Foraminal stenosis and radiculopathy secondary to tophaceous gout: illustrative case

Patrick Chang College of Medicine, Drexel University, Philadelphia, Pennsylvania

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Brandon C Rogowski College of Medicine, Drexel University, Philadelphia, Pennsylvania

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Khaled Abdel Aziz College of Medicine, Lake Erie College of Osteopathic Medicine, Erie, Pennsylvania; and

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Rosh Bharthi College of Medicine, Lake Erie College of Osteopathic Medicine, Erie, Pennsylvania; and

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Lance Valls Department of Neurosurgery, Allegheny Health Network, Pittsburgh, Pennsylvania

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Nathan Esplin Department of Neurosurgery, Allegheny Health Network, Pittsburgh, Pennsylvania

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Richard W Williamson Department of Neurosurgery, Allegheny Health Network, Pittsburgh, Pennsylvania

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BACKGROUND

Tophaceous gout is a severe form of gout that results in the formation of large nodules, or tophi, in the affected joints and surrounding tissues. Gouty tophi in the spine have a constellation of presentations that often mimic other pathologies and may not be easily discernable from more common pathologic processes.

OBSERVATIONS

A 47-year-old female with a history of chronic renal disease, obesity, gout, inflammatory polyarthritis, and multiple sclerosis presented with 6 months of low-back pain and lumbar radiculopathy affecting the right lower extremity. A lumbar magnetic resonance imaging study revealed right foraminal stenosis and spondylolisthesis at levels L4–5. An intraspinal extradural mass was noted adjacent to the traversing right L5 and exiting right L4 nerve roots. A bilateral decompressive laminectomy, facetectomy, and foraminotomy of L4–5 was performed. A calcific, chalky-white mass was discovered in the foramen, and pathology determined the specimen to be a gout tophus. Postoperatively, the patient endorsed the resolution of her preoperative symptoms, which have not returned on follow-up.

LESSONS

Reports of gouty depositions compressing the spinal cord in the current literature are relatively rare. Although the diagnosis of gouty tophi can only be confirmed histologically, patient history may serve as a helpful diagnostic tool.

ABBREVIATIONS

MRI = magnetic resonance imaging

BACKGROUND

Tophaceous gout is a severe form of gout that results in the formation of large nodules, or tophi, in the affected joints and surrounding tissues. Gouty tophi in the spine have a constellation of presentations that often mimic other pathologies and may not be easily discernable from more common pathologic processes.

OBSERVATIONS

A 47-year-old female with a history of chronic renal disease, obesity, gout, inflammatory polyarthritis, and multiple sclerosis presented with 6 months of low-back pain and lumbar radiculopathy affecting the right lower extremity. A lumbar magnetic resonance imaging study revealed right foraminal stenosis and spondylolisthesis at levels L4–5. An intraspinal extradural mass was noted adjacent to the traversing right L5 and exiting right L4 nerve roots. A bilateral decompressive laminectomy, facetectomy, and foraminotomy of L4–5 was performed. A calcific, chalky-white mass was discovered in the foramen, and pathology determined the specimen to be a gout tophus. Postoperatively, the patient endorsed the resolution of her preoperative symptoms, which have not returned on follow-up.

LESSONS

Reports of gouty depositions compressing the spinal cord in the current literature are relatively rare. Although the diagnosis of gouty tophi can only be confirmed histologically, patient history may serve as a helpful diagnostic tool.

ABBREVIATIONS

MRI = magnetic resonance imaging

Gout is a metabolic disorder that results from the accumulation of uric acid crystals in joints and soft tissues.1 Tophaceous gout is a severe form of gout that results in the formation of large nodules, or tophi, in the affected joints and surrounding tissues.1 Although gout most commonly affects the joints of the hands and feet, it can also affect the spine, leading to tophaceous deposits and potential neurological symptoms.2 Depending on location, gouty tophi in the spine have a constellation of presentations that often mimic other much more common pathologies such as nerve root compression from disc herniation or synovial cyst formation.3

There is limited literature available on tophaceous gout in the spine, mostly rare case reports or small series with some literature reviews.2–7 These reviews found that the most common site of involvement was the lumbar spine, followed by the cervical and thoracic spine.8,9 Furthermore, tophi were more likely to occur in the posterior elements of the spine, particularly the facet joints and spinous processes, with less common involvement of the vertebral bodies and intervertebral discs.9,10 Patients with spinal involvement tended to have longer disease duration, higher serum uric acid levels, and more severe tophaceous deposits in other joints.9

We present a unique presentation of tophaceous gout mimicking a herniated disc versus synovial cyst causing foraminal stenosis with radiculopathy.

Illustrative Case

The patient was a 47-year-old female with a past medical history significant for gout, inflammatory polyarthritis, chronic kidney disease, and obesity. She presented with 7 months of low-back pain and lumbar radiculopathy affecting the right lower extremity. On physical examination, she had full strength in both lower extremities. She reported numbness, tingling, and a sharp, shooting pain that began in her low lumbar back and radiated into her right buttocks and posterior leg. She received two steroid injections with only brief relief. She had prior episodes of gout flair ups that presented as joint pain with no tophus formation. They had been successfully treated with colchicine, with her most recent episode occurring approximately 3 months prior to her presentation in clinic.

A basic metabolic panel was significant for an elevated blood urea nitrogen of 30 mg/dL, creatinine of 2.7 mg/dL, and uric acid of 11.1 mg/dL. Magnetic resonance imaging (MRI) without contrast of the lumbar spine revealed an intraspinal, extradural, compressive mass causing right foraminal stenosis at L4–5 (Figs. 1 and 2), believed to be a calcific disc herniation or synovial cyst. The patient was taken to the operating room for a decompressive laminectomy, facetectomy, foraminotomy, and instrumented fusion of L4–5. A chalky, partially calcified mass was removed from this region in a piecemeal fashion and was sent to pathology. Histologically, the specimen appeared as a dense fibrovascular connective tissue with amorphous material and granulomatous reaction, and a diagnosis of gout tophus was made. Postoperatively, the patient reported significant improvement in her preoperative symptoms. Postoperative MRI with contrast of the lumbar spine showed significant improvement of the foraminal stenosis (Figs. 3 and 4) and she was discharged on postoperative day 3. At her 1-month follow-up, the patient reported complete resolution of her symptoms.

FIG. 1
FIG. 1

Preoperative sagittal (A) and axial (B) MRI studies of the lumbar spine without contrast highlighting, an intraspinal, extradural, compressive mass causing right foraminal stenosis at L4–5.

FIG. 2
FIG. 2

Preoperative T1-weighted sagittal MRI study of the lumbar spine without contrast, highlighting an intraspinal, extradural, compressive mass causing right foraminal stenosis at L4–5.

FIG. 3
FIG. 3

Postoperative sagittal (A) and axial (B) T2-weighted MRI studies of the lumbar spine without contrast, highlighting complete removal of the mass and successful decompression of the right L4–5 foramen.

FIG. 4
FIG. 4

Postoperative T1-weighted sagittal MRI study of the lumbar spine without contrast, highlighting complete removal of the mass and successful decompression of the right L4–5 foramen.

Patient Informed Consent

The necessary patient informed consent was obtained in this study.

Discussion

Observations

Gout, a condition in which uric acid crystals deposit in tissues and joints, can also affect the spine. Deposits of gouty tophus in the spine often arise from posterior elements of the spine particularly the facet joints and spinous processes.4 The formation of gouty tophi in these areas may be due to the increased inflammation caused by injury or degenerative conditions, triggering the cascade of gouty tophus formation.1,4 The diagnosis of spinal gouty tophus can be complicated because it presents with similar symptoms and imaging characteristics as other compressive spinal pathologies. This can lead to misdiagnosis and delayed treatment. For example, there have been cases in which spinal gouty tophus was initially diagnosed as tuberculous tenosynovitis or even malignancy due to the heterogeneous, hyperintense morphology of the lesion.2,6 Although lumbar spinal manifestations are the most common, the literature suggests that a tophus arising from vertebral body or disc space, as in this case, is exceedingly rare.4,9

Among the cases of spinal gout tophus in the current literature, the main reported similarity is an initial presentation of axial back pain in the setting of diagnosed gout, often already complicated by gouty tophi at nonspinal sites.10 Lumbar spinal manifestations are reportedly the most common.4 Currently, gouty tophus can only be diagnosed histologically through biopsy.9 The symptomatic and radiological mimicry of gouty tophus to other compressive spinal pathologies thus highlights the point that a history of diagnosed gout with complaints of axial back pain can be diagnostic indications to consider gouty tophus as part of the differential.9,10 In our case, the patient did have a history of gout and an elevated uric acid level, but no history of tophi.

The commonality of symptoms and nonspecific imaging characteristics elicited by spinal gouty tophus with other compressive spinal pathologies complicates the differential diagnoses at initial presentation and diagnostic imaging. Kostman et al.6 reported two cases initially diagnosed as tuberculous tenosynovitis that were later discovered to be gouty tophi when symptoms persisted refractory to antibiotics. Dwarki et al.2 illustrated gouty tophus masked as a malignancy on MRI due to the heterogeneous, hyperintense morphology of the lesion. Other case reports of gout tophus in the spine demonstrate a similar morphology to other intraspinal compressive morphologies with nonspecific overgrowth into surrounding tissues.1–10

Considering this early diagnosis could allow earlier specific treatment. Patients with radicular back pain, features of a mass on imaging, and active gout symptoms can be prescribed urate-lowering medications or increase their current medication dosage. If symptoms are resistant to gout medications or a significant mass is present, both of which were true for this patient, then surgical management would be considered appropriate. Although this pathophysiology is rare for intraspinal masses, it is an opportunity to treat patients conservatively and avoid surgical costs and complications.

Overall, although tophaceous gout in the spine is a rare complication of gout, it can lead to significant symptoms such as spinal cord compression and radiculopathy. Treatment typically involves a combination of medical management to reduce uric acid levels and surgical intervention to remove the tophi in severe cases.4

Lessons

The rare occurrence and lack of noninvasive diagnostic modalities for gouty tophus in the spine have contributed to the misdiagnoses and incidental findings of these cases. Toprover et al.10 demonstrated some evidence that there is comparable symptomatic resolution between surgical and pharmacological management of gouty tophus in the spine. As physicians become more aware of this pathology, an improved time to diagnosis with less invasive and cost-effective strategies will avoid subjecting patients to unnecessary medications, tests, or surgeries. Further work must be done to develop more standardized diagnostic criteria and treatments for patients presenting with spinal gout, and it should be considered in the differential for space occupying lesions in the lumbar spine in the setting of history of gout, even when there are no other tophi present.

Author Contributions

Conception and design: Rogowski, Aziz, Esplin, Williamson. Acquisition of data: Chang, Rogowski, Aziz, Esplin, Williamson. Analysis and interpretation of data: Rogowski, Aziz, Esplin, Williamson. Drafting the article: Chang, Rogowski, Aziz, Bharthi, Esplin. Critically revising the article: Chang, Rogowski, Bharthi, Valls, Esplin, Williamson. Reviewed submitted version of manuscript: Chang, Rogowski, Bharthi, Valls, Esplin, Williamson. Approved the final version of the manuscript on behalf of all authors: Chang. Administrative/technical/material support: Valls. Study supervision: Williamson.

Supplemental Information

Previous Presentations

An abstract of this case was presented as a poster presentation at the annual Pennsylvania Neurological Society Research Meeting, July 14–15, 2023, in Hershey, Pennsylvania.

References

  • 1

    Dalbeth N, Choi HK, Joosten LAB, et al. Gout. Nat Rev Dis Primers. 2019;5(1):69.

  • 2

    Dwarki K, Dothard A, Abadie B, Miles MC. Rogue one: a story of tophaceous gout in the spine. BMJ Case Rep. 2018;2018:bcr2017221163.

  • 3

    Fenton P, Young S, Prutis K. Gout of the spine. Two case reports and a review of the literature. J Bone Joint Surg Am. 1995;77(5):767771.

  • 4

    Jegapragasan M, Calniquer A, Hwang WD, Nguyen QT, Child Z. A case of tophaceous gout in the lumbar spine: a review of the literature and treatment recommendations. Evid Based Spine Care J. 2014;5(1):5256.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Gines R, Bates DJ. Tophaceous lumbar gout mimicking an epidural abscess. Am J Emerg Med. 1998;16(2):216.

  • 6

    Kostman JR, Rush P, Reginato AJ. Granulomatous tophaceous gout mimicking tuberculous tenosynovitis: report of two cases. Clin Infect Dis. 1995;21(1):217219.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Sanmillan Blasco JL, Vidal Sarro N, Marnov A, Acebes Martín JJ. Cervical cord compression due to intradiscal gouty tophus: brief report. Spine (Phila Pa 1976). 2012;37(24):E1534E1536.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Konatalapalli RM, Lumezanu E, Jelinek JS, Murphey MD, Wang H, Weinstein A. Correlates of axial gout: a cross-sectional study. J Rheumatol. 2012;39(7):14451449.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Elgafy H, Liu X, Herron J. Spinal gout: a review with case illustration. World J Orthop. 2016;7(11):766775.

  • 10

    Toprover M, Krasnokutsky S, Pillinger MH. Gout in the spine: imaging, diagnosis, and outcomes. Curr Rheumatol Rep. 2015;17(12):70.

  • Collapse
  • Expand
  • FIG. 1

    Preoperative sagittal (A) and axial (B) MRI studies of the lumbar spine without contrast highlighting, an intraspinal, extradural, compressive mass causing right foraminal stenosis at L4–5.

  • FIG. 2

    Preoperative T1-weighted sagittal MRI study of the lumbar spine without contrast, highlighting an intraspinal, extradural, compressive mass causing right foraminal stenosis at L4–5.

  • FIG. 3

    Postoperative sagittal (A) and axial (B) T2-weighted MRI studies of the lumbar spine without contrast, highlighting complete removal of the mass and successful decompression of the right L4–5 foramen.

  • FIG. 4

    Postoperative T1-weighted sagittal MRI study of the lumbar spine without contrast, highlighting complete removal of the mass and successful decompression of the right L4–5 foramen.

  • 1

    Dalbeth N, Choi HK, Joosten LAB, et al. Gout. Nat Rev Dis Primers. 2019;5(1):69.

  • 2

    Dwarki K, Dothard A, Abadie B, Miles MC. Rogue one: a story of tophaceous gout in the spine. BMJ Case Rep. 2018;2018:bcr2017221163.

  • 3

    Fenton P, Young S, Prutis K. Gout of the spine. Two case reports and a review of the literature. J Bone Joint Surg Am. 1995;77(5):767771.

  • 4

    Jegapragasan M, Calniquer A, Hwang WD, Nguyen QT, Child Z. A case of tophaceous gout in the lumbar spine: a review of the literature and treatment recommendations. Evid Based Spine Care J. 2014;5(1):5256.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Gines R, Bates DJ. Tophaceous lumbar gout mimicking an epidural abscess. Am J Emerg Med. 1998;16(2):216.

  • 6

    Kostman JR, Rush P, Reginato AJ. Granulomatous tophaceous gout mimicking tuberculous tenosynovitis: report of two cases. Clin Infect Dis. 1995;21(1):217219.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Sanmillan Blasco JL, Vidal Sarro N, Marnov A, Acebes Martín JJ. Cervical cord compression due to intradiscal gouty tophus: brief report. Spine (Phila Pa 1976). 2012;37(24):E1534E1536.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Konatalapalli RM, Lumezanu E, Jelinek JS, Murphey MD, Wang H, Weinstein A. Correlates of axial gout: a cross-sectional study. J Rheumatol. 2012;39(7):14451449.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Elgafy H, Liu X, Herron J. Spinal gout: a review with case illustration. World J Orthop. 2016;7(11):766775.

  • 10

    Toprover M, Krasnokutsky S, Pillinger MH. Gout in the spine: imaging, diagnosis, and outcomes. Curr Rheumatol Rep. 2015;17(12):70.

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