Advertisement

Review of spinal involvement in Chronic recurrent multifocal osteomyelitis (CRMO): What radiologists need to know about CRMO and its imitators

Published:September 23, 2021DOI:https://doi.org/10.1016/j.clinimag.2021.09.012

      Highlights

      • CRMO is a distinct disease entity, about one third of the patients have spinal disease.
      • Long-term morbidity and other disease associations are common.
      • Diagnosis often delayed, some mimickers are reviewed.
      • Imaging is crucial, especially WB-MRI.

      Abstract

      Chronic recurrent multifocal osteomyelitis (CRMO) is a distinct disease entity of unknown etiology primarily affecting children and adolescents. It is an autoinflammatory process that typically affects multiple bones with a waxing and waning course. About one third of the patients diagnosed with CRMO have spinal involvement which can lead to long term morbidity. The clinical presentation and imaging features of CRMO involving the spine are nonspecific and can mimic other disease processes like infection or malignancy. Since imaging plays a very important role in the diagnosis and management of CRMO, we intend to highlight various imaging patterns of spinal CRMO alongside its clinical features and briefly discuss its imitators, management and outcomes.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Clinical Imaging
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Giedion A.
        • Holthusen W.
        • Masel L.F.
        • Vischer D.
        Subacute and chronic “symmetrical” osteomyelitis.
        Ann Radiol (Paris). 1972; 15: 329-342
        • Brown T.
        • Wilkinson R.H.
        Chronic recurrent multifocal osteomyelitis.
        Radiology. 1988; 166: 493-496
        • Yu L.
        • Kasser J.R.
        • O’Rourke E.
        • Kozakewich H.
        Chronic recurrent multifocal osteomyelitis. Association with vertebra plana.
        J Bone Joint Surg Am. 1989; 71: 105-112
        • Carr A.J.
        • Cole W.G.
        • Roberton D.M.
        • Chow C.W.
        Chronic multifocal osteomyelitis.
        J Bone Joint Surg Br. 1993; 75: 582-591
        • Probst F.P.
        • Bjorksten B.
        • Gustavson K.H.
        Radiological aspect of chronic recurrent multifocal osteomyelitis.
        Ann Radiol (Paris). 1978; 21: 115-125
        • Martin J.C.
        • Desoysa R.
        • O’Sullivan M.M.
        • Silverstone E.
        • Williams H.
        Chronic recurrent multifocal osteomyelitis: spinal involvement and radiological appearances.
        Br J Rheumatol. 1996; 35: 1019-1021
        • Demharter J.
        • Bohndorf K.
        • Michl W.
        • Vogt H.
        Chronic recurrent multifocal osteomyelitis: a radiological and clinical investigation of five cases.
        Skeletal Radiol. 1997; 26: 579-588
        • Jurriaans E.
        • Singh N.P.
        • Finlay K.
        • Friedman L.
        Imaging of chronic recurrent multifocal osteomyelitis.
        Radiol Clin North Am. 2001; 39: 305-327
        • Hospach T.
        • Langendoerfer M.
        • von Kalle T.
        • Maier J.
        • Dannecker G.E.
        Spinal involvement in chronic recurrent multifocal osteomyelitis (CRMO) in childhood and effect of pamidronate.
        Eur J Pediatr. 2010; 169: 1105-1111
        • Jansson A.
        • Renner E.D.
        • Ramser J.
        • Mayer A.
        • Haban M.
        • Meindl A.
        • et al.
        Classification of non-bacterial osteitis: retrospective study of clinical, immunological and genetic aspects in 89 patients.
        Rheumatology (Oxford). 2007; 46: 154-160
        • d’Angelo P.
        • de Horatio L.T.
        • Toma P.
        • Ording Muller L.S.
        • Avenarius D.
        • von Brandis E.
        • et al.
        Chronic nonbacterial osteomyelitis - clinical and magnetic resonance imaging features.
        Pediatr Radiol. 2021; 51: 282-288
        • Anderson S.E.
        • Heini P.
        • Sauvain M.J.
        • Stauffer E.
        • Geiger L.
        • Johnston J.O.
        • et al.
        Imaging of chronic recurrent multifocal osteomyelitis of childhood first presenting with isolated primary spinal involvement.
        Skeletal Radiol. 2003; 32: 328-336
        • Falip C.
        • Alison M.
        • Boutry N.
        • Job-Deslandre C.
        • Cotten A.
        • Azoulay R.
        • et al.
        Chronic recurrent multifocal osteomyelitis (CRMO): a longitudinal case series review.
        Pediatr Radiol. 2013; 43: 355-375
        • El-Shanti H.I.
        • Ferguson P.J.
        Chronic recurrent multifocal osteomyelitis: a concise review and genetic update.
        Clin Orthop Relat Res. 2007; 462: 11-19
        • Ferguson P.J.
        • El-Shanti H.I.
        Autoinflammatory bone disorders.
        Curr Opin Rheumatol. 2007; 19: 492-498
        • Walsh P.
        • Manners P.J.
        • Vercoe J.
        • Burgner D.
        • Murray K.J.
        Chronic recurrent multifocal osteomyelitis in children: nine years’ experience at a statewide tertiary paediatric rheumatology referral centre.
        Rheumatology (Oxford). 2015; 54: 1688-1691
        • Huber A.M.
        • Lam P.Y.
        • Duffy C.M.
        • Yeung R.S.
        • Ditchfield M.
        • Laxer D.
        • et al.
        Chronic recurrent multifocal osteomyelitis: clinical outcomes after more than five years of follow-up.
        J Pediatr. 2002; 141: 198-203
        • Girschick H.J.
        • Huppertz H.I.
        • Harmsen D.
        • Krauspe R.
        • Muller-Hermelink H.K.
        • Papadopoulos T.
        Chronic recurrent multifocal osteomyelitis in children: diagnostic value of histopathology and microbial testing.
        Hum Pathol. 1999; 30: 59-65
        • Borzutzky A.
        • Stern S.
        • Reiff A.
        • Zurakowski D.
        • Steinberg E.A.
        • Dedeoglu F.
        • et al.
        Pediatric chronic nonbacterial osteomyelitis.
        Pediatrics. 2012; 130: e1190-e1197
        • Baulot E.
        • Bouillien D.
        • Giroux E.A.
        • Grammont P.M.
        Chronic recurrent multifocal osteomyelitis causing spinal cord compression.
        Eur Spine J. 1998; 7: 340-343
        • Hedrich C.M.
        • Hofmann S.R.
        • Pablik J.
        • Morbach H.
        • Girschick H.J.
        Autoinflammatory bone disorders with special focus on chronic recurrent multifocal osteomyelitis (CRMO).
        Pediatr Rheumatol Online J. 2013; 11: 47
        • Sugimoto H.
        • Tamura K.
        • Fujii T.
        The SAPHO syndrome: defining the radiologic spectrum of diseases comprising the syndrome.
        Eur Radiol. 1998; 8: 800-806
        • Tlougan B.E.
        • Podjasek J.O.
        • O'Haver J.
        • Cordova K.B.
        • Nguyen X.H.
        • Tee R.
        • et al.
        Chronic recurrent multifocal osteomyelitis (CRMO) and synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome with associated neutrophilic dermatoses: a report of seven cases and review of the literature.
        Pediatr Dermatol. 2009; 26: 497-505
        • Jurik A.G.
        • Egund N.
        MRI in chronic recurrent multifocal osteomyelitis.
        Skeletal Radiol. 1997; 26: 230-238
        • Fritz J.
        • Tzaribatchev N.
        • Claussen C.D.
        • Carrino J.A.
        • Horger M.S.
        Chronic recurrent multifocal osteomyelitis: comparison of whole-body MR imaging with radiography and correlation with clinical and laboratory data.
        Radiology. 2009; 252: 842-851
        • von Kalle T.
        • Heim N.
        • Hospach T.
        • Langendorfer M.
        • Winkler P.
        • Stuber T.
        Typical patterns of bone involvement in whole-body MRI of patients with chronic recurrent multifocal osteomyelitis (CRMO).
        Rofo. 2013; 185: 655-661
        • Andronikou S.
        • Mendes da Costa T.
        • Hussien M.
        • Ramanan A.V.
        Radiological diagnosis of chronic recurrent multifocal osteomyelitis using whole-body MRI-based lesion distribution patterns.
        Clin Radiol. 2019; 74: e3-e15
        • Gikas P.D.
        • Islam L.
        • Aston W.
        • Tirabosco R.
        • Saifuddin A.
        • Briggs T.W.
        • et al.
        Nonbacterial osteitis: a clinical, histopathological, and imaging study with a proposal for protocol-based management of patients with this diagnosis.
        J Orthop Sci. 2009; 14: 505-516
        • Khanna G.
        • Sato T.S.
        • Ferguson P.
        Imaging of chronic recurrent multifocal osteomyelitis.
        Radiographics. 2009; 29: 1159-1177
        • Roderick M.R.
        • Shah R.
        • Rogers V.
        • Finn A.
        • Ramanan A.V.
        Chronic recurrent multifocal osteomyelitis (CRMO) - advancing the diagnosis.
        Pediatr Rheumatol Online J. 2016; 14: 47
        • Mandell G.A.
        • Contreras S.J.
        • Conard K.
        • Harcke H.T.
        • Maas K.W.
        Bone scintigraphy in the detection of chronic recurrent multifocal osteomyelitis.
        J Nucl Med. 1998; 39: 1778-1783
        • Morbach H.
        • Schneider P.
        • Schwarz T.
        • Hofmann C.
        • Raab P.
        • Neubauer H.
        • et al.
        Comparison of magnetic resonance imaging and 99mTechnetium-labelled methylene diphosphonate bone scintigraphy in the initial assessment of chronic non-bacterial osteomyelitis of childhood and adolescents.
        Clin Exp Rheumatol. 2012; 30: 578-582
        • Acikgoz G.
        • Averill L.W.
        Chronic recurrent multifocal osteomyelitis: typical patterns of bone involvement in whole-body bone scintigraphy.
        Nucl Med Commun. 2014; 35: 797-807
        • Parisi M.T.
        Functional imaging of infection: conventional nuclear medicine agents and the expanding role of 18-F-FDG PET.
        Pediatr Radiol. 2011; 41: 803-810
        • Iyer R.S.
        • Thapa M.M.
        • Chew F.S.
        Chronic recurrent multifocal osteomyelitis: review.
        AJR Am J Roentgenol. 2011; 196: S87-S91
        • Deogaonkar K.
        • Ghandour A.
        • Jones A.
        • Ahuja S.
        • Lyons K.
        Chronic recurrent multifocal osteomyelitis presenting as acute scoliosis: a case report and review of literature.
        Eur Spine J. 2008; 17: S248-S252
        • Andronikou S.
        • Kraft J.K.
        • Offiah A.C.
        • Jones J.
        • Douis H.
        • Thyagarajan M.
        • et al.
        Whole-body MRI in the diagnosis of paediatric CNO/CRMO.
        Rheumatology (Oxford). 2020; 59: 2671-2680
        • Darge K.
        • Jaramillo D.
        • Siegel M.J.
        Whole-body MRI in children: current status and future applications.
        Eur J Radiol. 2008; 68: 289-298
        • Mugler 3rd., J.P.
        Optimized three-dimensional fast-spin-echo MRI.
        J Magn Reson Imaging. 2014; 39: 745-767
        • Leclair N.
        • Thormer G.
        • Sorge I.
        • Ritter L.
        • Schuster V.
        • Hirsch F.W.
        Whole-body diffusion-weighted imaging in chronic recurrent multifocal osteomyelitis in children.
        PLoS One. 2016; 11e0147523
        • Morone M.
        • Bali M.A.
        • Tunariu N.
        • Messiou C.
        • Blackledge M.
        • Grazioli L.
        • et al.
        Whole-body MRI: current applications in oncology.
        AJR Am J Roentgenol. 2017; 209: W336-W349
        • Arnoldi A.P.
        • Schlett C.L.
        • Douis H.
        • Geyer L.L.
        • Voit A.M.
        • Bleisteiner F.
        • et al.
        Whole-body MRI in patients with non-bacterial osteitis: radiological findings and correlation with clinical data.
        Eur Radiol. 2017; 27: 2391-2399
        • Zhao Y.
        • Sato T.S.
        • Nielsen S.M.
        • Beer M.
        • Huang M.
        • Iyer R.S.
        • et al.
        Development of a scoring tool for chronic nonbacterial osteomyelitis magnetic resonance imaging and evaluation of its interrater reliability.
        J Rheumatol. 2020; 47: 739-747
        • Hong S.H.
        • Choi J.Y.
        • Lee J.W.
        • Kim N.R.
        • Choi J.A.
        • Kang H.S.
        MR imaging assessment of the spine: infection or an imitation?.
        Radiographics. 2009; 29: 599-612
        • Ledermann H.P.
        • Schweitzer M.E.
        • Morrison W.B.
        • Carrino J.A.
        MR imaging findings in spinal infections: rules or myths?.
        Radiology. 2003; 228: 506-514
        • Tannenbaum M.F.
        • Noda S.
        • Cohen S.
        • Rissmiller J.G.
        • Golja A.M.
        • Schwartz D.M.
        Imaging musculoskeletal manifestations of pediatric hematologic malignancies.
        AJR Am J Roentgenol. 2020; 214: 455-464
        • Sato T.S.
        • Ferguson P.J.
        • Khanna G.
        Primary multifocal osseous lymphoma in a child.
        Pediatr Radiol. 2008; 38: 1338-1341
        • Murphey M.D.
        • Senchak L.T.
        • Mambalam P.K.
        • Logie C.I.
        • Klassen-Fischer M.K.
        • Kransdorf M.J.
        From the radiologic pathology archives: ewing sarcoma family of tumors: radiologic-pathologic correlation.
        Radiographics. 2013; 33: 803-831
        • Rodriguez D.P.
        • Poussaint T.Y.
        Imaging of back pain in children.
        AJNR Am J Neuroradiol. 2010; 31: 787-802
        • Makurthou A.A.
        • Oei L.
        • El Saddy S.
        • Breda S.J.
        • Castano-Betancourt M.C.
        • Hofman A.
        • et al.
        Scheuermann disease: evaluation of radiological criteria and population prevalence.
        Spine (Phila Pa 1976). 2013; 38: 1690-1694
        • Catalano-Pons C.
        • Comte A.
        • Wipff J.
        • Quartier P.
        • Faye A.
        • Gendrel D.
        • et al.
        Clinical outcome in children with chronic recurrent multifocal osteomyelitis.
        Rheumatology (Oxford). 2008; 47: 1397-1399
        • Gleeson H.
        • Wiltshire E.
        • Briody J.
        • Hall J.
        • Chaitow J.
        • Sillence D.
        • et al.
        Childhood chronic recurrent multifocal osteomyelitis: pamidronate therapy decreases pain and improves vertebral shape.
        J Rheumatol. 2008; 35: 707-712
        • Kerrison C.
        • Davidson J.E.
        • Cleary A.G.
        • Beresford M.W.
        Pamidronate in the treatment of childhood SAPHO syndrome.
        Rheumatology (Oxford). 2004; 43: 1246-1251
        • Panwar J.
        • Tolend M.
        • Lim L.
        • Tse S.M.
        • Doria A.S.
        • Laxer R.M.
        • et al.
        Whole-body MRI quantification for assessment of bone lesions in chronic nonbacterial osteomyelitis patients treated with pamidronate: a prevalence, reproducibility, and responsiveness study.
        J Rheumatol. 2021; 48: 751-759
        • Voit A.M.
        • Arnoldi A.P.
        • Douis H.
        • Bleisteiner F.
        • Jansson M.K.
        • Reiser M.F.
        • et al.
        Whole-body magnetic resonance imaging in chronic recurrent multifocal osteomyelitis: clinical longterm assessment may underestimate activity.
        J Rheumatol. 2015; 42: 1455-1462