British Journal of Radiology (2006) 79, 775-777
© 2006 British Institute of Radiology
doi: 10.1259/bjr/29157329
A case of spinal cord compression of unknown cause
D Butteriss, FRCR and
C Soh, FRCR
Department of Neuroradiology, Regional Neurosciences Centre, Newcastle General Hospital, Westgate Road, Newcastle-upon-Tyne NE4 6BE, UK
Correspondence: Dr C Soh
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Case report
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A 65-year-old woman presented to the accident and emergency department complaining of a 3-month history of falls, reduced power and numbness in her arms and legs, and urinary incontinence. Her status had deteriorated over the previous 4 weeks and she was bed-bound on admission. There was no significant past medical history. Examination revealed reduced power in all limbs, increased tone in the right upper limb, altered sensation below the shoulders and perianal/saddle paraesthesia. A presumptive diagnosis of spinal cord compression in the mid-cervical spine was made and the patient was referred for spinal MRI. Selected axial and sagittal images of the cervical (Figure 1
) and lumbar spine (Figure 2) are shown.
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Figure 1. Sagittal(a) T1 weighted, (b) T2 weighted MR images through the cervical spine. (c) Representative axial T1 weighted image through the cervical spine.
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Figure 2. Sagittal(a) T1 and (b) T2 weighted MR images through the lumbar spine. (c) Representative axial T2 weighted image through the lumbar spine.
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What do the images show?
Is there evidence of myelopathy?
What is your differential diagnosis?
CT of the cervical spine was subsequently performed, prior to surgery (Figure 3).
Does this alter or narrow your differential diagnosis?
MRI demonstrates low/intermediate signal masses on T1 and T2 imaging, involving the C3–C6 vertebral bodies, with destruction of C4 and C5 extension into the paravertebral soft tissues. At C4–C5 there is extradural compression of the cervical cord, with high intramedullary cord signal on T2 weighted imaging consistent with myelopathy. CT of this level shows a relatively high attenuation mass containing fragmentary calcification that is destroying the cervical vertebral bodies and extending into the surrounding soft tissues and into the spinal canal with thecal compression.
MRI of the lumbar spine shows involvement of the L3–S1 vertebral bodies, posterior elements and facet joints with small extradural masses, but no evidence of neural compression. Further imaging demonstrated further lesions in the sacroiliac joints, both hips and the pubic symphysis.
Neurosurgical C3–C6 partial anterior vertebrectomies with iliac crest grafting and plate fixation revealed pale, cheesy deposits, shown to be gouty tophi on histological investigation. Urate-lowering medical therapy was instituted.
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Discussion
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Gout is a relatively common metabolic condition characterized by deposition of monosodium urate crystals in joints and soft tissues. In Europe the incidence is approximately 0.2–0.5% and the male to female ratio is approximately 5:1. The acute presentation is with a monoarthritis, in 25% of cases affecting the first tarsometatarsal joint (podagra). Chronicity results in the formation of tophi within the soft tissues around joints and in the pinnae of the ears due to deposits of monosodium urate and associated inflammatory cells. This is rare before at least 10 years of acute attacks. The peripheral joints are most commonly affected, but occasionally spinal involvement with gouty tophi occurs [1].
The presentation of spinal tophaceous gout is non-specific, with local pain, radicular symptoms and paraparesis or tetraparesis occurring due to neural compression. There is usually, but not invariably, a history of prior acute attacks of gout, or of hyperuricaemia [2].
MRI appearances are variable. Tophi appear as homogeneous intermediate/low intensity masses on T1 weighted imaging, but have a variable T2 weighted appearance ranging from homogeneous low through heterogeneous signal to homogeneous high signal. Tophi may contain small areas of signal drop-out that have been shown to represent calcification on CT imaging. Enhancement post-gadolinium administration is also variable. Rim enhancement is the most common finding, but both complete lack of enhancement and homogeneous enhancement have both been described [3]. Appearances may mimic spinal infection, malignancy or haemorrhage [4].
Symptomatic spinal gout usually involves the epidural space, with variable involvement of the intradural component, ligamentum flavum, facet joints, posterior elements, vertebral bodies and paraspinal soft tissues [3].
Acute management in cases with neural compression usually requires surgical decompression, where the tophus appears as a chalky, cheesy or fibrous mass. Often the diagnosis is made on histological examination of the surgical sample. Local pain may respond to anti-inflammatory medication or colchicine. Long-term allopurinol therapy may result in reduction in size or even disappearance of tophi.
In conclusion, spinal tophaceous gout is a rare cause of spinal neural compression, but should be considered when MRI demonstrates intermediate/low signal on T1 weighted deposits with low signal foci on all sequences, especially if there is involvement of the posterior elements.
Received for publication June 21, 2005.
Revision received July 27, 2005.
Accepted for publication August 16, 2005.
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References
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- Huskisson EC, Drury PL. Rheumatology and bone disease. In: Kumar P, Clark M, editors. Clinical medicine. London, UK: Bailliere Tindall, 1994:409–11
- Paquette S, Lach B, Guiot B. Lumbar radiculopathy secondary to gouty tophi in the filum terminale in a patient without systemic gout: case report. Neurosurgery 2000;46:986–8.[CrossRef][Medline]
- Hsu C-Y, Shih T T-F, Huang K-M, Chen P-Q, Sheu J-J, Li Y-W. 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: case report and review of the literature. Neurosurgery 2001;48:1170–2.[CrossRef][Medline]
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Case report
Discussion
