CASE OF THE MONTH
Neck pain: an unusual presentation of a common disease
A C PANKHANIA, MBChB, MRCS, T PATANKAR, MBChB, DMRD, DMRE, DNBE, FRCR and D DU PLESSIS, MRCPath
Department of Neuroradiology and Neuropathology, Hope Hospital, Salford, Manchester M6 8HD,
Received 15 November
Revised 10 June 2005
Accepted 11 July 2005
’ 2006 The British Institute of
A 68-year-old man presented with 1 month history of
neck pain, progressively worsening sensory dysfunction
in the right hand, weakness of both hands and difficulty
walking. On clinical examination he was found to have
reduced power in both upper and lower limbs, with up-
going plantar reflexes.
MRI was performed using a Philips Gyroscan 1.5 T
machine using sagittal T1weighted turbo spin echo (TSE;
repetition time (TR) 400/echo time (TE) 10, matrix 512,
field of view (FOV) 2556255, slice thickness 3.0 mm/
0.3 mm, number of signal averages (NSA) 4), T2
weighted TSE (TR 3500/TE 120, matrix 512, FOV
2556255, slice thickness 3.0 mm/0.3 mm, NSA 4) and
axial T2weighted turbo field echo (TFE, TR 7.8/TE 3.9,
flip angle 45˚, matrix 512, FOV 2256225, slice thickness
3.5 mm/21.8 mm, NSA 3) sequences. Post-contrast
sagittal (as above) and axial T1weighted TFE (TR 9.4/
TE 4.6, flip angle 25˚, matrix 512, FOV 24562.4, slice
thickness 4.0 mm/22.0 mm, NSA 4) sequences were
also performed from C3 to D1 level. MRI demonstrated a
destructive lesion involving the right facet joint of C4/5
associated with a medially placed extradural mass of
intermediate signal on T1weighted images, intermediate
heterogeneous signal on T2 weighted images which
gadolinium (Figure 1). Enhancement was also present
in the joint and surrounding soft tissues. The soft tissue
mass was compressing and displacing the spinal cord
and intrinsic high signal was present in the cord on T2
weighted sequences. Similar but less severe changes
were also present in the right C2/C3 facet joint.
A CT scan performed to look for bony changes
revealed subtle eggshell calcification noted around the
extradural mass and well-defined erosive changes
involving the facets of C2/C3, C3/C4 and C4/C5
What is the differential diagnosis?
Address correspondence to: Dr Tufail Patankar, 30 Windy Hill
Drive, Bolton BL3 4TH, UK.
The British Journal of Radiology, 79 (2006), 537–539
The British Journal of Radiology, June 2006 537
Figure 2. CT scan shows well defined erosive change
involving the right C4/C5 facet joint.
Figure 3. Low power image showing tophaceous deposits
[black arrows] against a background of fibrosis and focal
chronic inflammation (haematoxylin and eosin stain, original
magnification 650). Inset: Birefringent needle shaped urate
crystals [white arrow] demonstrated by polarised light
(original magnification 6630).
Figure 1. MRI showing a destructive lesion involving the right facet joint of C4/5 associated with a medially placed extradural
mass compressing the spinal cord and of intermediate signal on (a) T1weighted images, (b) heterogeneous intermediate signal
on T2weighted images which showed (c) peripheral contrast enhancement post-gadolinium (arrow demonstrates well-defined
facet joint erosion).
A C Pankhania, T Patankar and D Du Plessis
538The British Journal of Radiology, June 2006
Imaging findings suggested a diagnosis of spinal gout.
The patient had no history or evidence of gout and
denied weight loss or trauma. Subsequently, the serum
urate level was found to be 0.49 mmol l21(normal
values 0.24–0.50 mmol l21). Inflammatory markers were
normal except for a minimally raised C-reactive protein,
which was 22 mg l21(normal ,10 mg l21).
Posterior surgical decompression and debulking of the
extradural mass was undertaken. Histology of the mass
showed areas of chronic inflammation and necrosis.
Some of the areas of the necrosis showed birefringent
needle shaped crystalline structures consistent with
urate crystals (Figure 3). The diagnosis was therefore
made of gout related arthropathy with tophus formation.
A good post-operative recovery was made and the
patient received medical therapy for gout.
Gout is a common metabolic disorder characterized by
episodes of recurrent arthritis and the presence of
monosodium urate in the affected tissues. The disease
tends to affect distal joints but involvement of the axial
skeleton, though rare, has been reported [1, 2] with less
than 40 cases reported in the world literature . The
distribution between cervical, thoracic and lumbar spine
is debatable [1, 2].
The imaging features of spinal gout can be non-specific
and can mimic infectious, inflammatory, degenerative or
neoplastic disease. The MR appearances are defined to a
great extent by the tophus but are variable. The tophi are
low to intermediate signal on T1weighted images, but
may be homogeneously low or high in signal on T2
weighted images [2, 4]. The most common pattern is
homogeneous intermediate signal on T1and heteroge-
neous intermediate to low signal on T2weighted imaging
, which are similar to the appearances seen on MR in
our patient. The variability of signal characteristics on
MR is thought to be due to variable levels of calcium
deposition within the tophus [2, 4]. The tophus may
show homogeneous enhancement or heterogeneous
peripheral enhancement following gadolinium  as in
Our case is unusual in its unilateral involvement of the
facets and that the patient had no radiological or clinical
evidence of gout [2, 5]. Infection and neoplastic process
were excluded on imaging because of multilevel invol-
vement centred on the facet joints. An inflammatory
condition such as rheumatoid disease was considered
unlikely as there was no involvement of other joints.
1. Duprez TP, et al. Gout in the cervical spine: MR pattern
mimicking disk vertebral infection. AJNR Am J Neuroradiol
2. Hsu C-Y, et al. Tophaceous gout of the spine: MR imaging
features. Clin Radiol 2002;57:919–25.
3. Barrett K, Miller ML, Wilson JT. Tophaceous gout of the
spine mimicking epidural infection: report and review of the
literature. Neurosurgery 2001;48:1170–3.
4. Yu JS, et al. MR imaging of tophaceous gout. AJR Am J
5. Kaye PV, Dreyer MD. Spinal gout: an unusual clinical and
cytological presentation. Cytopathology 1999;10:411–4.
Case of the month: Neck pain
The British Journal of Radiology, June 2006 539