A rare case report of an adult with intraspinal gouty stones and concurrent knee joint involvement

A rare case report of an adult with intraspinal gouty stones and concurrent knee joint involvement | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report A rare case report of an adult with intraspinal gouty stones and concurrent knee joint involvement Bo Cao, Jinlong Wang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5316922/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction Gout usually manifests as acute inflammatory arthritis affecting the peripheral joints, but spinal gout, especially that caused by tophi in the spinal canal, is very rare. Patients with spinal gout often present with nonspecific symptoms that mimic other spinal lesions, posing a challenge for diagnosis. This case report describes the unusual manifestation of tophi in the spinal canal and the gout in the knee, highlighting the complexity of treatment and the necessity of timely diagnosis and intervention. Case presentation A 22-year-old male with a history of hyperuricaemia presented with low back pain and radicular symptoms in the right lower extremity. Magnetic resonance imaging (MRI) and X-ray imaging revealed lumbar spinal stenosis and a mass at the L5/S1 level. The patient underwent surgical resection of the lesion in the spinal canal, and the intraoperative results confirmed the presence of monosodium urate (MSU) crystals. Meanwhile, the patient experienced severe gout in the knee, with manifestations of severe pain, swelling, and limited mobility. The patient's condition gradually improved after treatment with arthroscopic knee surgery and nonsteroidal anti-inflammatory drugs (NSAIDs). Pathological examination of the resected tissues confirmed a diagnosis of spinal and knee gout. Conclusion This case highlights the diagnostic challenge of treating spinal gout, especially when it manifests as tophi in the spinal canal. The postoperative risk of gout in knee joints makes treatment more complicated. Early identification and multidisciplinary treatment are key to optimizing the therapeutic effect. This case emphasizes the importance of comprehensive uric acid-lowering treatment and vigilant postoperative monitoring for preventing and controlling any complications of systemic gout. Spinal gout knee gout knee joint gouty arthritis lumbar fusion Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Gout is a chronic, systemic disease caused by monosodium urate (MSU) crystal deposition in tissues and affects mainly the joints 1 . Gout usually manifests as acute inflammatory arthritis, most commonly in peripheral joints such as the metatarsophalangeal joint (podagra) 2 . Its pathophysiology involves hyperuricaemia, which leads to crystal formation and inflammation, resulting in severe joint pain, swelling, and erythema 3 . In contrast, spinal gout, the deposition of MSU crystals in the vertebral body, is very rare, accounting for less than 1% of cases in some studies 4 , 5 . The formation of intraspinal tophi, cast-like deposits in the spinal canal or vertebral body that can mimic other spinal pathologies, such as tumours, infections, and degenerative diseases, in gout is even rarer 6 , 7 . Owing to the rarity and nonspecific clinical manifestations of spinal gout, its diagnosis is often delayed or missed 8 . Patients with spinal gout may experience chronic back pain, neurological deficits or radicular symptoms, leading clinicians to initially suspect more common causes, such as lumbar disc herniation or spinal stenosis 9 , 10 . The radiological examination results are usually nonspecific, making differential diagnosis challenging 11 . It is very important to recognize spinal gout as a potential cause of spinal lesions, especially for patients with known peripheral gout or hyperuricaemia, to avoid unnecessary delays in appropriate treatment 12 . This case report describes a very unusual manifestation of gout. The patient presented with tophi in the spinal canal, and gout in the knee. Although spinal gout is rare, tophi that actually form in the vertebral body are rarer, increasing the complexity of diagnosis and treatment. In this patient, spinal involvement was the initial leading cause due to severe back pain and radicular symptoms, after lumbar fusion and decompressive surgery, the patient experienced a knee arthroscopy for gout stone removal, highlighting the systemic nature of the disease. The challenges in this case were multifaceted, including the diagnostic difficulty in differentiating spinal gout and the therapeutic challenge in dealing with severe postoperative recurrence in distant joints. This case highlights the need to be highly vigilant for the manifestations of atypical gout, especially in patients with a history of hyperuricaemia, and the importance of careful postoperative management to prevent the recurrence of gout. The report also discusses the complex balance between surgical and systemic treatment for gout, providing extensive implications for treating similar patients. Case Report/Case Presentation The patient was a 22-year-old man who complained of persistent back pain, numbness and weakness in his right lower extremity for 6 months. His symptoms gradually worsened, eventually leading to difficulty walking and performing activities of daily living. The patient reported a history of gout and two episodes of heel pain in the past two years but did not receive systemic treatment for the conditions. The initial uric acid level was substantially elevated (836 µmol/L). At the time of medical treatment, he was not receiving any uric acid-lowering treatment, and his diet was full of purine-rich foods. During the physical examination, the patient experienced obvious numbness and a tingling sensation in the right lower extremity, especially in the outer side of the calf and the large toe, and the range of motion in the right knee was limited. Neurological examination revealed that the patient had mild muscle weakness and hypoesthesia at the L5-S1 dermatomes. CT(Fig. 1 ) and MR of the right knee showed extensive gouty stones in the anterior-posterior crossing of the right knee. Musculoskeletal examination revealed tenderness in the right iliacus muscle, and the right knee was slightly bent due to pain. Mild limitation of right knee flexion and extension on right knee examination. Magnetic resonance imaging (MRI) of the lumbar spine revealed a mass in the spinal canal at L4-L5(Fig. 2 ), nerve root compression, and calcified deposits in the lesion, which involved the facial joints and was suspected to be within the spinal canal. Non-contrast enhanced computed tomography (CT) confirmed the existence of multiple high-density lesions, suggesting the presence of tophi in the spinal canal. Dual energy CT (DECT) of the postoperative spine and preoperative knee Intraoperative pathology further confirmed gouty stones in the joints and spine. Laboratory examination (Table 1 ) revealed increased serum uric acid levels (836 µmol/L) and mildly elevated liver enzymes (alanine aminotransferase (ALT): 243 U/L, aspartate aminotransferase (AST): 113 U/L). Table 1 Identified gene mutations Gene Chromosome position Age Gender Occupation Medical History Initial Symptoms Uric Acid Level 22 years Male Office worker History of gout Back pain, lower extremity weakness 836 µmol/L The patient underwent surgical decompression and resection of the spinal canal lesion via laminectomy. During surgery, white chalk-like deposits were observed in the spinal canal, which were consistent with MSU crystals (Video. 1). The L5 nerve root was wrapped by gout stones, causing severe compression. Surgery included removal of these deposits and an L5-S1 disc herniation. Pathological analysis of the resected tissue confirmed the presence of gout stones. The patient's right knee underwent knee arthroscopy for gouty stone removal. A large number of gouty stones were seen around the anterior and posterior cruciate ligaments on intraoperative endoscopy. Intraoperative pathology further confirmed gouty stones. The right knee was released under intraoperative anesthesia. After surgery, the patient received comprehensive treatments(Table 2 ). A nonsteroidal anti-inflammatory drug (NSAID), loxoprofen sodium, was used to control inflammation and pain. Uric acid-lowering treatment: The patient started to take febuxostat 20 mg per day, and the dose was gradually increased according to the subsequently measured serum uric acid level. Physical rehabilitation: The patient was encouraged to perform active range-of-motion exercises of the spine and knee joints to prevent stiffness and improve mobility. In addition, the patient was instructed to perform low-intensity aerobic exercise to maintain joint flexibility and avoid aggravating symptoms. Table 2 Postoperative Management Strategies Strategy Details NSAIDs Corticosteroids Urate-Lowering Therapy Physical Rehabilitation Indomethacin 50 mg daily for pain management Methylprednisolone intra-articular injection in knee Allopurinol, dosage adjusted based on uric acid levels Range of motion exercises, strengthening We recommended that the patient adopt a low-purine diet, increase water intake and avoid alcohol to prevent the future recurrence of gout. The patient was also asked to regularly monitor his serum uric acid levels and continue to return for outpatient follow-up at the rheumatology department to adjust his uric acid-lowering treatment. During hospitalization, the patient’s back pain and numbness in the lower extremities were significantly alleviated, and his knee symptoms gradually resolved after intra-articular steroid injection. When discharged from the hospital, the doctors told him to continue taking NSAIDs and febuxostat and recommended that he regularly monitor his liver function and serum uric acid levels. In conclusion, this case illustrates the rare occurrence of tophi in the spinal canal complicated with an attack of gout in the knee joint after surgery. Early identification and comprehensive postoperative treatment of spinal gout are key to achieving good efficacy. Discussion Spinal gout is a rare condition, and its diagnosis is highly challenging because of its nonspecific symptoms and similarities with other spine lesions 13 . Gout is a metabolic disease that involves the deposition of MSU crystals in the peripheral joints, and its most common symptom is acute arthritis 14 . However, the spine can also be affected, especially in patients with long-term hyperuricaemia 15 . A literature review revealed that the incidence of spinal and knee gout is less than 1% among gout patients 16 . Therefore, spinal gout is an uncommon but important differential diagnosis for patients with back pain or spinal cord compression. S. A. Wan et al. argued that the spinal canal is even lower 17 . These tophi (or vertebral stones) may form in different locations of the spine, but especially in the lumbar spine, as in this case 18 . Although there are sporadic reports of gout stones affecting the spine, this case is unique since the stones were in the spinal canal, which poses a challenge to the diagnosis 19 . This condition is usually associated with more common spine diseases, such as tumours or infections. Few studies have investigated the exact incidence of this type of spinal lesion; therefore, this case is a rare and valuable addition to the medical literature on gout-associated spine diseases 20 . The pathophysiology of spinal gout involves the deposition of MSU crystals in the intervertebral discs, articular surfaces and ligaments and even spinal canal 21 , 22 . This deposition can lead to inflammation, tissue damage, and then compression of the spinal nerves or the spinal cord itself, causing neurological symptoms such as numbness and muscle weakness 23 . In this case, MSU crystals were found in the L4-L5 intervertebral space and were compressing the nerve root, causing radicular pain. The exact mechanism by which MSU crystals are deposited in the spine is not fully understood, but chronic hyperuricaemia and local tissue factors may play a role 24 . Interestingly, the patient experienced a concurrence of gout in the knee joint, indicating that there was a systemic reaction during surgical resection of the tophi in the spinal canal. Systemic inflammation may mobilize the original MSU deposits in the peripheral joints, resulting in an acute attack of gout. This "migrating seizure" phenomenon is a well-recognized but poorly understood complication, especially during systemic inflammation 25 . The clinical manifestations of spinal gout are nonspecific and may be similar to those of other conditions, such as spinal infection, tumours, and degenerative diseases; therefore, it is very difficult to differentially diagnose spinal gout 11 . In this case, the initial symptoms of back pain and numbness of the lower extremities led to an extensive differential diagnosis, including a spinal tumour or disc herniation, based on the findings of MRI and CT scanning. However, imaging examinations also revealed calcified lesions in the vertebral body, which, together with the patient’s hyperuricaemia and gout history, prompted the doctors to further investigate the cause of gout mimicking chondrosarcoma. Radiological imaging plays a critical role in managing gout, but it is often not sufficient for diagnosis 26 . Spinal lesions caused by gout may not present with the typical imaging features of gout in the peripheral joints, such as perforating erosions and overhanging edges. In this case, the high-density calcifications observed on CT imaging helped to differentiate gout from other spinal lesions, but intraoperative findings and histopathological analysis confirmed this diagnosis. Treatment of a patient with spinal gout and peripheral joint involvement requires a delicate balance between treating the spinal lesion and controlling the systemic hyperuricaemia 27 . The primary challenge in this case was to prevent the recurrence of gout after surgery while at the same time controlling the direct neurological symptoms caused by spinal nerve compression. Surgical decompression must be performed to relieve spinal cord compression, but this intervention may also aggravate the underlying systemic gout. The standard treatments for gout include uric acid-lowering treatments, such as allopurinol and febuxostat, and NSAIDs or corticosteroids to control acute attacks 28 . In this case, febuxostat was used to control the patient’s hyperuricaemia, but care should be exercised during dose adjustment to avoid overcorrection and further induction of gout attacks. In addition, the patient’s liver function was affected by elevated ALT and AST levels; therefore, such patients should be closely monitored to prevent the gout-treating drugs from inducing liver injury 29 . The patient experienced a concurrence of gout in the knee, highlighting a well-documented but not fully understood phenomenon in gout patients when systemic inflammation. Systemic inflammation can destabilize urate deposition in distant joints, resulting in an acute attack of gout. In this case, the gout attack manifested as acute knee and elbow pain. After NSAIDs, the patient’s symptoms were rapidly relieved, which highlights the importance of early and active treatment of postoperative gout attacks. Although the use of febuxostat to reduce uric acid was continued, the patient's treatment plan also emphasized long-term lifestyle changes, including diet adjustments and fluid supplementation, to prevent future recurrence 30 . This case highlights the challenges in diagnosing and treating spinal gout, especially the rare occurrence of MSU crystals in the spinal canal. For patients with back pain and neurological symptoms, it is important to consider spinal gout as a potential differential diagnosis as soon as possible to avoid delaying treatment. The postoperative treatment of gout requires a multidisciplinary approach to prevent systemic recurrence and ensure optimal rehabilitation. Ongoing studies on the pathophysiology and postoperative recurrence of spinal gout may provide more effective prevention and treatment strategies for similar cases in the future. Conclusions This case of intraspinal tophi with gout concurrence in the knee highlights several important lessons. First, although spinal gout is rare, it should be considered in patients with a history of hyperuricaemia and atypical back pain or neurological symptoms. The presence of MSU deposits in the spinal canal may mimic more common spinal lesions, making diagnosis difficult. Advanced imaging modalities, such as MRI and CT, combined with a detailed medical history and laboratory examination, are critical for early detection. Second, during the postoperative management of gout patients receiving spine surgery, careful monitoring is needed to prevent the recurrence of systemic disease, especially in the distal joints, as surgical stresses can induce acute attacks of gout. In terms of orthopaedic and rheumatology treatments, this case emphasizes the importance of multidisciplinary treatment of gout patients receiving spine surgery. Early detection of the effects of gout on the spine and timely surgical treatment can relieve neurological symptoms, but strategies to prevent postoperative recurrence should also be developed and employed. This includes careful titration of uric acid-lowering drugs, judicious use of anti-inflammatory drugs, and patient education on lifestyle changes to reduce the risk of future recurrence. The possibility of systemic recurrence should be considered in the preoperative assessment, and postoperative care must include close observation of symptoms in the peripheral joints. This case opens the way for further study of the mechanism of tophus formation in the spine and the long-term efficacy of surgical intervention. Future prospective studies should investigate the incidence and pathophysiology of spinal gout in gout patients to establish clearer diagnostic standards and treatment guidelines. In addition, studies on the recurrence of gout after surgery can elucidate better prevention and treatment strategies, thereby improving the outcomes of gout patients with spinal and peripheral joint manifestations. In summary, this rare case provides valuable insights into the complex interactions between spinal gout and systemic diseases, emphasizing the need for a comprehensive approach for diagnosis, surgery, and postoperative management. Declarations Acknowledgements We sincerely thank the medical personnel involved in the treatment of the patient, especially the rheumatology department and the orthopaedics department, for their hard work and contributions in handling this complex case. Special thanks are given to the nursing team for their valuable support during the preoperative and postoperative care of the patient. We also thank the peer reviewers for their insights and feedback, which have greatly improved the clarity and depth of this manuscript. Statement of Ethics Study approval statement: Ethics approval for this study was obtained from the Ethics Board of Shengli Oilfield Central Hospital.The ethics code :YXLL202412501. Consent to publish statement: Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal. Conflict of Interest Statement We declare that the publication of this case report is not associated with any conflicts of interest. There is no financial support from any pharmaceutical company or other third parties that might affect the contents of this study. All treatment and patient management decisions were based on clinical indications and best practices. All the authors listed have approved the manuscript that is enclosed. Funding Sources This work was supported China Scholarship Committee 202008440406. Author Contributions Jinlong Wang collected data. Bo Cao drafted and revised the manuscript. Data Availability Statement The authors confirm that the data supporting the fndings of this study are available within the article and its supplementary materials. Further enquiries can be directed to the corresponding author. References Martillo MA, Nazzal L, Crittenden DB. The crystallization of monosodium urate. Curr Rheumatol Rep. 2014;16:1–8. Manson JJ, Isenberg D, Chambers S, Shipley ME, Merrill JT. Rapid review of rheumatology and musculoskeletal disorders. 2014. Martinon F. Mechanisms of uric acid crystal-mediated autoinflammation. Immunol Rev. 2010;233(1):218–32. Toprover M, Mechlin M, Fields T, Oh C, Becce F, Pillinger MH. Monosodium urate deposition in the lumbosacral spine of patients with gout compared with non-gout controls: a dual-energy CT study. Seminars in Arthritis and Rheumatism; 2022: Elsevier; 2022. p. 152064. Feydy A, Lioté F, Carlier R, Chevrot A, Drapé J-L. Cervical spine and crystal-associated diseases: imaging findings. Eur Radiol. 2006;16:459–68. Wang W, Li Q, Cai L, Liu W. Lumbar spinal stenosis attributable to tophaceous gout: case report and review of the literature. Ther Clin Risk Manag 2017: 1287–93. Saketkoo LA, Virk Z-U, Espinoza LR, Robertson HJ, Ferreyro HR, Dyer HR. Axial gouty arthropathy. Am J Med Sci. 2009;338(2):140–6. Ma S, Zhao J, Jiang R, An Q, Gu R. Diagnostic challenges of spinal gout: a case series. Medicine. 2019;98(16):e15265. Elgafy H, Liu X, Herron J. Spinal gout: a review with case illustration. World J Orthop. 2016;7(11):766. Al-Jebaje Z, Elibol JM, Peters J, Alameri A. Spinal tophaceous gout presenting in a young adult without pain. Case Reports 2018; 2018: bcr-2018-224406. Toprover M, Krasnokutsky S, Pillinger MH. Gout in the spine: imaging, diagnosis, and outcomes. Curr Rheumatol Rep. 2015;17:1–9. Weaver JS, Vina ER, Munk PL, Klauser AS, Elifritz JM, Taljanovic MS. 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BSITI T. especially gout, were important causes of ecchymoses. Li S, Xu G, Liang J, Wan L, Cao H, Lin J. The role of advanced imaging in gout management. Front Immunol. 2022;12:811323. Zhou MX, Wu MM, Sang ML, Wu MJ. Clinical observation of posterior decompression, fusion and fixation in the treatment of spinal gout: a case series. J Orthop Surg Res. 2023;18(1):303. Keith MP, Gilliland WR. Updates in the management of gout. Am J Med. 2007;120(3):221–4. Lala V, Zubair M, Minter D. Liver function tests. StatPearls 2023. Dalbeth N, Choi HK, Joosten LA, Khanna PP, Matsuo H, Perez-Ruiz F, Stamp LK. Gout (primer). Nat Reviews: Disease Primers 2019; 5(1). Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5316922","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":371720725,"identity":"3465ed55-7d4b-4f6f-aa3d-255dc3573d92","order_by":0,"name":"Bo Cao","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABIUlEQVRIie3RsWqEMBjA8UhAl1g7Rq7QV7AIPRyKr6I49BU6iKQIdil09aBcX6FdnDrkEJwOXAO5QRFu9raD3lD15Cg0FrqVkv/woZFfiAQAmewPZg3zbnzzAO2mQvpnNKxUU2TdDzgQfCLouImYKMlIwEDGpsgcwLrdLbNL46ks2ircRBaPE7x7jy5c7KmVgDhEtc1Fxq9SFsDUK7bY2qwSM93mCGFPs0QHowjM9IwrhEEIfJJji/mxjSjtiYrFBH7oz9x9KfMv5ECjn4g60wn3X2lwIvcNoHCSOLF67aQFD95YYAOvyM1FR+pH2v3Luk5EZK7FDWtDfrMsV42yD3PjjN1WdE8jV3sICtx+J8fbEHfuk+mP4gz6WyGTyWT/s0+bBG3LFAJsKgAAAABJRU5ErkJggg==","orcid":"","institution":"Guangzhou Medical University, Qingyuan People's Hospital","correspondingAuthor":true,"prefix":"","firstName":"Bo","middleName":"","lastName":"Cao","suffix":""},{"id":371720726,"identity":"28d82595-c4dc-4fdf-a372-cfbf17617504","order_by":1,"name":"Jinlong Wang","email":"","orcid":"","institution":"Binzhou Medical University Affiliated Shengli Oilfield Central Hospital","correspondingAuthor":false,"prefix":"","firstName":"Jinlong","middleName":"","lastName":"Wang","suffix":""}],"badges":[],"createdAt":"2024-10-23 08:08:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5316922/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5316922/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":69355679,"identity":"56fe2a90-352e-44af-9bcc-96d1a2eabac0","added_by":"auto","created_at":"2024-11-19 13:43:19","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":401212,"visible":true,"origin":"","legend":"\u003cp\u003eCT Scan of the Spine and knee. a CT image showing the presence of gouty granulomas within the spinal canal at the L5-S1 level. b CT scan showing the isthmic fracture and the disc herniation at the L5-S1 level. Notable findings include changes in bone density and the presence of gouty stones. c. Dual-Energy CT (DECT) showing the presence of gouty stones. d e and f (DECT) a large number of gouty stones in the knee joints.\u003c/p\u003e","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-5316922/v1/d23fb3ba9a594779e43fffaf.png"},{"id":69354157,"identity":"68051ad2-3ca1-4aeb-ad83-6fe865e69d8a","added_by":"auto","created_at":"2024-11-19 13:35:19","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":372255,"visible":true,"origin":"","legend":"\u003cp\u003eMRI of the Spine and knee. a CT image showing the presence of gouty granulomas within the spinal canal at the L5-S1 level. b CT scan showing the isthmic fracture and the disc herniation at the L5-S1 level. Notable findings include changes in bone density and the presence of gouty stones. a and d Knee MRI showed a large number of gouty stones in the anterior and posterior cruciate ligaments.\u003c/p\u003e","description":"","filename":"Onlinefloatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-5316922/v1/65736caf91bbb0757fa65c3c.png"},{"id":69354162,"identity":"7c3e5ca0-1167-45ff-9075-5840192f8545","added_by":"auto","created_at":"2024-11-19 13:35:20","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":378920,"visible":true,"origin":"","legend":"\u003cp\u003eIntraoperative histopathological images of gout. Intraoperative gouty histopathological images showed structures consistent with gouty foreign body granuloma.\u003c/p\u003e","description":"","filename":"Onlinefloatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-5316922/v1/2aa535d612f698b529f8ec87.png"},{"id":69356510,"identity":"6b6970a3-413e-4334-ae35-78b31a67fbe9","added_by":"auto","created_at":"2024-11-19 13:51:19","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":556153,"visible":true,"origin":"","legend":"\u003cp\u003eIntraoperative images from the surgical procedure. Intraoperative detection of knee flexion and extension. Intraoperative endoscopy revealed a large number of gouty stones around the anterior and posterior cruciate ligaments of the knee.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-5316922/v1/4e55e93a55c6a0fea148e695.png"},{"id":70216590,"identity":"e9527e77-80cd-4e0e-a3db-6691e464c4f2","added_by":"auto","created_at":"2024-11-29 15:46:57","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2556962,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5316922/v1/3cce3d02-00a6-4cc2-bce4-ef70456f3b0f.pdf"},{"id":69355677,"identity":"bfdbbcbb-57f7-4c0d-bcea-ef7429e0d19e","added_by":"auto","created_at":"2024-11-19 13:43:19","extension":"docx","order_by":9,"title":"","display":"","copyAsset":false,"role":"supplement","size":15922,"visible":true,"origin":"","legend":"","description":"","filename":"video.docx","url":"https://assets-eu.researchsquare.com/files/rs-5316922/v1/8932920b9bfb4f9662d4c2a2.docx"},{"id":69354160,"identity":"a286eee0-5a1b-48d5-aeee-fed85afdeb76","added_by":"auto","created_at":"2024-11-19 13:35:19","extension":"mp4","order_by":10,"title":"","display":"","copyAsset":false,"role":"supplement","size":3354672,"visible":true,"origin":"","legend":"","description":"","filename":"1.mp4","url":"https://assets-eu.researchsquare.com/files/rs-5316922/v1/df234a9335afba02b8f2f214.mp4"}],"financialInterests":"No competing interests reported.","formattedTitle":"A rare case report of an adult with intraspinal gouty stones and concurrent knee joint involvement","fulltext":[{"header":"Introduction","content":"\u003cp\u003eGout is a chronic, systemic disease caused by monosodium urate (MSU) crystal deposition in tissues and affects mainly the joints\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. Gout usually manifests as acute inflammatory arthritis, most commonly in peripheral joints such as the metatarsophalangeal joint (podagra)\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. Its pathophysiology involves hyperuricaemia, which leads to crystal formation and inflammation, resulting in severe joint pain, swelling, and erythema\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. In contrast, spinal gout, the deposition of MSU crystals in the vertebral body, is very rare, accounting for less than 1% of cases in some studies\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e. The formation of intraspinal tophi, cast-like deposits in the spinal canal or vertebral body that can mimic other spinal pathologies, such as tumours, infections, and degenerative diseases, in gout is even rarer\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eOwing to the rarity and nonspecific clinical manifestations of spinal gout, its diagnosis is often delayed or missed\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. Patients with spinal gout may experience chronic back pain, neurological deficits or radicular symptoms, leading clinicians to initially suspect more common causes, such as lumbar disc herniation or spinal stenosis\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. The radiological examination results are usually nonspecific, making differential diagnosis challenging\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. It is very important to recognize spinal gout as a potential cause of spinal lesions, especially for patients with known peripheral gout or hyperuricaemia, to avoid unnecessary delays in appropriate treatment\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThis case report describes a very unusual manifestation of gout. The patient presented with tophi in the spinal canal, and gout in the knee. Although spinal gout is rare, tophi that actually form in the vertebral body are rarer, increasing the complexity of diagnosis and treatment. In this patient, spinal involvement was the initial leading cause due to severe back pain and radicular symptoms, after lumbar fusion and decompressive surgery, the patient experienced a knee arthroscopy for gout stone removal, highlighting the systemic nature of the disease.\u003c/p\u003e \u003cp\u003eThe challenges in this case were multifaceted, including the diagnostic difficulty in differentiating spinal gout and the therapeutic challenge in dealing with severe postoperative recurrence in distant joints. This case highlights the need to be highly vigilant for the manifestations of atypical gout, especially in patients with a history of hyperuricaemia, and the importance of careful postoperative management to prevent the recurrence of gout. The report also discusses the complex balance between surgical and systemic treatment for gout, providing extensive implications for treating similar patients.\u003c/p\u003e"},{"header":"Case Report/Case Presentation","content":"\u003cp\u003eThe patient was a 22-year-old man who complained of persistent back pain, numbness and weakness in his right lower extremity for 6 months. His symptoms gradually worsened, eventually leading to difficulty walking and performing activities of daily living. The patient reported a history of gout and two episodes of heel pain in the past two years but did not receive systemic treatment for the conditions. The initial uric acid level was substantially elevated (836 \u0026micro;mol/L). At the time of medical treatment, he was not receiving any uric acid-lowering treatment, and his diet was full of purine-rich foods.\u003c/p\u003e \u003cp\u003eDuring the physical examination, the patient experienced obvious numbness and a tingling sensation in the right lower extremity, especially in the outer side of the calf and the large toe, and the range of motion in the right knee was limited. Neurological examination revealed that the patient had mild muscle weakness and hypoesthesia at the L5-S1 dermatomes. CT(Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) and MR of the right knee showed extensive gouty stones in the anterior-posterior crossing of the right knee. Musculoskeletal examination revealed tenderness in the right iliacus muscle, and the right knee was slightly bent due to pain. Mild limitation of right knee flexion and extension on right knee examination.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eMagnetic resonance imaging (MRI) of the lumbar spine revealed a mass in the spinal canal at L4-L5(Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e), nerve root compression, and calcified deposits in the lesion, which involved the facial joints and was suspected to be within the spinal canal. Non-contrast enhanced computed tomography (CT) confirmed the existence of multiple high-density lesions, suggesting the presence of tophi in the spinal canal. Dual energy CT (DECT) of the postoperative spine and preoperative knee Intraoperative pathology further confirmed gouty stones in the joints and spine. Laboratory examination (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) revealed increased serum uric acid levels (836 \u0026micro;mol/L) and mildly elevated liver enzymes (alanine aminotransferase (ALT): 243 U/L, aspartate aminotransferase (AST): 113 U/L).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eIdentified gene mutations\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGene\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eChromosome position\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003cp\u003eGender\u003c/p\u003e \u003cp\u003eOccupation\u003c/p\u003e \u003cp\u003eMedical History\u003c/p\u003e \u003cp\u003eInitial Symptoms\u003c/p\u003e \u003cp\u003eUric Acid Level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22 years\u003c/p\u003e \u003cp\u003eMale\u003c/p\u003e \u003cp\u003eOffice worker\u003c/p\u003e \u003cp\u003eHistory of gout Back pain, \u003cbr\u003elower extremity weakness\u003c/p\u003e \u003cp\u003e836 \u0026micro;mol/L\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe patient underwent surgical decompression and resection of the spinal canal lesion via laminectomy. During surgery, white chalk-like deposits were observed in the spinal canal, which were consistent with MSU crystals (Video. 1). The L5 nerve root was wrapped by gout stones, causing severe compression. Surgery included removal of these deposits and an L5-S1 disc herniation. Pathological analysis of the resected tissue confirmed the presence of gout stones.\u003c/p\u003e \u003cp\u003eThe patient's right knee underwent knee arthroscopy for gouty stone removal. A large number of gouty stones were seen around the anterior and posterior cruciate ligaments on intraoperative endoscopy. Intraoperative pathology further confirmed gouty stones. The right knee was released under intraoperative anesthesia.\u003c/p\u003e \u003cp\u003eAfter surgery, the patient received comprehensive treatments(Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). A nonsteroidal anti-inflammatory drug (NSAID), loxoprofen sodium, was used to control inflammation and pain. Uric acid-lowering treatment: The patient started to take febuxostat 20 mg per day, and the dose was gradually increased according to the subsequently measured serum uric acid level. Physical rehabilitation: The patient was encouraged to perform active range-of-motion exercises of the spine and knee joints to prevent stiffness and improve mobility. In addition, the patient was instructed to perform low-intensity aerobic exercise to maintain joint flexibility and avoid aggravating symptoms.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePostoperative Management Strategies\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStrategy\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDetails\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNSAIDs\u003c/p\u003e \u003cp\u003eCorticosteroids\u003c/p\u003e \u003cp\u003eUrate-Lowering Therapy\u003c/p\u003e \u003cp\u003ePhysical Rehabilitation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIndomethacin 50 mg daily for pain management\u003c/p\u003e \u003cp\u003eMethylprednisolone intra-articular injection in knee\u003c/p\u003e \u003cp\u003eAllopurinol, dosage adjusted based on uric acid levels\u003c/p\u003e \u003cp\u003eRange of motion exercises, strengthening\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eWe recommended that the patient adopt a low-purine diet, increase water intake and avoid alcohol to prevent the future recurrence of gout. The patient was also asked to regularly monitor his serum uric acid levels and continue to return for outpatient follow-up at the rheumatology department to adjust his uric acid-lowering treatment. During hospitalization, the patient\u0026rsquo;s back pain and numbness in the lower extremities were significantly alleviated, and his knee symptoms gradually resolved after intra-articular steroid injection. When discharged from the hospital, the doctors told him to continue taking NSAIDs and febuxostat and recommended that he regularly monitor his liver function and serum uric acid levels.\u003c/p\u003e \u003cp\u003eIn conclusion, this case illustrates the rare occurrence of tophi in the spinal canal complicated with an attack of gout in the knee joint after surgery. Early identification and comprehensive postoperative treatment of spinal gout are key to achieving good efficacy.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eSpinal gout is a rare condition, and its diagnosis is highly challenging because of its nonspecific symptoms and similarities with other spine lesions\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e. Gout is a metabolic disease that involves the deposition of MSU crystals in the peripheral joints, and its most common symptom is acute arthritis\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. However, the spine can also be affected, especially in patients with long-term hyperuricaemia\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e. A literature review revealed that the incidence of spinal and knee gout is less than 1% among gout patients\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e. Therefore, spinal gout is an uncommon but important differential diagnosis for patients with back pain or spinal cord compression.\u003c/p\u003e \u003cp\u003eS. A. Wan et al. argued that the spinal canal is even lower\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e. These tophi (or vertebral stones) may form in different locations of the spine, but especially in the lumbar spine, as in this case\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e. Although there are sporadic reports of gout stones affecting the spine, this case is unique since the stones were in the spinal canal, which poses a challenge to the diagnosis\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e. This condition is usually associated with more common spine diseases, such as tumours or infections. Few studies have investigated the exact incidence of this type of spinal lesion; therefore, this case is a rare and valuable addition to the medical literature on gout-associated spine diseases\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe pathophysiology of spinal gout involves the deposition of MSU crystals in the intervertebral discs, articular surfaces and ligaments and even spinal canal\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e,\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e. This deposition can lead to inflammation, tissue damage, and then compression of the spinal nerves or the spinal cord itself, causing neurological symptoms such as numbness and muscle weakness\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e. In this case, MSU crystals were found in the L4-L5 intervertebral space and were compressing the nerve root, causing radicular pain. The exact mechanism by which MSU crystals are deposited in the spine is not fully understood, but chronic hyperuricaemia and local tissue factors may play a role\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eInterestingly, the patient experienced a concurrence of gout in the knee joint, indicating that there was a systemic reaction during surgical resection of the tophi in the spinal canal. Systemic inflammation may mobilize the original MSU deposits in the peripheral joints, resulting in an acute attack of gout. This \"migrating seizure\" phenomenon is a well-recognized but poorly understood complication, especially during systemic inflammation\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe clinical manifestations of spinal gout are nonspecific and may be similar to those of other conditions, such as spinal infection, tumours, and degenerative diseases; therefore, it is very difficult to differentially diagnose spinal gout\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. In this case, the initial symptoms of back pain and numbness of the lower extremities led to an extensive differential diagnosis, including a spinal tumour or disc herniation, based on the findings of MRI and CT scanning. However, imaging examinations also revealed calcified lesions in the vertebral body, which, together with the patient\u0026rsquo;s hyperuricaemia and gout history, prompted the doctors to further investigate the cause of gout mimicking chondrosarcoma.\u003c/p\u003e \u003cp\u003eRadiological imaging plays a critical role in managing gout, but it is often not sufficient for diagnosis\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e. Spinal lesions caused by gout may not present with the typical imaging features of gout in the peripheral joints, such as perforating erosions and overhanging edges. In this case, the high-density calcifications observed on CT imaging helped to differentiate gout from other spinal lesions, but intraoperative findings and histopathological analysis confirmed this diagnosis.\u003c/p\u003e \u003cp\u003eTreatment of a patient with spinal gout and peripheral joint involvement requires a delicate balance between treating the spinal lesion and controlling the systemic hyperuricaemia\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e. The primary challenge in this case was to prevent the recurrence of gout after surgery while at the same time controlling the direct neurological symptoms caused by spinal nerve compression. Surgical decompression must be performed to relieve spinal cord compression, but this intervention may also aggravate the underlying systemic gout.\u003c/p\u003e \u003cp\u003eThe standard treatments for gout include uric acid-lowering treatments, such as allopurinol and febuxostat, and NSAIDs or corticosteroids to control acute attacks\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e. In this case, febuxostat was used to control the patient\u0026rsquo;s hyperuricaemia, but care should be exercised during dose adjustment to avoid overcorrection and further induction of gout attacks. In addition, the patient\u0026rsquo;s liver function was affected by elevated ALT and AST levels; therefore, such patients should be closely monitored to prevent the gout-treating drugs from inducing liver injury\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe patient experienced a concurrence of gout in the knee, highlighting a well-documented but not fully understood phenomenon in gout patients when systemic inflammation. Systemic inflammation can destabilize urate deposition in distant joints, resulting in an acute attack of gout. In this case, the gout attack manifested as acute knee and elbow pain.\u003c/p\u003e \u003cp\u003eAfter NSAIDs, the patient\u0026rsquo;s symptoms were rapidly relieved, which highlights the importance of early and active treatment of postoperative gout attacks. Although the use of febuxostat to reduce uric acid was continued, the patient's treatment plan also emphasized long-term lifestyle changes, including diet adjustments and fluid supplementation, to prevent future recurrence\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThis case highlights the challenges in diagnosing and treating spinal gout, especially the rare occurrence of MSU crystals in the spinal canal. For patients with back pain and neurological symptoms, it is important to consider spinal gout as a potential differential diagnosis as soon as possible to avoid delaying treatment. The postoperative treatment of gout requires a multidisciplinary approach to prevent systemic recurrence and ensure optimal rehabilitation. Ongoing studies on the pathophysiology and postoperative recurrence of spinal gout may provide more effective prevention and treatment strategies for similar cases in the future.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis case of intraspinal tophi with gout concurrence in the knee highlights several important lessons. First, although spinal gout is rare, it should be considered in patients with a history of hyperuricaemia and atypical back pain or neurological symptoms. The presence of MSU deposits in the spinal canal may mimic more common spinal lesions, making diagnosis difficult. Advanced imaging modalities, such as MRI and CT, combined with a detailed medical history and laboratory examination, are critical for early detection. Second, during the postoperative management of gout patients receiving spine surgery, careful monitoring is needed to prevent the recurrence of systemic disease, especially in the distal joints, as surgical stresses can induce acute attacks of gout.\u003c/p\u003e \u003cp\u003eIn terms of orthopaedic and rheumatology treatments, this case emphasizes the importance of multidisciplinary treatment of gout patients receiving spine surgery. Early detection of the effects of gout on the spine and timely surgical treatment can relieve neurological symptoms, but strategies to prevent postoperative recurrence should also be developed and employed. This includes careful titration of uric acid-lowering drugs, judicious use of anti-inflammatory drugs, and patient education on lifestyle changes to reduce the risk of future recurrence. The possibility of systemic recurrence should be considered in the preoperative assessment, and postoperative care must include close observation of symptoms in the peripheral joints.\u003c/p\u003e \u003cp\u003eThis case opens the way for further study of the mechanism of tophus formation in the spine and the long-term efficacy of surgical intervention. Future prospective studies should investigate the incidence and pathophysiology of spinal gout in gout patients to establish clearer diagnostic standards and treatment guidelines. In addition, studies on the recurrence of gout after surgery can elucidate better prevention and treatment strategies, thereby improving the outcomes of gout patients with spinal and peripheral joint manifestations. In summary, this rare case provides valuable insights into the complex interactions between spinal gout and systemic diseases, emphasizing the need for a comprehensive approach for diagnosis, surgery, and postoperative management.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe sincerely thank the medical personnel involved in the treatment of the patient, especially the rheumatology department and the orthopaedics department, for their hard work and contributions in handling this complex case. Special thanks are given to the nursing team for their valuable support during the preoperative and postoperative care of the patient. We also thank the peer reviewers for their insights and feedback, which have greatly improved the clarity and depth of this manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatement of Ethics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStudy approval statement:\u0026nbsp;Ethics approval for this study was obtained from the Ethics Board of\u0026nbsp;Shengli Oilfield Central Hospital.The ethics code :YXLL202412501.\u003c/p\u003e\n\u003cp\u003eConsent to publish statement: Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe declare that the publication of this case report is not associated with any conflicts of interest. There is no financial support from any pharmaceutical company or other third parties that might affect the contents of this study. All treatment and patient management decisions were based on clinical indications and best practices. All the authors listed have approved the manuscript that is enclosed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Sources\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported China Scholarship Committee 202008440406.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eJinlong Wang collected data. Bo Cao drafted and revised the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors confirm that the data supporting the fndings of this study are available within the article and its supplementary materials. Further enquiries can be directed to the corresponding author.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMartillo MA, Nazzal L, Crittenden DB. The crystallization of monosodium urate. Curr Rheumatol Rep. 2014;16:1\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eManson JJ, Isenberg D, Chambers S, Shipley ME, Merrill JT. Rapid review of rheumatology and musculoskeletal disorders. 2014.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMartinon F. Mechanisms of uric acid crystal-mediated autoinflammation. Immunol Rev. 2010;233(1):218\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eToprover M, Mechlin M, Fields T, Oh C, Becce F, Pillinger MH. Monosodium urate deposition in the lumbosacral spine of patients with gout compared with non-gout controls: a dual-energy CT study. 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Primer on the rheumatic diseases. Springer; 2008. pp. 42\u0026ndash;93.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eO\u0026rsquo;Dell MC, Kohler NJ, Harshman BK, Messina SA, Wasyliw CW, Felsberg G, Bancroft LW. Degenerative disease of the spine and other spondyloarthropathies. Imaging Pelvis Musculoskelet Syst Special Appl CAD 2016: 179\u0026ndash;203.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBSITI T. especially gout, were important causes of ecchymoses.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi S, Xu G, Liang J, Wan L, Cao H, Lin J. The role of advanced imaging in gout management. Front Immunol. 2022;12:811323.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhou MX, Wu MM, Sang ML, Wu MJ. Clinical observation of posterior decompression, fusion and fixation in the treatment of spinal gout: a case series. J Orthop Surg Res. 2023;18(1):303.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKeith MP, Gilliland WR. Updates in the management of gout. Am J Med. 2007;120(3):221\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLala V, Zubair M, Minter D. Liver function tests. \u003cem\u003eStatPearls\u003c/em\u003e 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDalbeth N, Choi HK, Joosten LA, Khanna PP, Matsuo H, Perez-Ruiz F, Stamp LK. Gout (primer). Nat Reviews: Disease Primers 2019; 5(1).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Spinal gout, knee gout, knee joint, gouty arthritis, lumbar fusion","lastPublishedDoi":"10.21203/rs.3.rs-5316922/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5316922/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eIntroduction\u003c/h2\u003e \u003cp\u003eGout usually manifests as acute inflammatory arthritis affecting the peripheral joints, but spinal gout, especially that caused by tophi in the spinal canal, is very rare. Patients with spinal gout often present with nonspecific symptoms that mimic other spinal lesions, posing a challenge for diagnosis. This case report describes the unusual manifestation of tophi in the spinal canal and the gout in the knee, highlighting the complexity of treatment and the necessity of timely diagnosis and intervention.\u003c/p\u003e\u003ch2\u003eCase presentation\u003c/h2\u003e \u003cp\u003eA 22-year-old male with a history of hyperuricaemia presented with low back pain and radicular symptoms in the right lower extremity. Magnetic resonance imaging (MRI) and X-ray imaging revealed lumbar spinal stenosis and a mass at the L5/S1 level. The patient underwent surgical resection of the lesion in the spinal canal, and the intraoperative results confirmed the presence of monosodium urate (MSU) crystals. Meanwhile, the patient experienced severe gout in the knee, with manifestations of severe pain, swelling, and limited mobility. The patient's condition gradually improved after treatment with arthroscopic knee surgery and nonsteroidal anti-inflammatory drugs (NSAIDs). Pathological examination of the resected tissues confirmed a diagnosis of spinal and knee gout.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThis case highlights the diagnostic challenge of treating spinal gout, especially when it manifests as tophi in the spinal canal. The postoperative risk of gout in knee joints makes treatment more complicated. Early identification and multidisciplinary treatment are key to optimizing the therapeutic effect. This case emphasizes the importance of comprehensive uric acid-lowering treatment and vigilant postoperative monitoring for preventing and controlling any complications of systemic gout.\u003c/p\u003e","manuscriptTitle":"A rare case report of an adult with intraspinal gouty stones and concurrent knee joint involvement","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-19 13:35:14","doi":"10.21203/rs.3.rs-5316922/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1bc68e1a-f360-44c6-b0c7-8f005abf1846","owner":[],"postedDate":"November 19th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-11-29T15:38:49+00:00","versionOfRecord":[],"versionCreatedAt":"2024-11-19 13:35:14","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5316922","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5316922","identity":"rs-5316922","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}