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

Abstract

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.