New research presented this week at ACR Convergence 2022, the annual meeting of the American College of Rheumatology, shows that spinal disease, once considered a rarity in recurrent chronic multifocal osteomyelitis, affects up to 10-35% of patients and is asymptomatic in one third (Abstract #1942).
Chronic relapsing multifocal osteomyelitis (CRMO) is an autoinflammatory disease of the bones that mainly affects girls, although it can also affect boys. Long-term clinical outcomes for most children with CRMO are generally good. However, the widespread use of whole-body MRI has led to an increase in reports of spinal disease in CRMO patients, with varying degrees of severity, and vertebral fractures. Although the reported incidence of spinal disease is 10% to 35%, little is known about the risk factors for the condition. The researchers conducted this study to characterize the clinical features of spinal disease and to identify patients with CRMO at risk, who need more frequent screening and immediate therapeutic intervention to prevent fractures and deformities.
Using a retrospective chart review, the researchers identified 36 cases of spine disease in CRMO patients based on MRI findings and compared them to 36 controls (CRMO patients without spine disease). The majority of patients with spinal disease were Caucasian and 57% were children. Most (92%) had thoracic vertebral involvement, 20% had advanced compression fractures (flat vertebrae), and 42% had associated autoimmune disease.
Nearly half had no back pain at the start of CRMO, while 69% complained of back pain just before spinal disease was diagnosed. More than one-third (31%) were asymptomatic, and spinal disease was found incidentally during whole-body MRI. Nocturnal pain and sleep disturbances were significantly higher compared to controls. More than a third of patients were taking nonsteroidal anti-inflammatory drugs (NSAIDs) when they developed spinal disease, but most reported pain and poor disease control despite medication.
Because we only have a few previous studies, the findings were not expected, but they made a lot of sense in hindsight. Still, the finding of a higher proportion of men with spinal disease in CRMO is new and surprising. It could point to the fact that men are more likely to develop severe disease with complications in CRMO compared to women and may suggest the need for more frequent screening and treatment protocols for men with CRMO. This would be another area of research to help better understand the disease.”
Shima Yasin, MD, MSc, Assistant Professor of Pediatrics and Rheumatology, University of Iowa Carver School of Medicine and lead author of the study
He adds that complaints of back pain, night pain, and sleep disturbances are risk factors and should prompt early detection of spinal disease in CRMO patients. Despite opposition from some insurers, Dr. Yasin says that all CRMO patients should have full-body MRI scans every six months and more often if there are changes.
“We have no proven serum or urine biomarkers to assess disease activity. MRIs are very sensitive in detecting active lesions and guiding treatment. For patients who have asymptomatic lesions, the only way to prevent worsening and progression is to use MRI to detect lesions early and initiate treatment,” says Dr. Yasin.
“In our center we created a protocol called CRMO Whole-Body MRI STIR [short tau inversion recovery] which is faster and very informative in CRMO cases. This protocol saves time and is possibly less expensive. Based on this study and others, we encourage all providers to obtain whole-body MRIs in confirmed cases of CRMO for close follow-up and therapeutic decision-making.”
Dr. Yasin adds that this study is just a starting point. Because CRMO is so rare, it is difficult for a single center to treat enough patients to answer research questions.
“We hope to enroll more CRMO patients in our study to better understand the disease and how to treat it effectively to improve outcomes. Patient participation is key; collaboration from our colleagues would be extremely helpful,” says Dr. Yasin .