[Vertebral manifestation of chronic recurrent multifocal osteomyelitis (CRMO)]

Spine Involvement and Vertebral Deformity in Patients Diagnosed with Chronic Recurrent Multifocal Osteomyelitis

BACKGROUND

Chronic recurrent multifocal osteomyelitis (CRMO) is an inflammatory disorder of bone, typically arising adjacent to the physes of long bones but also seen throughout the skeleton. For patients with spinal involvement, CRMO lesions can cause compression deformities with a range of severity from minimal anterior wedging to circumferential height loss, known as vertebra plana. This study examines a large cohort of CRMO patients to determine the prevalence of spine involvement and vertebral deformity.

METHODS

This is a retrospective review of all patients with a diagnosis of CRMO seen at our institution between January 2003 and December 2020. These patients were identified through a prospectively maintained database of all CRMO patients seen at the institution. A retrospective review was undertaken to identify all patients with spinal involvement and determine the prevalence of CRMO in the spine and its effects on vertebral height and deformity.

RESULTS

Of 170 patients included in this study, 48 (28.2%) were found to have spinal involvement. Among patients with spinal involvement, vertebral body lesions were identified in 27 (56.3%) patients. The remaining lesions were in the sacrum or posterior elements. Radiographic evidence of the vertebral body height loss was noted in 23 of these 27 patients.

CONCLUSIONS

This cohort of CRMO patients demonstrates that 28% of patients have spinal involvement, and 48% of those patients have vertebral body height loss. While the ideal treatment for spinal CRMO has yet to be determined, imaging studies, including whole-body MRI and spine-specific MRI, are useful in identifying vertebral lesions and deformities. Identification and surveillance of these lesions are important as the disorder has a relapsing and remitting course, and patients can develop significant vertebral body height loss. Once deformity has developed, we have seen no evidence of reconstitution of the height of the collapsed vertebra. Bisphosphonates have been successful in preventing the progression of vertebral body height loss.

LEVEL OF EVIDENCE

Level II: Retrospective study investigating spinal involvement and prevalence of vertebral body deformity in patients diagnosed with CRMO.

Not all benign: disease course, complications, and sequalae of chronic recurrent multifocal osteomyelitis in children

PURPOSE OF REVIEW

Advances in pathogenesis of chronic recurrent multifocal osteomyelitis in children (CRMO) have shaped therapeutic strategies. The use of whole-body MRI (WBMRI) and improved awareness of CRMO has increased rates and timeliness of CRMO diagnoses. In this review, we highlight the findings from recently published CRMO cohorts and describe the course, complications, and long-term sequalae of CRMO. It is important for clinicians to be aware of the potential for long-term sequelae in order to optimize therapy and avoid complications.

RECENT FINDINGS

Despite recent advances in defining disease pathogenesis, children with CRMO continue to suffer from complications and deformities. Involvement of the spine can be asymptomatic and is not as rare as previously suggested. This can result in damaging outcomes, such as vertebral fractures and permanent deformities. A subset of patients has polycyclic disease course and some continue to have active disease for years and well into adulthood, with significant impacts on quality of life.

SUMMARY

These recent findings have considerable implication on clinical practice regarding diagnosis, treatment, and monitoring of the disease. Collectively, they support the need for continued monitoring of the disease and screening using comprehensive imaging, such as WBMRI.

The Many Faces of Pediatric Chronic Recurrent Multifocal Osteomyelitis (CRMO): A Practical Location- and Case-Based Approach to Differentiate CRMO From Its Mimics

Chronic recurrent multifocal osteomyelitis (CRMO) is an autoinflammatory bone disease of childhood and adolescence characterized by episodic bone pain. Diagnosis relies heavily on whole-body MRI and is made by excluding a wide variety of other disorders with overlapping imaging features, depending on location, marrow distribution, and the presence or absence of multifocality. We present an overview of the clinical and imaging features of CRMO and, through various clinical scenarios, provide tips for tailoring the differential diagnosis based on location and distribution of encountered abnormalities. LEVEL OF EVIDENCE: 4 TECHNICAL EFFICACY STAGE: 3.

Syndromes with chronic non-bacterial osteomyelitis in the spine

Chronic non-bacterial osteomyelitis (CNO) has been known for over of 40 years. It is an underrecognized entity due to the low number of described cases and poor propagation awareness of the problem. Chronic non-bacterial osteomyelitis is usually confused with infectious spondylodiscitis or malignant lesions, both primary and metastatic. Failing to consider CNO as one of possible lesions of the spine among an array of differential diagnoses may lead to a prolonged ineffective treatment increasing treatment-related morbidity. In this paper the authors describe these two syndromes, with a possible autoimmune background – chronic recurrent multifocal osteomyelitis (CRMO) and SAPHO syndrome – that include CNO being among the manifestations. The authors present the spinal symptomatology of CNO for both syndromes published so far to help spine clinicians organize the information for better usage in everyday clinical practice.

Spinal involvement in chronic recurrent multifocal osteomyelitis (CRMO) in childhood and effect of pamidronate

There are only a few studies that address the frequency and type of spinal involvement in patients with chronic recurrent multifocal osteomyelitis (CRMO) as well as the outcome of these patients treated with pamidronate (PAM). We performed a retrospective study on patients with CRMO and analyzed clinical and pain assessments as well as regional and whole body MRI findings and compared with posttreatment findings. Of 102 children and adolescents with CRMO, 27 (26%) had involvement of the spine. Vertebral deformities were seen in 14 of these 27 patients, scoliosis or kyphosis in 6. After routine whole body MRI, 19 complained of back pain, whereas eight were asymptomatic with spinal lesions detected incidentally. A total of 72 spinal lesions were detected, thoracic vertebrae being the most commonly affected. Seven patients were treated with PAM; all of whom had vertebral deformities and ongoing back pain. Pain resolution was achieved within 3 months of PAM treatment in every case. One patient subsequently developed a pain amplification syndrome. Repeat MRI performed at a mean interval of 13 months revealed partial or complete resolution of vertebral hyperintensities in every patient. Improvement of vertebral height was seen in a total of three vertebrae in two patients. Severe side effects were not observed. In conclusion, we demonstrated that spinal involvement and associated vertebral deformities with or without kyphoscoliosis are not rare in CRMO, and PAM appears to be an effective and safe treatment for this condition. Although controlled studies are urgently needed, the use of PAM for refractory CRMO with extended spinal involvement (vertebral deformities, kyphosis, and scoliosis) should be considered, especially after failing of conventional therapy.

Chronic recurrent multifocal osteomyelitis primarily affecting the spine treated with anti-TNF therapy

STUDY DESIGN

A case report describing chronic recurrent multifocal osteomyelitis (CRMO) with initial presentation limited to spine, successfully treated by anti-TNF-alpha therapy after failure of conventional treatment methods.

OBJECTIVE

To describe an unusual manifestation and treatment of a rare disease.

SUMMARY OF BACKGROUND DATA

CRMO is a rare inflammatory bone disease that should be differentiated from bacterial osteomyelitis. Rarely, it can affect the spine and in this case the most important differential diagnosis is infectious spondylodiscitis. The disease has an unpredictable course with exacerbations and spontaneous remissions. Although the majority of cases remit spontaneously (or after the use of nonsteroidal anti-inflammatory drugs [NSAIDs]), some progressive and resistant cases have been reported.

METHODS

We describe a case of CRMO with an unusual clinical presentation emphasizing the importance of this finding as a differential diagnosis of spondylodiscitis and comment on the available treatment alternatives.

RESULTS

A 17-year-old man presented with debilitating dorsal spine pain. Magnetic resonance imaging of the spine revealed bone lesions at multiple vertebral levels. After failure of antibiotic treatment, the diagnosis of CRMO was suggested. An initial good response to NSAIDs was followed by a recurrent course and involvement of peripheral joints besides the use of corticosteroids and other drugs. The introduction of infliximab was followed by complete remission of the disease.

CONCLUSION

Our observation highlights the need of awareness for the differential diagnosis in suspected cases of osteomyelitis not responding to antibiotics. Anti-TNF-alpha agents should be considered in CRMO refractory cases.

Chronic recurrent multifocal osteomyelitis: comparison of whole-body MR imaging with radiography and correlation with clinical and laboratory data

PURPOSE

To describe whole-body magnetic resonance (MR) imaging appearance of chronic recurrent multifocal osteomyelitis (CRMO) and assess the role of MR imaging versus radiography in diagnosis of disease and correlation with clinical findings and laboratory data.

MATERIALS AND METHODS

Institutional review board approved this retrospective HIPAA-compliant study; informed consent was waived. T1-weighted, short inversion time inversion-recovery, and contrast material-enhanced T1-weighted whole-body MR imaging was performed and two-plane radiographs, clinical findings, and laboratory data were reviewed in 13 children (median age, 13 years) with CRMO. Lesion depiction, location, and characterization and extraskeletal abnormalities were evaluated. MR imaging findings were compared with clinical and laboratory data and radiographic results. Data analysis was performed, and diagnostic performance statistics of radiography, physical examination results, and serum inflammatory markers were calculated. General multilevel linear modeling framework was used. Odds ratios were calculated to estimate effect of age, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) level on reliabilities. Associations of ESR and CRP level with total number of lesions were assessed (chi(2) test).

RESULTS

MR imaging depicted 101 ill-defined edemalike osseous lesions. Most frequent anatomic sites were distal femur (21%, 21 of 101), proximal tibia (17%, 17 of 101), and distal tibia and fibula (14% each, 14 of 101). In tubular bones (70 anatomic sites), metaphysis (86%, 60 of 70) and epiphysis (67%, 47 of 70) were involved. Contiguous physeal relationship (89%, 66 of 74), periosteal reaction (48%, 48 of 101), and symmetric involvement (85%, 11 of 13) were present. MR imaging demonstrated multifocality in all patients. There were no extraskeletal abnormalities and no relationship between serum inflammatory markers and number of symptomatic anatomic sites (P = .472). Sensitivity for radiography was 0.13 (70 of 119); physical examination, 0.31 (52 of 299); and serum inflammatory markers, 0.15 (two of 13).

CONCLUSION

Whole-body MR imaging is useful for detection of CRMO, particularly in indeterminate cases, because it is more likely to show abnormalities.

Chronic recurrent multifocal osteomyelitis presenting as acute scoliosis: a case report and review of literature

Chronic relapsing multifocal osteomyelitis (CRMO) is a rare condition. It commonly affects the clavicle and pelvis. Rarely it can affect the spine. Spinal deformity due to CRMO is rare. We report a case of acute scoliosis due to CRMO. A 10-year-old girl with CRMO presented with acute painful scoliosis of her spine. She was neurologically intact. Imaging suggested a neoplastic process involving T10, L2 and L3. Further imaging and subsequent biopsy was performed and a diagnosis of CRMO was established. Spinal involvement with deformity is uncommon. It is commonly misdiagnosed as infection or a neoplasm and unnecessary aggressive surgical and antibiotic therapy instituted. A high index of suspicion is needed to diagnose this disease and thus manage it appropriately. This patient with a previously normal spine had a long right sided thoracic scoliosis. We think that the particular pattern of scoliosis was a protective mechanism to offload the right sided T10 vertebral pedicle. Prognosis is generally good although the disease can relapse and remit over many years. At 9 months follow up, the lesions were resolving and the deformity had resolved. CRMO presenting as acute scoliosis is rare and to our knowledge this is the second recognised case in the reported world literature.