Gout is a common metabolic disorder resulting from supersaturation of uric acid in extracellular fluid and deposition of monosodium urate crystals in tissues. Gouty arthritis typically affects the peripheral joints of the appendicular skeleton, especially the feet and hands. Gouty involvement of the spine, however, is not as rare as generally perceived. Although it may be asymptomatic, tophaceous axial gout is also a well-documented cause of acute back pain, radiculopathy, and frank cord compression. As with the appendicular skeleton, it takes several years of gout before radiological evidence of erosive change or tophi is apparent in the axial skeleton. This is best detected by CT imaging. The sequelae of cord compression can be reversed with timely surgical intervention and maintenance of uric acid-lowering therapy. The long-term effects of urate-lowering therapies on axial gout have not been studied.