Axial skeleton involvement in gout: clinical spectrum and dual-energy computed tomography findings from a descriptive real-world study.

INTRODUCTION: Axial gout is a rare and often underdiagnosed manifestation of gout, characterized by monosodium urate (MSU) crystal deposition within the axial skeleton, particularly the spine and sacroiliac joints. Unlike classical gout, which presents with acute peripheral joint inflammation, axial involvement may mimic other rheumatologic or spinal disorders due to its varied and atypical presentation. OBJECTIVES: To assess the clinical spectrum of axial gout and to determine the axial MSU burden and its anatomical distribution. METHODS: Adult patients (> 18 years) with suspected or diagnosed gout with axial symptoms (pain-VAS > 40/100 mm) visiting the institute during study period were enrolled and those with concomitant diagnosis of axial spondyloarthritis, spinal infections, malignancy and prolapsed intervertebral discs were excluded. All demographic, clinical, radiological parameters were assessed and statistically analysed. RESULTS: A total of 27 patients (mean age 48.6 years; 85.2% male) were included. DECT demonstrated widespread monosodium urate deposition, predominantly in lumbar intervertebral discs (88.9%), sacral foramina (70.4%), and sacral ala (66.7%). Atypical sites included the atlanto-occipital, pelvis and coccyx. Patients had a high disease burden, with mean serum uric acid of 8.48 ± 2.89 mg/dL, spinal pain VAS 49.4 ± 11.7, HAQ 2.27 ± 0.56, and GIQ 66.4 ± 19.1. CONCLUSIONS: Axial gout should be considered in the differential diagnosis of axial pain syndromes, particularly in patients with hyperuricemia or known gout. Increased awareness and advanced imaging techniques are critical in improving the recognition and timely management of this uncommon but significant clinical entity.