Disclosures: Vikaran Kadaba, MD: No financial relationships or conflicts of interest

Case Diagnosis: Incomplete Paraplegia Secondary to Suspected Gout of the Epidural Space

Case Description: An elderly patient with history of gout, degenerative arthritis, and thoracic compression fractures presents with 2 months of progressive back pain, bilateral lower extremity weakness, urinary retention, and stool incontinence. Pertinent exam findings included 4/5 lower extremity strength with exception of full strength at ankle joint, intact sensation to light touch including perineal region, and bilateral non-sustained clonus. Labs showed elevated inflammatory markers (ESR, CRP, WBC) with a serum urate level of 6. Autoimmune (ANA, ANCA, anti-RNP, anti-Smith, anti-SSA/SSB, RF) and infectious workups were negative. Lumbar spine MRI revealed new contrast enhancement of L3-L4 facets with extension into epidural space and paraspinal muscles concerning for infection/inflammation and L4-5 degenerative stenosis without cord compression similar to prior imaging.

Setting: Tertiary Care Hospital (Unity Hospital, Rochester NY)Assessment/

Results: Imaging was discussed at multidisciplinary neuro conference and attributed to axial tophaceous gout. Empiric antibiotics were ultimately discontinued in favor of a course of steroids and colchicine. No cultures or biopsy obtained as interventional teams in favor of conservative treatment. Of note, a biopsy of thoracic and lumbar spine one month prior was negative for infection or malignancy. The patient was ultimately treated with a course of steroids and colchicine before transfer to acute rehabilitation center with diagnosis of incomplete paraplegia due to suspected tophaceous gout. She was discharged home after 2-week stay with significant functional improvement, urinary continence, improvement of neurogenic bowel, although function still fluctuated with pain control.

Discussion: Rarely, tophaceous gout may present in the spine, resulting in myelopathy and functional impairment. While no biopsy was completed, this patient functionally improved with prednisone and colchicine, suggesting patients may avoid unnecessary surgical decompression if spinal tophaceous gout remains on the differential diagnosis.

Conclusion: Multidisciplinary team discussions and broad differential diagnoses are important to determine optimal treatment.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/incomplete-paraplegia-secondary-to-suspected-gout-of-the-epidural-space-a-case-report/