Surgical versus pharmacologic treatment of intraspinal gout

A controversy between pharmacologic and surgical treatment of intraspinal gout exists in the literature. If gout is diagnosed timely, pharmacologic therapy may avert the need of surgery. The lack of readily available synovial fluid makes the diagnosis particularly difficult. The purpose of this study was to evaluate the clinical pictures and magnetic resonance imaging features in rapid differentiations of intraspinal gout. I retrospectively evaluated lumbar intraspinal tophaceous gout without the classic radiographic punched-out lesions. Four patients (average age, 65 years) had a history of hyper-uricemia with multiple tophaceous deposits in the joints or visceral organs or both. The common presentations were low back pain with or without inflammatory reaction (fever, elevated C-reactive protein level, and mild leukocytosis). The patients also presented with intermittent claudication or radiculopathy of variable duration or both. The gouty tophi yielded homogeneous and hypointense masses on T1- and T2-weighted images, with multiple hypointense speckles. The masses were located in bilateral lumbar facet joints in all patients, with additional midline extension along the ligamentum flavum in three. All patients had uneventful outcomes after surgical decompression and pharmacologic treatment. Rapid deposition of tophi may aggravate nerve compression. If neurologic deficits are found, surgical decompression can provide a satisfactory outcome.