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Tophaceous gout of the lumbar spine mimicking pyogenic discitis
The Spine Journal 7 (2007) 94–99
Case Study
Tophaceous gout of the lumbar spine mimicking pyogenic discitis Kyung-Soo Suk, MDa,*, Ki-Tack Kim, MDa, Sang-Hun Lee, MDa, Sung-Woo Park, MDa, Yong-Koo Park, MDb a
Department of Orthopaedic Surgery, School of Medicine, Kyung-Hee University, Seoul, Korea b Department of Pathology, School of Medicine, Kyung-Hee University, Seoul, Korea Received 11 October 2005; accepted 14 January 2006
Abstract
BACKGROUND CONTEXT: Gout of the spine is very rare. Forty-one cases of gout affecting the spine have been reported. PURPOSE: To present a patient with tophaceous gout of the lumbar spine mimicking pyogenic discitis. STUDY DESIGN: Case report. METHODS: The medical record, including operative notes, progress notes, discharge summary, clinical notes, radiological study, and pathological studies was reviewed. RESULTS: The patient had acute low back pain and radiculopathy with high spiking fever. Therefore, pyogenic discitis was suspected. However, histological diagnosis revealed tophaceous gout. CONCLUSIONS: Tophaceous gout of the spine is very rare. However, when a patient presents with acute back pain and fever, spinal gout should be considered, particularly in a patient with a previous history of hyperuricemia or gout. Ó 2007 Elsevier Inc. All rights reserved.
Keywords:
Gout; Pyogenic discitis; Spine
Introduction Gout is a metabolic disease involving the peripheral joints. Gouty arthritis of the axial joints, the spine in particular, is very rare. Only 41 cases of gout involving the spine have been reported in the literature [1–8]. We present a case of gouty spondyloarthropathy which was initially suspected as pyogenic discitis. Case report A 55-year-old male patient had severe low back pain and radiating pain to both lower extremities that lasted for a week. He had a history of being an alcoholic who drank one bottle of Soju (Korean vodka) every day. During the past
FDA device/drug status: not applicable. Nothing of value received from a commercial entity related to this manuscript. * Corresponding author. Department of Orthopaedic Surgery, School of Medicine, Kyung Hee University, #1 Heogi-dong, Dongdamun-ku, Seoul, Korea, 130-702. Tel.: 822-958-8345; fax: 822-964-3865. E-mail address: [email protected] (K.-S. Suk) 1529-9430/06/$ – see front matter Ó 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.spinee.2006.01.009
7 days he did not eat any meals, but only drank alcohol to relieve severe low back pain. Physical examination revealed a fever of 40 C. There were erythematous changes and local heat on his left ankle. On the straight leg raising test, the right leg was raised 10 degrees, and the left leg, 30 degrees. Grade III (fair) motor weakness was found with the right ankle and big toe dorsiflexion. There was hypoesthesia on the right L4 and L5 sensory dermatome. There was no bladder or bowel involvement. The knee jerk reflex slightly decreased on bilateral knees (þ/þ), and the ankle jerk was normoactive. Blood cultures were negative. The white blood cell count increased to 14,800/mm3 (normal range, 4000–10,000/mm3), and the erythrocyte sedimentation rate was 52 mm/hr and the corrected erythrocyte sedimentation rate was 37 mm/hr (normal range, lower than 9 mm/hr). The C-reactive protein was 22.1 mg/dL (normal range, lower than 0.5 mg/dL). Laboratory findings supported acute infection. The serum g-gamma-glutamyltransferase level was very high at 626 u/dL (normal range, lower than 50 u/dL), making us suspect an alcoholic liver disease. The serum uric acid level was 12.6 mg/dL (normal range, 3.0–8.3 mg/dL). The patient had no prior history of gouty attack. Plain lumbar spine anteriorposterior and lateral radiographs showed narrowing of the
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Fig. 1. Plain lumbar spine anterior-posterior and lateral radiographs show narrowing of the L4–L5 disc space with degenerative spurs and sclerosis and the erosion of end plates.
L4–L5 disc space with degenerative spurs and sclerosis and the erosion of end plates (Fig. 1). Whole-body technetium99m bone scan showed hot uptake involving the L4–L5 region and the left ankle (Fig. 2). Suspecting pyogenic discitis, we took magnetic resonance (MR) images. The MR images were suggestive of a large herniated disc at L4–L5 level that caused severe compression of the L4 and L5 roots and the cauda equina. The T1-weighted MR image presented low to intermediate signal intensity on the herniated disc material and in the L4–L5 disc space. The T2-weighted MR image showed low signal intensity on the herniated disc material with high signal intensity on its peripherals and on the right side of the L4–L5 disc space. Gadoliniumenhanced T1-weighted MR imaging showed peripheral enhancement of the herniated disc material and an enhanced lesion on the right side of the L4–L5 disc space (Fig. 3). There was no evidence of abscess in the MR images. Multifocal infection was suspected at first. Pyogenic arthritis of the ankle, liver abscess (the patient had huge liver hepatomegaly), and septic conditions were suspected. However, the analysis, smear (Gram stain), and culture of joint fluid from the ankle were all negative. The fibrinogen degradation product (FDP) and D-dimer concerning sepsis were also negative, and abdominal ultrasound was normal except hepatomegaly.
Under the impression of pyogenic discitis, we started treatment with broad-spectrum intravenous antibiotics (first generation cephalosporin and aminoglycoside), but the patient’s low back pain and radiating pain to both lower extremities persisted and he remained febrile. Laboratory study showed continuously increasing white blood cell count, and elevated erythrocyte sedimentation rate and Creactive protein. Blood and urine cultures were negative. On the patient’s fourteenth hospital day, laminectomy was performed at L4. The patient underwent L4–L5 discectomy and L4–L5 posterior lumbar interbody fusion using an autogenous iliac bone graft and an autogenous laminar bone block with pedicle screw fixation (Figs. 4 and 5). Intraoperative findings showed that the removed disc material was in mix with the white chalky material that was glittering like sand granules. No purulent material was found, and a culture of the chalky material revealed no bacterial growth. The pathological examination of the specimen revealed a pinkish amorphous granular material in a linear needle pattern with a negative birefringence by polarized light microscopy. The amorphous tophaceous deposit was surrounded by multinucleated giant cells and macrophage. These findings were compatible with tophaceous gout (monosodium urate crystal deposition) (Fig. 6). After the surgery, the patient felt comfortable with marked
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Fig. 2. Whole-body technetium-99m bone scan shows hot uptake involving the L4–L5 region and the left ankle.
improvement of his low back pain and radiating pain to both lower extremities. His generalized discomfort and fever also disappeared. The serum uric acid level markedly decreased from 12.6 mg/dL to 6.6 mg/dL after surgery (on the first postoperative day). As he felt mild discomfort on the left ankle, we used colchicine, nonsteroidal antiinflammatory drug, and allopurinol for its treatment.
Discussion Gout of the axial skeleton is an unusual manifestation of tophaceous gout. A recent review found 37 reported cases [1], and we found five additional cases [2–5] including the one in the current study. These patients were predominantly men and ranged in age from 33 to 76 years. In 28 of the 42 reported cases, the patients had a previous history of gout, and 21 of the 42 patients experienced severe polyarticular gout. Cervical, thoracic, and lumbosacral spine involvement have all been reported. Clinical features of spinal gout range from neck or back pain alone to various neurological symptoms, including radiculopathy, myelopathy, and cauda equina syndrome.
Eight reported patients [1–3] including the patient of the current study presented back pain in association with fever. Therefore, epidural abscess or pyogenic spondylodiscitis had been suspected. In the current case, the patient complained of severe low back pain with high spiking fever. He also had severe limitation in straight leg raising, and laboratory data concerning infection supported acute infection. These data led to the diagnosis of pyogenic discitis and to initiation of intravenous antibiotics treatment. After 2-week conservative treatment, however, there was no improvement in his symptoms and laboratory findings. Thus, surgical treatment was planned. We had thought that anterior lumbar interbody fusion was the best treatment choice for pyogenic discitis. However, as the patient also presented radiculopathy caused by a huge disc herniation (in fact, the herniated disc material was later identified as tophi), we decided to perform posterior decompression by laminectomy, discectomy, and drainage. Intraoperative findings revealed that the disc material was composed of white, chalky, granular, and glittering sand-like materials, which were different from the usual herniated disc material. Moreover, there was no evidence of infection. Thus, we changed the surgical method to posterior lumbar interbody fusion using
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97
Fig. 3. The magnetic resonance (MR) images reveal a huge disc herniation at L4–L5 level that causes severe compression of the L4 and L5 roots and the cauda equina. The T1-weighted MR image presents low to intermediate signal intensity on the herniated disc material and in the L4–L5 disc space. The T2weighted MR image shows low signal intensity on the herniated disc material with high signal intensity on its peripherals and on the right side of the L4–L5 disc space. The gadolinium-enhanced T1-weighted MR image shows peripheral enhancement of the herniated disc material and an enhanced lesion on the right side of the L4–L5 disc space.
an autogenous iliac bone graft and an autogenous laminar bone block with pedicle screw fixation. After the surgery, his generalized discomfort and fever also disappeared. The serum uric acid level markedly decreased from 12.6 mg/dL to 6.6 mg/dL after the surgery (on the first postoperative day). We thought that immediate improvement of his generalized discomfort, fever and uric acid level was the result of dilution of serum uric acid level by hydration during the surgery. We did not believe that surgical removal of large gouty tophus had led to normalization of uric acid levels. Plain radiographs of the spine in gout may be normal or may show nonspecific degenerative changes or vertebral end plate erosions. Radiographic evidence of spinal erosions was seen in 16 of 26 patients whose radiography was taken [1,7,8]. In the current case, narrowing of the disc space with degenerative spurs and sclerosis as well as the erosion of end plates was observed on radiographs. We assumed that the erosion of end plates was caused by gouty tophi as in the peripheral joints. The MR images of a tophaceous deposit in the spine produce abnormal signal on both T1- and T2-weighted images that enhance with gadolinium administration.
However, reported MR images of spinal gout are various. In the current case, the T1-weighted MR image showed low to intermediate signal intensity; the T2-weighted MR image, low signal intensity on the herniated disc material with high signal intensity on its peripherals and in the disc space; and the gadolinium-enhanced T1-weighted MR image, peripheral enhancement of the herniated disc material and an enhanced lesion in the disc space. Thus, it is difficult to diagnose spinal gout with MR images only. In the current case, we observed hyperuricemia with swelling and erythematous changes on the left ankle, which led us to suspect gout on the ankle. However, as we had never experienced gout of the spine before, spinal gout was not the initial diagnosis we made. Based on the result of our case, we believe a past history of gout or the presence of active gout of the peripheral joints, particularly severe tophaceous gout, raise the clinical suspicion of spinal gout. Conclusion Tophaceous gout of the spine is very rare. However, when a patient presents acute back pain and fever, spinal
98
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Fig. 4. Laminectomy was performed at L4. The patient underwent L4–L5 discectomy and L4–L5 posterior lumbar interbody fusion using an autogenous iliac bone graft and an autogenous laminar bone block with pedicle screw fixation.
Fig. 5. Postoperative computed tomographic scan shows good restoration of the L4–L5 disc space with an autogenous bone graft by posterior lumbar interbody fusion.
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99
Fig. 6. The amorphous tophaceous deposit is surrounded by multinucleated giant cells and macrophage (A). A pinkish amorphous granular material is seen with a linear needle pattern of bright negative birefringence in polarized light (B, black arrow).
gout should be considered, particularly in a patient with a previous history of hyperuricemia or gout. References [1] Barret K, Miller ML, Wilson JT. Tophaceous gout of the spine mimicking epidural infection; case report and review of the literature. Neurosurgery 2001;48:1170–3. [2] Yen PS, Lin JF, Chen SY, Lin SZ. Tophaceous gout of the lumbar spine mimicking infectious spondylitis and epidural abscess: MR imaging findings. J Clin Neurosci 2005;12:44–6. [3] Diaz A, Porhiel V, Sabatier P, Ragragui O, Comoy J, Leriche B. Tophaceous gout of the cervical spine, causing cord compression:
[4]
[5] [6]
[7] [8]
case report and review of the literature. Neurochirurgie 2003;49: 600–4. Souza AW, Fontenele S, Carrete H Jr, Fernandes AR, Ferrari AJ. Involvement of the thoracic spine in tophaceous gout: a case report. Clin Exp Rheumatol 2002;20:228–30. Yen HL, Cheng CH, Lin JW. Cervical myelopathy due to gouty tophi in the intervertebral disc space. Acta Neurochir (Wien) 2002;144:205–7. Bonaldi VM, Duong H, Starr MR, Sarazin L, Richardson J. Tophaceous gout of the lumbar spine mimicking an epidural abscess: MR features. Am J Neuroradiol 1996;17:1949–52. Lagier R, Mac Gee W. Spondylodiscal erosions due to gout: anatomico-radiological study of a case. Ann Rheum Dis 1983;42:350–3. 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;77A:767–71.
Case Study
Tophaceous gout of the lumbar spine mimicking pyogenic discitis Kyung-Soo Suk, MDa,*, Ki-Tack Kim, MDa, Sang-Hun Lee, MDa, Sung-Woo Park, MDa, Yong-Koo Park, MDb a
Department of Orthopaedic Surgery, School of Medicine, Kyung-Hee University, Seoul, Korea b Department of Pathology, School of Medicine, Kyung-Hee University, Seoul, Korea Received 11 October 2005; accepted 14 January 2006
Abstract
BACKGROUND CONTEXT: Gout of the spine is very rare. Forty-one cases of gout affecting the spine have been reported. PURPOSE: To present a patient with tophaceous gout of the lumbar spine mimicking pyogenic discitis. STUDY DESIGN: Case report. METHODS: The medical record, including operative notes, progress notes, discharge summary, clinical notes, radiological study, and pathological studies was reviewed. RESULTS: The patient had acute low back pain and radiculopathy with high spiking fever. Therefore, pyogenic discitis was suspected. However, histological diagnosis revealed tophaceous gout. CONCLUSIONS: Tophaceous gout of the spine is very rare. However, when a patient presents with acute back pain and fever, spinal gout should be considered, particularly in a patient with a previous history of hyperuricemia or gout. Ó 2007 Elsevier Inc. All rights reserved.
Keywords:
Gout; Pyogenic discitis; Spine
Introduction Gout is a metabolic disease involving the peripheral joints. Gouty arthritis of the axial joints, the spine in particular, is very rare. Only 41 cases of gout involving the spine have been reported in the literature [1–8]. We present a case of gouty spondyloarthropathy which was initially suspected as pyogenic discitis. Case report A 55-year-old male patient had severe low back pain and radiating pain to both lower extremities that lasted for a week. He had a history of being an alcoholic who drank one bottle of Soju (Korean vodka) every day. During the past
FDA device/drug status: not applicable. Nothing of value received from a commercial entity related to this manuscript. * Corresponding author. Department of Orthopaedic Surgery, School of Medicine, Kyung Hee University, #1 Heogi-dong, Dongdamun-ku, Seoul, Korea, 130-702. Tel.: 822-958-8345; fax: 822-964-3865. E-mail address: [email protected] (K.-S. Suk) 1529-9430/06/$ – see front matter Ó 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.spinee.2006.01.009
7 days he did not eat any meals, but only drank alcohol to relieve severe low back pain. Physical examination revealed a fever of 40 C. There were erythematous changes and local heat on his left ankle. On the straight leg raising test, the right leg was raised 10 degrees, and the left leg, 30 degrees. Grade III (fair) motor weakness was found with the right ankle and big toe dorsiflexion. There was hypoesthesia on the right L4 and L5 sensory dermatome. There was no bladder or bowel involvement. The knee jerk reflex slightly decreased on bilateral knees (þ/þ), and the ankle jerk was normoactive. Blood cultures were negative. The white blood cell count increased to 14,800/mm3 (normal range, 4000–10,000/mm3), and the erythrocyte sedimentation rate was 52 mm/hr and the corrected erythrocyte sedimentation rate was 37 mm/hr (normal range, lower than 9 mm/hr). The C-reactive protein was 22.1 mg/dL (normal range, lower than 0.5 mg/dL). Laboratory findings supported acute infection. The serum g-gamma-glutamyltransferase level was very high at 626 u/dL (normal range, lower than 50 u/dL), making us suspect an alcoholic liver disease. The serum uric acid level was 12.6 mg/dL (normal range, 3.0–8.3 mg/dL). The patient had no prior history of gouty attack. Plain lumbar spine anteriorposterior and lateral radiographs showed narrowing of the
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95
Fig. 1. Plain lumbar spine anterior-posterior and lateral radiographs show narrowing of the L4–L5 disc space with degenerative spurs and sclerosis and the erosion of end plates.
L4–L5 disc space with degenerative spurs and sclerosis and the erosion of end plates (Fig. 1). Whole-body technetium99m bone scan showed hot uptake involving the L4–L5 region and the left ankle (Fig. 2). Suspecting pyogenic discitis, we took magnetic resonance (MR) images. The MR images were suggestive of a large herniated disc at L4–L5 level that caused severe compression of the L4 and L5 roots and the cauda equina. The T1-weighted MR image presented low to intermediate signal intensity on the herniated disc material and in the L4–L5 disc space. The T2-weighted MR image showed low signal intensity on the herniated disc material with high signal intensity on its peripherals and on the right side of the L4–L5 disc space. Gadoliniumenhanced T1-weighted MR imaging showed peripheral enhancement of the herniated disc material and an enhanced lesion on the right side of the L4–L5 disc space (Fig. 3). There was no evidence of abscess in the MR images. Multifocal infection was suspected at first. Pyogenic arthritis of the ankle, liver abscess (the patient had huge liver hepatomegaly), and septic conditions were suspected. However, the analysis, smear (Gram stain), and culture of joint fluid from the ankle were all negative. The fibrinogen degradation product (FDP) and D-dimer concerning sepsis were also negative, and abdominal ultrasound was normal except hepatomegaly.
Under the impression of pyogenic discitis, we started treatment with broad-spectrum intravenous antibiotics (first generation cephalosporin and aminoglycoside), but the patient’s low back pain and radiating pain to both lower extremities persisted and he remained febrile. Laboratory study showed continuously increasing white blood cell count, and elevated erythrocyte sedimentation rate and Creactive protein. Blood and urine cultures were negative. On the patient’s fourteenth hospital day, laminectomy was performed at L4. The patient underwent L4–L5 discectomy and L4–L5 posterior lumbar interbody fusion using an autogenous iliac bone graft and an autogenous laminar bone block with pedicle screw fixation (Figs. 4 and 5). Intraoperative findings showed that the removed disc material was in mix with the white chalky material that was glittering like sand granules. No purulent material was found, and a culture of the chalky material revealed no bacterial growth. The pathological examination of the specimen revealed a pinkish amorphous granular material in a linear needle pattern with a negative birefringence by polarized light microscopy. The amorphous tophaceous deposit was surrounded by multinucleated giant cells and macrophage. These findings were compatible with tophaceous gout (monosodium urate crystal deposition) (Fig. 6). After the surgery, the patient felt comfortable with marked
96
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Fig. 2. Whole-body technetium-99m bone scan shows hot uptake involving the L4–L5 region and the left ankle.
improvement of his low back pain and radiating pain to both lower extremities. His generalized discomfort and fever also disappeared. The serum uric acid level markedly decreased from 12.6 mg/dL to 6.6 mg/dL after surgery (on the first postoperative day). As he felt mild discomfort on the left ankle, we used colchicine, nonsteroidal antiinflammatory drug, and allopurinol for its treatment.
Discussion Gout of the axial skeleton is an unusual manifestation of tophaceous gout. A recent review found 37 reported cases [1], and we found five additional cases [2–5] including the one in the current study. These patients were predominantly men and ranged in age from 33 to 76 years. In 28 of the 42 reported cases, the patients had a previous history of gout, and 21 of the 42 patients experienced severe polyarticular gout. Cervical, thoracic, and lumbosacral spine involvement have all been reported. Clinical features of spinal gout range from neck or back pain alone to various neurological symptoms, including radiculopathy, myelopathy, and cauda equina syndrome.
Eight reported patients [1–3] including the patient of the current study presented back pain in association with fever. Therefore, epidural abscess or pyogenic spondylodiscitis had been suspected. In the current case, the patient complained of severe low back pain with high spiking fever. He also had severe limitation in straight leg raising, and laboratory data concerning infection supported acute infection. These data led to the diagnosis of pyogenic discitis and to initiation of intravenous antibiotics treatment. After 2-week conservative treatment, however, there was no improvement in his symptoms and laboratory findings. Thus, surgical treatment was planned. We had thought that anterior lumbar interbody fusion was the best treatment choice for pyogenic discitis. However, as the patient also presented radiculopathy caused by a huge disc herniation (in fact, the herniated disc material was later identified as tophi), we decided to perform posterior decompression by laminectomy, discectomy, and drainage. Intraoperative findings revealed that the disc material was composed of white, chalky, granular, and glittering sand-like materials, which were different from the usual herniated disc material. Moreover, there was no evidence of infection. Thus, we changed the surgical method to posterior lumbar interbody fusion using
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97
Fig. 3. The magnetic resonance (MR) images reveal a huge disc herniation at L4–L5 level that causes severe compression of the L4 and L5 roots and the cauda equina. The T1-weighted MR image presents low to intermediate signal intensity on the herniated disc material and in the L4–L5 disc space. The T2weighted MR image shows low signal intensity on the herniated disc material with high signal intensity on its peripherals and on the right side of the L4–L5 disc space. The gadolinium-enhanced T1-weighted MR image shows peripheral enhancement of the herniated disc material and an enhanced lesion on the right side of the L4–L5 disc space.
an autogenous iliac bone graft and an autogenous laminar bone block with pedicle screw fixation. After the surgery, his generalized discomfort and fever also disappeared. The serum uric acid level markedly decreased from 12.6 mg/dL to 6.6 mg/dL after the surgery (on the first postoperative day). We thought that immediate improvement of his generalized discomfort, fever and uric acid level was the result of dilution of serum uric acid level by hydration during the surgery. We did not believe that surgical removal of large gouty tophus had led to normalization of uric acid levels. Plain radiographs of the spine in gout may be normal or may show nonspecific degenerative changes or vertebral end plate erosions. Radiographic evidence of spinal erosions was seen in 16 of 26 patients whose radiography was taken [1,7,8]. In the current case, narrowing of the disc space with degenerative spurs and sclerosis as well as the erosion of end plates was observed on radiographs. We assumed that the erosion of end plates was caused by gouty tophi as in the peripheral joints. The MR images of a tophaceous deposit in the spine produce abnormal signal on both T1- and T2-weighted images that enhance with gadolinium administration.
However, reported MR images of spinal gout are various. In the current case, the T1-weighted MR image showed low to intermediate signal intensity; the T2-weighted MR image, low signal intensity on the herniated disc material with high signal intensity on its peripherals and in the disc space; and the gadolinium-enhanced T1-weighted MR image, peripheral enhancement of the herniated disc material and an enhanced lesion in the disc space. Thus, it is difficult to diagnose spinal gout with MR images only. In the current case, we observed hyperuricemia with swelling and erythematous changes on the left ankle, which led us to suspect gout on the ankle. However, as we had never experienced gout of the spine before, spinal gout was not the initial diagnosis we made. Based on the result of our case, we believe a past history of gout or the presence of active gout of the peripheral joints, particularly severe tophaceous gout, raise the clinical suspicion of spinal gout. Conclusion Tophaceous gout of the spine is very rare. However, when a patient presents acute back pain and fever, spinal
98
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Fig. 4. Laminectomy was performed at L4. The patient underwent L4–L5 discectomy and L4–L5 posterior lumbar interbody fusion using an autogenous iliac bone graft and an autogenous laminar bone block with pedicle screw fixation.
Fig. 5. Postoperative computed tomographic scan shows good restoration of the L4–L5 disc space with an autogenous bone graft by posterior lumbar interbody fusion.
K.-S. Suk et al. / The Spine Journal 7 (2007) 94–99
99
Fig. 6. The amorphous tophaceous deposit is surrounded by multinucleated giant cells and macrophage (A). A pinkish amorphous granular material is seen with a linear needle pattern of bright negative birefringence in polarized light (B, black arrow).
gout should be considered, particularly in a patient with a previous history of hyperuricemia or gout. References [1] Barret K, Miller ML, Wilson JT. Tophaceous gout of the spine mimicking epidural infection; case report and review of the literature. Neurosurgery 2001;48:1170–3. [2] Yen PS, Lin JF, Chen SY, Lin SZ. Tophaceous gout of the lumbar spine mimicking infectious spondylitis and epidural abscess: MR imaging findings. J Clin Neurosci 2005;12:44–6. [3] Diaz A, Porhiel V, Sabatier P, Ragragui O, Comoy J, Leriche B. Tophaceous gout of the cervical spine, causing cord compression:
[4]
[5] [6]
[7] [8]
case report and review of the literature. Neurochirurgie 2003;49: 600–4. Souza AW, Fontenele S, Carrete H Jr, Fernandes AR, Ferrari AJ. Involvement of the thoracic spine in tophaceous gout: a case report. Clin Exp Rheumatol 2002;20:228–30. Yen HL, Cheng CH, Lin JW. Cervical myelopathy due to gouty tophi in the intervertebral disc space. Acta Neurochir (Wien) 2002;144:205–7. Bonaldi VM, Duong H, Starr MR, Sarazin L, Richardson J. Tophaceous gout of the lumbar spine mimicking an epidural abscess: MR features. Am J Neuroradiol 1996;17:1949–52. Lagier R, Mac Gee W. Spondylodiscal erosions due to gout: anatomico-radiological study of a case. Ann Rheum Dis 1983;42:350–3. 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;77A:767–71.