82-Year-Old Man With Gout, Hypertension, Dizziness, and Neck Pain

An 82-year-old African American male with a history of hypertension and polyarticular tophaceous gout presented to the emergency department (ED) with acute onset of dizziness, neck pain and bilateral upper extremity weakness that had arisen periodically over the previous two months.

He described his neck pain as 10 on a scale of 1 to 10, aching, non-radiating, associated with movement and worst in the morning. He attributed the pain to his sleeping posture. His symptoms had progressed in the two weeks prior to admission, culminating in numbness and weakness in the hands. He reported two episodes of syncope while turning his head, one at the dentist’s office and another during a car ride. On both occasions syncopal episode was preceded by dizziness, tingling, and numbness in his arms and accompanied by weakness, nausea, and visual disturbances. He denied postictal confusion, urine or stool incontinence, or any history of trauma.

His home medications included 0.6 mg colchicine and 100 mg allopurinol, both daily,  for crystal-proven gout that was diagnosed 30 years ago. His most recent gout flare was 2 years ago. He reported that each flare lasts for 10 days, with joint pain and swelling.

Noteworthy laboratory findings on admission were sedimentation rate (10 mm/hr), CRP (<2.9mg/l) and uric acid level (4.9 mg/dl). RF and CCP antibody levels were within normal ranges.  

The musculoskeletal exam showed upper cervical and paracervical tenderness, Heberden's and Bouchard's nodes in both hands, multiple subcutaneous nodules with synovial thickening of the olecranon bursa bilaterally, marked limitation of movement in the shoulders, and weakness in the upper extremitiies.

A radiograph of the cervical spine appears above. What cause do you suspect for his symptoms? Which further tests would you order?

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