If you have ever had back pain, you know how difficult it can be to pinpoint the cause. From bone spurs to overworked muscles to slipped discs, there’s no shortage of ailments that could be at the root of your aching lumbar.
And here’s one more. Over the last 10 years, rheumatologists have documented more cases of gout appearing in the spine. So if you are one of the 8 million Americans with this inflammatory form of arthritis – and you have unexplained back or neck pain, tingling sensations down your arm or leg, or numbness – there’s a small chance the culprit could be your gout.
How Common is Spinal Gout?
Gout in the spine is extremely rare. A study published in 2016 in the European Spine Journal found only 131 cases described in medical journals. But Theodore Fields, MD, a rheumatologist at The Hospital for Special Surgery in New York City, says it’s more common than we think.
“Some early studies suggest there is more gout in the spine that we previously thought. Most doctors just aren’t looking for it,” he says. “Patients with spinal gout usually have a previous history of gout in other places.”
Gout typically affects the big toe joint and other extremities first, including the knees and tips of the fingers. People often describe an attack of gout as being so painful they are unable to put on a shoe or drive to the hospital. However, Dr. Fields says it is certainly possible that someone could present with back pain as an initial symptom.
“Gout can travel to almost any joint over time,” says Dr. Fields. “If someone has untreated gout for 10 to 20 years, it is not rare to get it in their fingers, wrists, cervical and lumbar joints, and even occasionally the elbows. The only place it is really rare to get gout is in the hip.”
How Gout Can Affect the Spine
A study published in 2016 in the World Journal of Orthopedics reviewed 68 published case reports of people diagnosed with spinal gout from 2010 to 2014. Some 69% of patients experienced back or neck pain and 66% of patients had elevated uric acid levels. Dr. Fields says, “In addition to back pain, people describe classic neuropathy, including pinched nerve pain down the arm.”
More than half of these patients had a surgical procedure called a laminectomy to relieve the pressure on their spinal cord or nerve roots. Another 29% responded to non-invasive treatments like uric acid-lowering medications.
But Brian F. Mandell, MD, rheumatologist at the Cleveland Clinic in Ohio and board member of The Gout & Uric Acid Education Society, cautions that most people with spinal gout don’t have any symptoms (asymptomatic).
Historically, he says, doctors have thought of spinal gout as affecting transplant patients taking organ-rejection drugs like cyclosporine – which are known to send uric acid levels through the roof. Then researchers began looking at pictures of the spine with advanced imaging known as “dual energy CT scans” and found gout in places they never expected.
“With the new dual energy CT scans we have today, you will actually be able to see clumps of uric acid colored green along the spine. You can see a definitive collection in the area where the symptoms are and predict which nerves would be involved,” explains Dr. Fields.
Still, there is more deposition than there are attacks, explains Dr. Mandell. “When you do look for it, it is certainly more common than we thought. But clinically it is not a very common problem.”
Are Patients Being Overlooked?
Dr. Fields says the back pain of an attack could be mistaken for something else and treated as such. But what the patient really needs is medication to lower their uric acid level.
“Even though a doctor may know the patient has gout, they may assume the back pain is from a herniated disc or osteoarthritis,” he explains. They have to do imaging or a biopsy to find the uric acid deposits in the spine.
Spinal gout is rare, but it may be worth talking to your doctor about if you have back pain and a history of gout. You should be even more suspicious if you use diuretics, have high blood pressure or are obese. Early diagnosis and treatment with uric acid-lowering drugs can prevent the need for surgical intervention.
Author: Carolyn Sayre