Lesson of the month 1: Tophaceous gouty arthropathy of the lumbar spine Gout, classically affecting the fi rst metatarsal joints, knees, fi ngers and ears, is seldom thrown out as a differential when a patient complains of lower back pain. Symptoms presented by patients with spinal gout may be non-specifi c and varied; at times, the only clue being that the patient has a previous history of gout. Prompt treatment with anti-infl ammatory medication once diagnosis is reached helps to alleviate pain and improves the prognosis of the disease. Therefore, it is vital for the treating physician to keep an open mind and consider spinal gout as a diagnosis once other sinister causes such as osteomyelitis have been ruled out. This greatly reduces the morbidity associated with late treatment of spinal gout.