Patient: Male, 65-year-old Final Diagnosis: Gout Symptoms: Back pain • weaknes of lower limbs Clinical Procedure: — Specialty: General and Internal Medicine Objective: Unusual clinical course Background: Spinal gout is not so uncommon. The numbers of case reports are low because of underdiagnosis. Nevertheless, the presentation of spinal gout in a patient who was never diagnosed with gout or hyperuricemia is rare. In addition, the probability of occurrence of spinal gout at the thoracic spine is low, making this case unique. Late or missed diagnosis causes treatment delays with grave outcomes. Case Report: A 65-year-old man with a past medical history of chronic lymphocytic leukemia presented with rapid and progressive weakness of the lower extremities that led to complete paraplegia over 2 weeks. Magnetic resonance imaging showed severe central canal stenosis with disc protrusion and a T4-5 ventral mass with abnormal marrow signaling. The margins at the erosion were sclerotic, and malignancy was top on the differential diagnosis. Open minimally invasive laminectomy with discectomy at T4-5 was done. Sections on the biopsy specimen demonstrated fragments of benign cartilage and bone and multiple granulomas palisading around areas of crystalline material, consistent with tophaceous gout. He was started on a urate-lowering treatment per the American College of Rheumatology guideline. Unfortunately, due to the late patient presentation, neurologic recovery was not possible. Conclusions: This case report illustrates an unusual presentation of gout with a catastrophic complication that could have been prevented with early diagnosis and treatment. Some reports have described patients with tophaceous deposits in the absence of gout flare among patients with urate overproduction due to myeloproliferative disorders. Further studies are needed to explore such relationships.