胸椎管内痛风一例报告及系统文献综述

Gout in thoracic spinal canal:a case report and systematic review

目的探讨脊柱椎管内痛风的临床表现、流行病学特征和诊疗现状。方法收治1例59岁男性患者,症状为胸背部疼痛伴双下肢无力、感觉减退及行走踩棉花感。影像学检查示T8,9水平椎管内占位病变伴重度椎管狭窄。全身麻醉下行后路T8,9椎板切除减压、病灶清除及T7~T10椎弓根螺钉内固定术,术后病理学诊断为胸椎管内痛风。以"gout"、"gout of spinal canal"、"gout of spine"、"intraspinal gout"、"椎管内痛风"、"痛风"、"脊柱痛风"为关键词在中英文数据库中共检索到62例椎管内痛风患者,统计现有全部椎管内痛风患者的年龄、性别、发病部位、痛风或高尿酸血症病史、实验室指标及影像学资料。结果63例椎管内痛风患者中,男54例(87.1%,54/62)、女8例(12.9%,8/62),男女比为6.75∶1,另1例不详。年龄52(35,67)岁(范围20~82岁),发病高峰期为60~79岁。56例(88.9%,56/63)脊柱单一部位发病,其中腰骶椎26例(46.4%),其次为胸椎22例(39.3%)、颈椎8例(14.3%);7例为两个及两个以上部位同时发病,占全部患者的11.1%(7/63)。53例(91.4%,53/58)有高尿酸血症病史,病程3个月至28年,平均8.6年。临床症状无特异性,70.5%(43/61)有病变局部疼痛感,98.4%(60/61)存在不同程度的神经功能障碍。X线检查多无阳性表现;41例有CT影像学资料的患者表现为椎管内中高密度椭圆形或不规则钙化影31例、中低密度软组织肿块影10例;96.2%(51/53)的患者MRI表现为T1WI中等或低信号、T2WI高信号或低信号(高信号40例、高信号或混杂信号13例)。63例均由病理检查确诊,其中5例有镜下组织学特征描述,表现为异物肉芽肿改变,在异物巨细胞的细胞质中见红染的类结晶样物沉积,偏光显微镜下呈双折光性梭形或针状结晶。结论脊柱椎管内痛风罕见,其临床表现、实验室检查及影像学资料缺乏特异性;双能CT识别痛风具有较高的灵敏度和特异度,诊断主要依靠病理。存在脊柱不稳或神经症状时应手术,基础降尿酸治疗可降低急性发作风险。

Objective To summarize the clinical manifestations,epidemiological features and progress of diagnosis and treatment of gout in the spinal canal.Methods A 59-year-old male patient was admitted to the hospital due to back pain,weakness in both lower limbs,hypoaesthesia and feeling of walking and stepping on cotton for more than one month.The preoperative imaging examination showed there were space-occupying lesions in the spinal canal at the T8,9 level with severe canal stenosis.The patient underwent posterior T8,9 laminectomy decompression,debridement and T7-T10 pedicle screw internal fixation under general anesthesia.The thoracic spinal gout was diagnosed by postoperative pathology.Further,the following keywords,"gout","gout of spinal canal","gout of spine"and"intraspinal gout",were used to search in the Chinese and English databases.A total of 62 patients with intraspinal gout were retrieved.The age,gender,involved disease,history of gout or hyperuricemia,laboratory indicators and imaging data of 63 patients were collected.Results A total of 63 patients with intraspinal gout were retrieved.The gender of one patient was unknown.The remaining patients included 54 males(87.1%,54/62)and 8 females(12.9%,8/62)with the ratio of male to female 6.75∶1.The average age was 52(35,67)years(range 20-82 years)and the peak onset period was 60-79 years.Fifty-six cases(88.9%,56/63)of all patients suffered the disease from one single site of the spine,including 26 cases in the lumbar-sacral(46.4%),22 cases(39.3%)in the thoracic spine and 8 cases(14.3%)in the cervical spine.However,only 7 patients had the disease at more than two sites at the same time accounting for 11.1%of all patients(7/63).Fifty-three patients(91.4%,53/58)had a history of hyperuricemia with an average duration of 8.6 years(range 3 months to 28 years).The clinical symptoms of intraspinal gout were not specific.There were 70.5%(43/61)patients had local pain and up to 98.4%(60/61)patients had varying degrees of neurological dysfunction.X-ray examinations often showed no positive results due to technical limitations.Among 41 patients with CT imaging data,31 cases showed mid-to-high density elliptical or irregular calcifications in the spinal canal and the remaining 10 patients showed medium-low density soft tissue masses.There were 96.2%(51/53)of patients with intraspinal gout showed medium or low signal on T1WI MRI examination but without high signal or low signal on T2WI(40 cases of high signal,13 cases of high signal or mixed signal).All 63 patients were finally diagnosed by pathological examination and 5 of them with histological features.The main pathological features included foreign body granuloma,red-stained crystal-like deposits in the cytoplasm of foreign body giant cells,birefringent spindle or needle-like crystals under polarized light microscope.Conclusion Gout in the spinal canal is a rare condition.Dual-energy CT has high sensitivity and specificity in identifying gout and it can provide a more accurate method in diagnosis of spinal gout.However,the final diagnosis depends on postoperative pathology.If case of spinal instability or neurological dysfunction,surgery had to be performed.Hyperuricemia should be treated in order to reduce the risk of acute attacks.