Summary

A 90-year-old female with a medical history of untreated gout presented to the emergency department with acute low back pain. On physical examination, the area over the 4th lumbar spinous process was extremely tender. Serum C-reactive protein was 184 mg/L, and uric acid was 8.3 mg/dl.

Conventional [Figure 1A] and dual-energy computed tomography (DECT) [Figure 1B] studies of the lumbar spine showed multiple tophi-engulfing posterior vertebral structures of the involved vertebral unit, including the spinous and transverse processes and facet joints. This condition is schematically shown in Figure 1C with asterixis indicating tophi-induced erosion and osteolysis of the spinous process.

The patient was treated for a suspected acute gouty attack with prednisone and colchicine followed by allopurinol treatment with rapid and uneventful recovery.

Axial gout is an underdiagnosed and potentially curable cause of recurrent low back pain [1,2]. Referral to DECT should be considered in patients with uncontrolled gout and concurrent back pain.