June 2003 Case of the Month

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History: The patient is a 50-year-old man who has had ever increasing back pain over the past year. This is his first spine study. He has characteristic changes in his hands.

Compiled by: Dennis K. Bielecki, MD, 06/01/03

Image 1 and 1A: Almost mid-sagittal T2 image of the lumbar spine.

The image demonstrates lumpy bumpy low signal masses involving the L5-S1, L4-5 and L3-4 disc spaces that almost totally obliterate the intervertebral discs, and erode into the bony endplates of the adjacent vertebral bodies. No osteoedema is appreciated. The spinal canal is impinged upon by these masses at all three levels, but more so at L5-S1. These masses are indicated by yellow arrows on the adjacent image. A red arrow indicates the most prominent cord impingement at L5-S1.

Image 2 and 2A: Sagittal T2 image through the facet joints of the spine

Here we see that these low signal masses impinge upon but also involve the apophyseal joints at L5-S1, L4-L5, and L3-4, almost totally obliterating the intervertebral foramen at L5-S1 and substantially encroaching on the foramina of L4-5 and L3-4. (The masses are indicated by yellow arrows on the adjacent image, and the points of foraminal impingement are indicated by red arrows. Note the foramen at L2-3 (Green arrowheads) are the normal oval configuration.

PATHOLOGY: Needle biopsy of these masses was consistent with gouty tophi filled with urate crystals.

DIAGNOSIS: Gout with spinal involvement

DISCUSSION:

Spinal manifestations of gout are extremely uncommon. Tkach and others noted vertebral osteophytosis in gouty patients. Although many have observed patients with gout whose radiographs of the spine revealed diffuse idiopathic skeletal hyperostosis, the two conditions may not be related, as spinal osteophytosis is extremely common in elderly patients.

Documented urate deposition in the spine is exceedingly rare. Associated radiographic abnormalities in the cervical segment include erosions of the odontoid process or endplates of the vertebral bodies, disc space narrowing, and vertebral subluxation. Spinal cord compression has been reported as a complication of gout. Patients with myeloradiculopathy, which resulted from intraspinal compression of neural elements from urate deposition, have been found to have extradural defects that were noted on myelography and confirmed on histologic examination. Erosions of the vertebral bodies or posterior elements of the lumbar spine in patients with gout were described by Forrester and Nesson in 1973 and more recently by Burnham and coworkers and Lagier and MacGee. In these patients radiographic findings in the vertebrae were typical for gout and were associated with extensive involvement at multiple areas in the axial and extra-axial skeleton, as seen in this patient. Discovertebral changes in gout, however, may resemble those of infection or intervertebral osteochondrosis. Rarely, gouty changes are observed in the axial skeleton when alterations in the appendicular skeleton are not prominent.

REFERENCES:

Resnick, D: Diagnosis of Bone and Joint Disorders, 3rd Ed. 1995.