Gouty involvement of the spinal column is not as rare as generally perceived. Tophaceous gout involving the spinal column is a well-documented cause of myelopathy and frank cord compression. It takes several years of gout before bony destruction is radiologically apparent. If erosive or tophaceous gout is present, magnetic resonance imaging signal enhancement offers diagnostic guidance. Non-tophaceous gout of the spine may also show signal enhancement consistent with inflammation. The sequelae of cord compression can be reversed with timely surgical intervention and maintenance of uric acid-lowering therapy; in some cases, medical therapy alone can reverse the findings of radiculopathy. Growing evidence suggests that the tangled web of hypertension, diabetes, and atherosclerotic disease are risk factors for gout and hyperuricemia and may, in fact, be the result of higher than physiologically tolerable levels of uric acid in humans. Here, 52 additional cases to the 73 collated by Hou et al (Surg Neurol. 2007;67:65-73), reinforce that gout is a major contender on the differential diagnosis of back-related presentations in patients at high risk for gout. The pervasiveness of cardiovascular disease and chronic back pain warrants a closer look into a possible occult contributor to the prevalence of chronic back pain: gout.