Spinal involvement in chronic recurrent multifocal osteomyelitis - diagnostics, treatment and what remains in the shadows: A literature review

doi:10.5312/wjo.v16.i10.109095

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World Journal of Orthopedics

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2218-5836

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World J Orthop. Oct 18, 2025; 16(10): 109095
Published online Oct 18, 2025. doi: 10.5312/wjo.v16.i10.109095

Spinal involvement in chronic recurrent multifocal osteomyelitis - diagnostics, treatment and what remains in the shadows: A literature review

Veronika V Petukhova, Alexey S Maletin, Alexander Yu Mushkin, Mikhail M Kostik

Veronika V Petukhova, Alexey S Maletin, Alexander Yu Mushkin, Department of Pediatric Orthopedics and Surgery, Saint-Petersburg Research Institute of Phthisiopulmonology, Saint Petersburg 191036, Russia

Alexander Yu Mushkin, Department of Traumatology and Orthopedic, Pavlov First Saint-Petersburg State Medical University, Saint Petersburg 197022, Russia

Mikhail M Kostik, Hospital Pediatry, Saint-Petersburg State Pediatric Medical University, Saint Petersburg 194100, Russia

Author contributions: Petukhova VV and Maletin AS performed the research, analyzed the data, and wrote the manuscript; Mushkin AY and Kostik MM edited the manuscript; all authors have read and approved the final manuscript.

Conflict-of-interest statement: The authors report having no relevant conflicts of interest for this article.

PRISMA 2009 Checklist statement: The authors have read the PRISMA 2009 Checklist, and the manuscript was prepared and revised according to the PRISMA 2009 Checklist.

Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/

Corresponding author: Mikhail M Kostik, MD, PhD, Professor, Hospital Pediatry, Saint-Petersburg State Pediatric Medical University, Lytovskaya 2, Saint Petersburg 194100, Russia. kost-mikhail@yandex.ru

Received: April 30, 2025
Revised: June 4, 2025
Accepted: September 1, 2025
Published online: October 18, 2025
Processing time: 169 Days and 18.7 Hours

Abstract

BACKGROUND

Chronic recurrent multifocal osteomyelitis (CRMO) is a rare autoinflammatory bone disorder primarily affecting children and adolescents. Spinal involvement in CRMO is common and can lead to significant clinical features and complications, including severe chronic back pain and spinal deformities with possible spinal cord compression.

AIM

To summarize the information about vertebral involvement in CRMO patients, including the clinical features, diagnostic approaches, and treatment outcomes.

METHODS

Sixty-three manuscripts (2005-2025) were found in PubMed, including case reports, retrospective cohort studies, randomized controlled trials, and imaging studies. The focus was on spinal involvement features, diagnostic imaging, treatment strategies, and long-term outcomes in pediatric CRMO patients.

RESULTS

Spinal involvement in CRMO ranges from 28% to 81% among patients with CRMO. Patients typically present with localized back pain, back stiffness, and, in more severe cases, spinal deformities such as kyphosis or scoliosis. Multifocal lesions are frequently observed, with the thoracic spine being the most commonly affected area. Whole-body magnetic resonance imaging (WBMRI) has emerged as the gold standard for effectively revealing multifocal bone lesions and spinal involvement. However, a bone biopsy is often needed to rule out infection or malignancy. Bisphosphonate treatment showed a high response rate (90.9%), while tumor necrosis factor-alpha (TNF-α) inhibitors were less effective (66.7%). Long-term follow-up is crucial, as relapses and progression of spinal deformities can occur even with treatment.

CONCLUSION

Spinal involvement in CRMO often leads to chronic pain, vertebral deformities, and rare spinal deformities. Early diagnosis using WBMRI, combined with treatment with bisphosphonates and TNF-α inhibitors, could improve outcomes.

Keywords: Chronic recurrent multifocal osteomyelitis; Nonbacterial osteomyelitis; Whole-body magnetic resonance imaging; Nonsteroid anti-inflammatory drugs; Bisphosphonates; Tumor necrosis factor-alpha inhibitors

Core Tip: Non-bacterial osteomyelitis with vertebrae involvement has differences not only in clinical and laboratory features but also in the effectiveness of therapeutic options. The literature on this issue is extremely scarce, mainly focusing on the diagnostic and imaging features of the disease. The analysis of 63 publications (2005-2024) selected by the keywords "chronic recurrent multifocal osteomyelitis", "spine", "vertebral form of non-bacterial osteomyelitis", and "SAPHO" is presented. The researchers' consensus emphasizes the variety of radiation manifestations, the need to integrate whole-body magnetic resonance imaging into the diagnostic algorithm, the possibility of spinal complications (including spinal deformities and neurological complications), and the step-by-step principle of treatment, with a recommendation to include bisphosphonates in the first line of therapy.