol. 2007;67:65-73), reinforce that gout is a major contender on the differential diagnosis of back-related presentations in patients at high risk for gout. The pervasiveness of cardiovascular disease and chronic back pain warrants a closer look into a possible occult contributor to the prevalence of chronic back pain: gout.

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Fever and back pain - a case report of spinal gout.
Schorn C, Behr C, Schwarting A.
Dtsch Med Wochenschr. 2010 Jan;135(4):125-128 (http://www.ncbi.nlm.nih.gov/pubmed/20101555?dopt=Abstract)

HISTORY AND PHYSICAL FINDINGS: A 67-years-old man suffered from relapsing moderate fever and back pain after arthroscopy of the knee under peridural anaesthesia. Antibiotics given for suspected iatrogenic infection was started, but was without improvement. After 4 months under several antibiotic regimes his condition rapidly deteriorated with high fever, excruciating lumbar back pain associated with elevated ESR/WBC (ESR = erythrocyte sedimentation rate, WBC = white blood cell count) along with arthritis of the shoulders, wrists, knees and ankles. Physical findings comprised swelling and restricted movement of the affected joints as well as pain related stiffness and immobility of the spine, but no neurological abnormalities.

CLINICAL INVESTIGATIONS: An magnetic resonance imaging (MRI) of the lumbar spine revealed the uncommon finding of multilevel facet joint arthritis at lumbar L2/3 and L4/5, accompanied by cystic erosions of the lamina and widespread dorsal soft tissue edema. Serum uric acid was 11 mg/dl. Uric acid was found in the synovial fluid of the knees.

DIAGNOSIS, TREATMENT AND FOLLOW UP: The fever, spinal symptoms as well as imaging findings improved together with the peripheral arthritis when treatment with colchicine and steroids was started, establishing the diagnosis of spinal gout. In the following year, no further or back pain or fever occurred. Despite continued allopurinol therapy the gouty arthritis of the peripheral joints rrecurred.

CONCLUSION: Despite its rarity, spinal gout should be considered in the differential diagnosis of intractable backpain and fever especially when imaging studies reveal posterior element involvement.