gms | German Medical Science

Symptomatic gout tophi of the spine are a rare complication of tophaceous gout. There are no typical symptoms and the tophus frequently mimics a spinal infection or tumor. We here report on a case history of a large lumbar gout tophus together with intraoperative, MRI and histological findings.

A 29-year-old previously healthy patient presenting with a L5 radiculopathy was refered to our department. The lumbar MRI revealed a 4.5x4.5x2.8 cm large process which enhanced contrast. It destroyed both L4/L5 facet joints and the left lamina L4 and further spread epidurally from L3 to L5 with compression of the left L5 root. There was no fever, but CRP and leucocyts were marginally elevated. Pain was resistant to conservative treatment and due to the destroying process with contrast enhancement, we saw an indication for surgery.

An open biopsy was performed and the left sided L5 root was decompressed. The lesion consisted of chalky white material, all cultures taken remained sterile. The histological examination showed the typical picture of a gouty tophus with aggregates of urate crystals surrounded by an intense inflammatory reaction.

To our knowledge, our patient’s lesion is the largest ever published spinal gouty tophus. In line with previously reported cases of spinal gout tophus, its MRI appearance imitates an abscess or a malignant tumor. If gout is suspected and if there is no need for emergent decompression of neuronal structures, a CT-guided fine needle biopsy can establish the diagnosis. Then the pharmacological treatment should be optimized in order to prevent surgical procedures. In addition, the diagnosis of spinal gout will frequently be missed unless a histological examination is performed. The case report presented illustrates that despite all means of today’s radiology gout is still “the great deceiver” and has to be considered in cases of spinal infections without positives cultures.