British Journal of Radiology (2006) 79, 537-539
© 2006 British Institute of Radiology
doi: 10.1259/bjr/28763793
Neck pain: an unusual presentation of a common disease
A C Pankhania, MBChB, MRCS,
T Patankar, MBChB, DMRD, DMRE, DNBE, FRCR and
D Du Plessis, MRCPath
Department of Neuroradiology and Neuropathology, Hope Hospital, Salford, Manchester M6 8HD, UK
Correspondence: Dr Tufail Patankar, 30 Windy Hill Drive, Bolton BL3 4TH, UK.
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Introduction
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A 68-year-old man presented with 1 month history of neck pain, progressively worsening sensory dysfunction in the right hand, weakness of both hands and difficulty walking. On clinical examination he was found to have reduced power in both upper and lower limbs, with up-going plantar reflexes.
MRI was performed using a Philips Gyroscan 1.5 T machine using sagittal T1 weighted turbo spin echo (TSE; repetition time (TR) 400/echo time (TE) 10, matrix 512, field of view (FOV) 255x255, slice thickness 3.0 mm/0.3 mm, number of signal averages (NSA) 4), T2 weighted TSE (TR 3500/TE 120, matrix 512, FOV 255x255, slice thickness 3.0 mm/0.3 mm, NSA 4) and axial T2 weighted turbo field echo (TFE, TR 7.8/TE 3.9, flip angle 45°, matrix 512, FOV 225x225, slice thickness 3.5 mm/–1.8 mm, NSA 3) sequences. Post-contrast sagittal (as above) and axial T1 weighted TFE (TR 9.4/TE 4.6, flip angle 25°, matrix 512, FOV 245x2.4, slice thickness 4.0 mm/–2.0 mm, NSA 4) sequences were also performed from C3 to D1 level. MRI demonstrated a destructive lesion involving the right facet joint of C4/5 associated with a medially placed extradural mass of intermediate signal on T1 weighted images, intermediate heterogeneous signal on T2 weighted images which showed peripheral contrast enhancement post-gadolinium (Figure 1
). Enhancement was also present in the joint and surrounding soft tissues. The soft tissue mass was compressing and displacing the spinal cord and intrinsic high signal was present in the cord on T2 weighted sequences. Similar but less severe changes were also present in the right C2/C3 facet joint.
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Figure 1. MRI showing a destructive lesion involving the right facet joint of C4/5 associated with a medially placed extradural mass compressing the spinal cord and of intermediate signal on (a) T1 weighted images, (b) heterogeneous intermediate signal on T2 weighted images which showed (c) peripheral contrast enhancement post-gadolinium (arrow demonstrates well-defined facet joint erosion).
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A CT scan performed to look for bony changes revealed subtle eggshell calcification noted around the extradural mass and well-defined erosive changes involving the facets of C2/C3, C3/C4 and C4/C5 (Figure 2).
What is the differential diagnosis?
Imaging findings suggested a diagnosis of spinal gout. The patient had no history or evidence of gout and denied weight loss or trauma. Subsequently, the serum urate level was found to be 0.49 mmol l–1 (normal values 0.24–0.50 mmol l–1). Inflammatory markers were normal except for a minimally raised C-reactive protein, which was 22 mg l–1 (normal <10 mg l–1).
Posterior surgical decompression and debulking of the extradural mass was undertaken. Histology of the mass showed areas of chronic inflammation and necrosis. Some of the areas of the necrosis showed birefringent needle shaped crystalline structures consistent with urate crystals (Figure 3). The diagnosis was therefore made of gout related arthropathy with tophus formation. A good post-operative recovery was made and the patient received medical therapy for gout.
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Figure 3. Low power image showing tophaceous deposits[black arrows] against a background of fibrosis and focal chronic inflammation (haematoxylin and eosin stain, original magnification x50). Inset: Birefringent needle shaped urate crystals [white arrow] demonstrated by polarised light (original magnification x630).
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Discussion
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Gout is a common metabolic disorder characterized by episodes of recurrent arthritis and the presence of monosodium urate in the affected tissues. The disease tends to affect distal joints but involvement of the axial skeleton, though rare, has been reported [1, 2] with less than 40 cases reported in the world literature [3]. The distribution between cervical, thoracic and lumbar spine is debatable [1, 2].
The imaging features of spinal gout can be non-specific and can mimic infectious, inflammatory, degenerative or neoplastic disease. The MR appearances are defined to a great extent by the tophus but are variable. The tophi are low to intermediate signal on T1 weighted images, but may be homogeneously low or high in signal on T2 weighted images [2, 4]. The most common pattern is homogeneous intermediate signal on T1 and heterogeneous intermediate to low signal on T2 weighted imaging [2], which are similar to the appearances seen on MR in our patient. The variability of signal characteristics on MR is thought to be due to variable levels of calcium deposition within the tophus [2, 4]. The tophus may show homogeneous enhancement or heterogeneous peripheral enhancement following gadolinium [2] as in this case.
Our case is unusual in its unilateral involvement of the facets and that the patient had no radiological or clinical evidence of gout [2, 5]. Infection and neoplastic process were excluded on imaging because of multilevel involvement centred on the facet joints. An inflammatory condition such as rheumatoid disease was considered unlikely as there was no involvement of other joints.
Received for publication November 15, 2004.
Revision received June 10, 2005.
Accepted for publication July 11, 2005.
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References
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- Duprez TP, et al. Gout in the cervical spine: MR pattern mimicking disk vertebral infection. AJNR Am J Neuroradiol 1996;17:151–3.[Abstract]
- Hsu C-Y, et al. Tophaceous gout of the spine: MR imaging features. Clin Radiol 2002;57:919–25.[CrossRef][Medline]
- Barrett K, Miller ML, Wilson JT. Tophaceous gout of the spine mimicking epidural infection: report and review of the literature. Neurosurgery 2001;48:1170–3.[CrossRef][Medline]
- Yu JS, et al. MR imaging of tophaceous gout. AJR Am J Roentgenol 1997;168:523–7.[Abstract/Free Full Text]
- Kaye PV, Dreyer MD. Spinal gout: an unusual clinical and cytological presentation. Cytopathology 1999;10:411–4.[Medline]
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Introduction
Discussion
