Unusual Presentation of Spinal Gout: 2 Cases Report and Literature Review.

INTRODUCTION: Gouty spondyloarthropathy is generally believed to be uncommon. Together with the fact that it can mimic a variety of disease entities, it imposes significant diagnostic challenge in our clinical practice. In this article, we report two patients diagnosed with spinal gout, and both were initially suspected to have a pyogenic infection. CASE REPORTS: The first patient, a 66-year-old man, was admitted for fever and a short history of bilateral upper limb weakness. Clinical, biochemical, and radiological investigation results were suggestive of C5/6 infective spondylodiscitis with resultant cervical myelopathy. The second patient, a 68-year-old man, was admitted for fever and bilateral lower limb weakness and numbness compatible with cauda equina syndrome. Imaging showed L4/5 lytic spondylolisthesis with suspected abscesses formation around the pars defects. Both underwent emergency operations. Histological examinations of intraoperative specimens in both cases revealed tophaceous gout and microbiological studies were all negative. Urate-lowering agent was started for hyperuricemia. They both had partial neurological recovery. CONCLUSION: These two cases highlight how axial gout can mimic infective spondyloarthropathy clinically. In patients with multiple risk factors for gout presenting with back conditions, spinal gout should be considered as one ofthe differential diagnosis. With the availability of advanced imaging modality, dual-energy computed tomography scan, pre-operative diagnosis of axial gout is now possible which may have implications on subsequent surgical approaches and medical treatment. Collaboration with the medical team to achieve good serum urate control is important to prevent disease recurrence.

An optimal, cost-effective laparoscopic appendectomy technique for our surgical residents.

Since early 1999, we have implemented a standardized technique for laparoscopic appendectomy, which is simple, safe and easily learned and mastered by our residents. Besides superior ergonomics, it offers cosmetic advantages. It is inexpensive as only reusable instruments are used. It incorporates useful modifications, such as the use of suprapubic ports, inferior approach with repositioning of the videoscope from the umbilical port to the left suprapubic port, laparoscopic gauze swabs and instrument-assisted knotting, as well as skeletonization of the appendix. We analyze the outcome of this technique between January 2000 and December 2002. The overall conversion rate of 713 laparoscopic appendectomies was 8.7%, which is comparable with the "best" rates in international literature. Operative times (mean, 59.0 minutes) and the complication rate (6.7%) compared favorably with previous reports on resident training. In summary, our residents feel comfortable with our standardized approach, while producing acceptable results with low cost.