1 case of lumbar slip-and-combine single-sided joint protrusion gout deposit.

Gout is a metabolic disease caused by the metabolic disorder of radon, and urate crystals are deposited in soft tissue to form gout stones, most of which affect the end joints of the body's limbs, and can also invade the spine.
spinal gout can be developed in the vertebral gap, vertebral tube, joint bursts and other tissues, cervical vertebrae, thoracic spine, lumbar vertebrae can be affected, of which the lumbar vertebrae are the most common (56%), thoracic vertebrae, cervical vertebrae rare.
February 2019, the hospital admitted 1 case due to low back pain, left lower limb pain admitted to the hospital, confirmed to L4 vertebral I degree before slip and left joint protrusion gout deposit, after surgery symptoms significantly alleviated, the diagnosis and treatment process is reported as follows.
case data patient, male, 49 years old, was admitted to hospital with 10 years of back pain and three months of pain in the lower left limb.
has a history of gout for more than 10 years, intermittent oral benzodiazepine and nonsteroidal anti-inflammatory drugs, poor uric acid control, gout has violated the 1st toe joint, knee joint, left wrist joint.
the patient's right hand can be seen gout almanac deposition (Figure 1a), the main complaint of low back pain, the right side is very difficult to stretch movement;
check body: lower lumbar tenderness, punch positive, right focus on the left, lumbar front convex increase, hip back convex; right knee redness, local skin temperature rise; left lower limb tibia and first toe back stretch muscle strength weakened (4 levels), left lower leg straight leg lift test positive (40 degrees), left lower knee reflection jump, double lower limb muscle force, feeling, tendon examination is not abnormal.
laboratory examination: C reactive protein (CRP) 0.7mg/L, red blood cell deposition rate (ESR) 4mm/h, uric acid 605 ?mol/L; white blood cell count 9.47 x 109/L, neutrophil count 5.84 x 109/L.
imaging examination: CT show L4 vertebral double-sided vertebral arch gorge crack (Figure 1b, c); power bit X-ray showL4/L5 vertebral instability, L4 vertebral forward slip (Figure 1d, e); MRI l4/L5 The intervertebral disc protrudes backwards, the corresponding horizontal epidural sac is pressurized (Figure 1f-g), the L4/L5 right joint protrusion T2WI signal increases (Figure 1h);
electromyography of the left lower limb neurogenic damage electrophysiological changes, and The main L4, 5 nerve roots.
Pain Visual Simulation Scale (VAS) scored 6 points for right back pain and 3 points for left lower limb pain.
three weeks of oral painkillers, acupuncture, physiotherapy and other non-surgical treatment sons at the local community rehabilitation hospital before admission, with poor results.
patients admitted to the hospital to continue non-surgical treatment, the pain is still not significantly alleviated, so require seeking surgery.
the relevant examination before surgery, in the general anesthesia downstream L4/L5 disc removal decompression, vertebral slip dislocation reset, intervertebral bone fusion, intra-vertebral arch screw fixation.
was found during the removal of L4's right-hand lower joint protrusion saurate with extensive white gravel-like foreign sedimentation (Figure 1j), and no foreign body deposition on the left side (Figure 1k).
white gravel-like foreign body sent to pathology examination, the results show local inflammatory cells immersion, soft tissue around a bit calcified stove, in line with gout changes (Figure 1l).
postoperative patients low-cut diet, to give anti-inflammatory, promote uric acid excretion and other treatment, the second day wearing waist support off the bed activities, after surgery 3dX tablets show slip-off reset satisfaction (Figure 1m, n), low back pain and left lower limb pain significantly alleviated.
8 months after the telephone follow-up, the patient's back pain and left lower limb pain disappeared, VAS score right back pain 2 points, left lower limb pain 0 points, return to normal working life, continue oral benzobromaline treatment of gout, good uric acid control.
discussion of spinal gout is mainly due to the absence of effective control of long-term hyperuric acidemia.
, 35% of spinal gout patients have a history of gout for more than 3 years.
Jegapragasan and others believe that for patients with long-term back pain, there is a history of gout, especially when physical examination found that the skin or joints have gout nodules, should consider the possibility of gout spina;
patients admitted to the hospital with severe right back pain, the surgery found gout stone deposited in the right joint protrusion, the left side did not find gout tissue, can partially explain the right side of the back pain symptoms more than the left clinical manifestations.
patients with a history of gout for more than 10 years, admitted to the hospital to see the middle finger gout deposit, the operation saw joint protrusion gout deposit, pathology confirmed as gout crystallization.
, therefore, when patients with chronic back pain have a long history of gout and corresponding gout signs, the possibility of spinal gout should be considered.
literature reported that when urate attacks the spinal joint, all parts of the spine can be violated, including vertebral, intervertebral disc, joint protrusions, ligaments and epidural tissue, in which joint protrusions are first eroded.
urate is first deposited in the sac, causing sacitis, causing back pain, and then gradually eroding the joint surface and other parts of the vertebrae, which in turn lead to spinal instability, and even degenerative slip.
studies have shown that when gout is affected by joint protrusions, it can cause a cystitisreaction reaction to joints and damage to ligaments, joints and bones, leading to section instability.
in addition, according to biomechanics analysis, the lower lumbar spine is an important part of the human body load, when joint protrusions due to gout deposit damage, easy to lead to the stability of the spine damage. The mechanism of
lumbar slip-and-combine joint protrusion gout deposit is not clear at present.
Bonaldi and other studies pointed out that the occurrence of spinal gout is closely related to the degenerative change of the spine, because in various parts of the spine, the lumbar vertebrae bear the largest weight, the first degenerative change, so the lumbar lumbar gout is much higher than the cervical and thoracic vertebrae.
Tan Xiaoyun and other studies have found that the lumbar joint protrusion synapses compared to other parts of the blood supply is poor, joint protrusion local blood supply disorder may be the cause of spinal gout good on the joint joint joint potential cause.
in addition, the study of the joint synapses and other studies further found that the local pH of joint protrusions is low, indicating that the internal environment is moderately acidic, acidic environment is conducive to urate dissolved deposition, partly explains why the urate is first deposited in the joint protrusion.
Chang's study also found that the pH of the joint fluid is low, resulting in urate in the blood being deposited first in the joint protrusions.
at present, the diagnosis of spinal gout can not be separated from the clinical symptoms, signs, laboratory and imaging test support, but the gold standard of diagnosis still depends on histopathological examination.
laboratory examination, the vast majority of patients were associated with abnormal lysic acid.
imaging examinations (X-rays, CT, and MRI) were not specific to the diagnosis of spinal gout.
early X-ray test performance of lesions was negative, and in the late middle and late stage X-ray and CT examination could show severe vertebral and small joint scoutoring or irregular bone damage.
MRI has a high sensitivity in diagnosing spinal gout, but the specificity is not strong, there are literature reports, the ureat crystalline tissue deposited in the spine on The T1WI performance of medium or low signal, in T2WI often show high signal, enhance MRI as an uneven enhancement signal.
the patient's MRI showed the right joint protrusion T2WI signal increased, the left joint protrusion signal is normal, during surgery to remove the two-sided joint protrusion synapse found the right joint protrusion gout deposit, left side no gout stone, preoperative MRI performance and the results of the test in surgery.
patients with vertebral and joint protrusions did not see bone damage, which may be related to the short-term reposition of gout and the damage to bone.
, the imaging of spinal gout is complex, lacking specificity, and it is difficult to diagnose spinal gout.
the sensitivity of dual-energy dual-source CT confirmed gout can reach 91.9%, the specificity is 85.4%, the working principle is mainly based on the decay of the number of atoms, because the number of atoms of calcium is higher than urate, in the attenuation of the energy changes, the difference in energy attenuation through the computer directly into different CT values, the final output is shown as urate (green light) and calcium salt (purple light), so as to accurately distinguish the acidorate crystallization.
is considered the most promising gout screening tool because it not only clearly shows gout crystallization, but also identifies urate deposits.
patients due to admission to the main complaint of low back pain and radiation pain in the lower left limb, combined with preoperative imaging examination, considering L4/L5 disc protrusion and slip is the main cause of low leg pain, so the diagnosis of gout-based spinabitis caused sufficient attention, ignoring the preoperative lumbar double-source CT examination.
the patient's ex-surgery knee joint double-energy double-source CT examination, to clarify the joint cavity a large amount of gout stone deposits, or the diagnosis of gout-based spina bifida has a certain hint value.
in the treatment of patients with spinal disease, for the past has a history of gout or the presence of visible appearance of gout stone deposition or quadriplegic joint double-source CT clear gout sedimentation, should cause clinicians to be highly concerned about the diagnosis of gout spina bifida.
currently non-surgical treatment is used in patients with gout spina bifida withnosic symptoms, including hypothermia diet and drug treatment (autumn daffodil, nonsteroidal anti-inflammatory drugs and glucocorticoids), and attention is paid to avoiding induced factors.
when patients have obvious spinal cord and nerve root pressure and cause corresponding clinical symptoms, surgical treatment should be preferred, through surgical decompression, removal of gout, fusion fixed reconstruction of the stability of the spine.
, such as jogenlong, for those diagnosed with gout spina bifida and imaging show that bone damage is significantly associated with neurooppression symptoms, should be treated as soon as possible to protect nerve function.
because cases of gout spina bifida are clinically rare, the current literature is only found in scattered case reports, and is difficult to confirm purely through clinical symptoms, signs, imaging performance and laboratory examination, clinical diagnosis usually relies on intraoperative detection to find gout, and postoperative pathological slicing tips in line with gout-like changes.
Draganescu and others believe that the key to gout spinabitis treatment is to reduce the concentration of uric acid in the body, because long-term high uric acid levels will increase uric acid deposition, so whether or not surgery, need to systematically develop a uric acid reduction program.
Yu Yunlong and other reported 1 case of L4 vertebrae slip back and nerve compression patients, through surgical treatment was finally diagnosed as L4/L5 gout discitis, due to timely treatment coupled with the postoperative norms of anti-uitonic acid treatment, postoperative nerve function significantly improved.
King and others believe that the acute attack of lumbar pain, often accompanied by severe back pain symptoms, at this time if the treatment of uric acid reduction and simple pain relief is often not ideal, and delayed treatment has the risk of paraplegia, it should be diagnosed and treated as soon as possible.
Dh?te, etc., also stressed the importance of early drug therapy for gout-based spinabitis, through long-term standard uric acid treatment is expected to reduce the ureat crystals deposited in the spinal sections gradually disappear, thus avoiding surgical treatment.
the author reported a case of cervical bout of bifida, surgical treatment, after surgery to low-level diet, anti-inflammatory, uric acid excretion and other treatment, patients neck pain and right upper limb pain significantly alleviated, the effect is good.
atypical clinical manifestations of lumbar gout bifida, lack of specificity in laboratory and imaging examination, and are not easily diagnosed clinically.
long-term urate erosion will lead to bone damage in the vertebral joints, causing vertebral instability, and even gout pressure the spinal nerve roots, there is a risk of paraplegic paralysis.
clinicians should pay enough attention to the diagnosis of gout spinabitis, the surgery forward spine double-source CT examination is conducive to early diagnosis, during the operation to detect the discovery of white gravel-like substances should be highly suspected of urate crystallization and as soon as possible to send pathological examination, help inglisal diagnosis.
reviewed past case reports, most gout spina bifida is treated with surgery, surgery can fully reduce stress and rebuild spinal stability, the effect is ideal. After
combined with diet, drugs and other standardized anti-gout treatment can get satisfactory results.
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