Case Report: Clinical characteristics and management strategies of intraspinal tophaceous gout: a case series and literature review.

BACKGROUND

Intraspinal tophaceous gout, defined as monosodium urate crystal deposition within the effective spinal canal causing neural compression, is a rare subtype of spinal gout with no unified diagnostic standard. Despite documented gout history, it is frequently misdiagnosed preoperatively.

METHODS

We retrospectively analyzed five male patients with pathologically confirmed intraspinal tophaceous gout (median age 25 years, range 21-48) admitted to two tertiary hospitals between January 2018 and May 2026, alongside a systematic literature review of strictly defined cases.

RESULTS

The preoperative misdiagnosis rate was 60%. Computed tomography values of 142-272 Hounsfield units provided diagnostic clues, yet no patient underwent preoperative dual-energy computed tomography. Three patients underwent open decompression with fusion, one endoscopic decompression, and one computed tomography-guided biopsy followed by conservative observation; pathology confirmed gouty tophus or granuloma in all. One patient developed a postoperative intraspinal hematoma on day 4, a previously unreported complication. Long-term follow-up revealed multiple vertebral compression fractures and thoracic spinal cord injury in one patient with poor compliance with urate-lowering therapy, a bone event that requires long-term vigilance. Pooled analysis of the 38 strictly defined cases (33 literature cases plus this series) confirmed that the preoperative misdiagnosis rate exceeds 50% and that most lesions are epidural.

CONCLUSION

Intraspinal tophaceous gout should be considered in young male patients with back pain and neural deficits, even with known gout history. A stepwise imaging strategy, individualized surgical or biopsy-first management, vigilant postoperative monitoring, and long-term urate-lowering therapy are essential for optimal outcomes.