1129 - Thoracic Myelopathy Secondary to Axial Gout

Case Diagnosis: Axial Gout

Case Description: 77-year-old male with a 30-year history of L4–L5 laminectomy and tophaceous gout, averaging 10 flares annually despite colchicine 1.2 mg, indomethacin 50 mg, and allopurinol 300 mg daily, presented with progressively worsening bilateral lower extremity weakness, paresthesias below the umbilicus, and gait difficulty for one month. Symptoms began shortly after an acute gout flare involving the right 4th–5th proximal interphalangeal joints, bilateral 1st metatarsals, and axial spine. Uric acid was 7.8 mg/dL, and oral steroids were initiated. Weakness progressed, necessitating axillary crutches. MRI thoracic spine demonstrated T9–T10 foraminal stenosis with myelomalacia; CT revealed erosive facet changes and vertebral body calcifications. Patient underwent T9–T10 laminectomy, complicated by a postoperative rim-enhancing fluid collection; the sample was culture-negative but notable for polymorphonuclear neutrophils and T2/STIR hyperintensity, suggestive of acute inflammation and possible gout flare, with associated worsening myelomalacia.

Discussions: Axial gout is rare and often underrecognized, as symptoms and imaging can mimic degenerative, infectious, or neoplastic disease. It is most common in the lumbar spine. Chronic gout may lead to facet erosions, calcifications, and spinal stenosis, creating a substrate for progressive neurologic compromise, as seen in this patient with longstanding disease and prior lumbar surgery. Superimposed acute flares, suggested by postoperative inflammatory findings, can exacerbate inflammation and worsen myelomalacia. Crystal confirmation remains the gold standard, though spinal aspiration is often impractical, and dual-energy CT can detect urate deposits but is limited by availability and cost.

Conclusions: This case highlights how longstanding chronic gout may contribute to structural spinal changes, predisposing to progressive neurologic compromise, while superimposed acute flares can further exacerbate spinal cord injury. It emphasizes the importance of vigilant recognition and management of both chronic and acute gout with urate-lowering and anti-inflammatory therapy to prevent further neurologic deterioration.