The biomarker landscape in rheumatoid arthritis (RA) is evolving from reliance on traditional markers toward integrated, multimodal strategies enabling precision medicine approaches. To critically evaluate emerging biomarkers across serological, cellular, genetic, imaging, and multi-omic domains, distinguishing those approaching clinical readiness from those requiring further development. In this study, a narrative review of the literature published between 2000 and 2024 relevant to clinical decision-making in RA was conducted. Among novel serological markers, 14-3-3η protein and anti-carbamylated protein antibodies show the strongest validation for seronegative disease and prognostic stratification. Calprotectin demonstrates utility for disease activity monitoring and de-escalation decisions. Multi-biomarker disease activity scores provide an objective assessment but lack outcome trial validation. Musculoskeletal ultrasound offers accessible imaging biomarker capability, while MRI bone marrow edema remains the strongest structural progression predictor. Synovial tissue pathotyping has demonstrated proof-of-concept for treatment stratification. Genetic, epigenetic, and metabolomic approaches remain investigational. Key clinical implications include using 14-3-3η and calprotectin to inform seronegative diagnosis and de-escalation decisions, integrating ultrasound for remission verification, and recognizing that emerging biomarkers for extra-articular complications, including cardiovascular risk and venous thromboembolism, represent important unmet needs.

Despite the increasing use of MARS (metal artifact reduction sequence) MRI to investigate painful total hip arthroplasties (THA), no validated criteria exist for diagnosing femoral stem loosening. To evaluate MARS MRI for the diagnosis of aseptic stem loosening and determine its diagnostic accuracy. One hundred fourteen consecutive cases with THA revision surgery and MARS MRI of the hip were retrospectively included. Two blinded musculoskeletal radiologists independently assessed periprosthetic bone resorption (PPBR), bone marrow edema (BME), periosteal reaction (PR), and periprosthetic osteolysis (PO) in 14 Gruen zones (GZ). Intraoperative findings at revision surgery served as the ground truth. A predictive model was created using binomial logistic regression models to predict the probability of a loose stem with maximizing positive predictive value (PPV) and accuracy. Interobserver reliability was assessed with absolute agreement, Cohen κ and Gwet AC1. During surgery, 66 stems were fixed and 48 loose. PPBR occurred significantly more frequently in loose stems across all GZs except GZ11. Proximal PPBR was also observed in fixed stems (up to 23%), whereas middle and distal PPBR were rare (≤3%). BME was most prevalent proximally in all stems (fixed/loose: 39%/60%) with significant differences medially and distally. PR was significantly more frequent in loose stems in the middle and distal GZs. PO were rare, most occurred in GZ7. The predictive model considering proximal PPBR, mid-distal PPBR, mid-distal PR, and distal BME performed with a sensitivity of 0.708, specificity of 0.970, PPV 0.944, negative predictive value 0.821. Interobserver agreement (Gwet AC1) in the considered zones was for PPBR between 0.80 and 0.98, BME 0.91 to 0.99, PR 0.87 to 0.97. MARS MRI is reproducible and accurate for assessing stem loosening. PPBR, BME, and PR can also be found in fixed THA in the proximal region, whereas they indicate loosening in the middle and distal stem region.

Knee osteoarthritis (OA) is a prevalent degenerative joint disease characterized by cartilage degradation and inflammation, leading to pain and functional limitations. Emerging evidence suggests that physiological levels of prostaglandin E2 (PGE2) are crucial for maintaining subchondral bone remodeling balance via skeletal interoception. More and more evidence supports that standard dose or higher doses of celecoxib (≥ 200mg/day) may disrupt this balance by significantly reducing PGE2 levels, potentially accelerating OA progression. This study aims to compare the efficacy of conventional-dose celecoxib (200mg/day) versus low-dose celecoxib (100mg/day) in treating patients with mild to moderate knee OA over a 3-month treatment period and 3-month follow-up. This randomized, double-blind, parallel-group trial will enroll 200 participants diagnosed with mild to moderate knee OA (Kellgren-Lawrence grades I-III), who will be randomized in a 1:1 ratio to receive either conventional (200mg/day) or low-dose (100mg/day) celecoxib for consecutive 3months. After the administration, patients were followed up for 3months. The primary outcome will be the change in pain intensity, which was measured using the visual analog scale (VAS), from baseline to 24weeks, evaluated via the VAS. Secondary outcomes include biomarkers of bone metabolism and safety parameters, including Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), subchondral bone structure (assessed by high-resolution CT), subchondral bone marrow edema (assessed by MRI), bone turnover markers, and serum levels of PGE2 and COX2. Safety will be assessed by monitoring the incidence and severity of adverse events. We hypothesize that low-dose celecoxib (100mg/day) is posited to preserve physiological PGE2 levels, maintain skeletal interoception supporting balanced bone remodeling while alleviating pain, and slow the progression of OA. This RCT protocol addresses a critical gap in OA treatment by investigating the potential of low-dose celecoxib to balance pain management with disease modification. By preserving physiological PGE2 levels and skeletal interoception, low-dose celecoxib may offer a safer and more effective alternative to standard-dose treatment, particularly for patients with I-III grade OA. Chinese Clinical Trial Registry ChiCTR2400080744. Registered on February 6, 2024.

To evaluate the efficacy and outcomes of extracorporeal shockwave therapy (ESWT) for bone pathologies including fractures, osteonecrosis/avascular necrosis, bone stress injury (BSI), medial tibial stress syndrome (MTSS), and bone marrow edema syndrome (BMES). Systematic review. Search performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses of 3 databases: Cochrane Library, Embase (Elsevier), and PubMed (NLM). Studies included randomized controlled trials, cohort studies, case series, and case reports that investigated the efficacy of ESWT for the management of BSI, BMES, MTSS, delayed or nonunion fracture, or osteonecrosis/avascular necrosis of bone. Fifty-three studies with 1835 adult patients (608 women, 910 men, 317 unspecified) were included. Studies were defined using Oxford level of evidence rating: 7 level I (13.2%), 4 level II (7.5%), 4 level III (7.5%), 24 level IV (45.2%), and 14 level V (26.4%). Four of 7 level I studies showed similar effectiveness of ESWT compared with surgery for the treatment of long bone nonunion fractures (n = 1) and early stage osteonecrosis of the femoral head (n = 1), exercise program for MTSS (n = 1), and medication management for BMES (n = 1). Efficacy for management of BSI had lower level of evidence. Twenty-two studies reported on safety with no significant adverse events. The limited high-level studies suggest ESWT may offer an effective noninvasive treatment of most bone pathologies with favorable safety profile. Additional high-quality studies particularly in BSI may inform use of ESWT for bone pathologies.

ObjectiveTo evaluate the prevalence and anatomical distribution of inflammatory and structural MRI lesions in axial spondyloarthritis (axSpA) and compare these between patients with isolated axial involvement and those with peripheral manifestations.MethodsData from the Assessment of SpondyloArthritis International Society (ASAS) Classification Cohort were analysed. Peripheral involvement was defined as past or current arthritis/dactylitis/enthesitis. Sacroiliac joint (SIJ) and spinal MRI lesions typical of axSpA were classified per ASAS lesion definitions and centrally read with multi-reader majority agreement (lesion present if called by the majority; SIJ ≥4/7, spine ≥5/9 readers). Comparisons between patients with and without peripheral manifestations were made.ResultsAmong 199 axSpA patients with SIJ MRI, 67 also had spinal MRI. Subchondral SIJ bone marrow oedema (BMO) was observed in 49%, without quadrant preference or subgroup differences. Other SIJ inflammatory lesions ranged from 4%–18%. Erosions (35%) and fat lesions (22%) were the most frequent structural lesions. In the spine, BMO, fat lesions and syndesmophytes/ankylosis were detected in 38%, 25% and 5%, respectively, with similar subgroup frequencies. Among 40 patients with both SIJ and whole spine MRI, inflammatory lesions were observed in both sites in 18%, SIJ only in 38%, and spine only in 20%. Structural lesions occurred in both sites in 19%, SIJ only in 30%, and spine only in 5%, with no subgroup differences.ConclusionThe prevalence and anatomical distribution of ASAS-defined MRI lesions was similar across axSpA subgroups. Notably, 20% exhibited spine-only inflammation, suggesting potential added diagnostic and monitoring value of spinal MRI, warranting further study.

MRI has limited accuracy in diagnosing complex regional pain syndrome Type 1 - a systematic review of the literature.

ObjectiveTo develop a deep learning algorithm for semiquantification of spinal inflammation in patients with axial spondyloarthritis (SpA).MethodsThe study included 330 participants with axial SpA. All patients underwent whole spine MRI with short τ inversion recovery (STIR) sequence by 3T MR unit. Three independent readers identified regions of interest to locate bone marrow oedema (BMO) and performed Spondyloarthritis Research Consortium of Canada (SPARCC) scoring. Two deep learning models based on attention Unet were developed. The BMO model differentiated image with or without spinal inflammation. The vertebral body (VB)-intervertebral disc (IVD) model identified discovertebral units for localisation. The intraclass correlation coefficient (ICC) and Pearson coefficient were used to evaluate agreement and correlation between scorings by human readers and deep learning-based pipeline. Performance of the models was evaluated using sensitivity, specificity, accuracy and Dice coefficient.ResultsThe ICC and the Pearson coefficient of SPARCC scores between human readers and the deep learning-based scoring pipeline were 0.80 and 0.82, respectively. The sensitivity and specificity of spinal inflammation identification were 0.90 and 0.84, respectively. The Dice coefficients were 0.81 (VB) and 0.80 (IVD) in images with spinal inflammation.ConclusionThe high consistency of the scoring pipeline with human readers suggested that the deep learning-based algorithm has the potential to provide semiquantitative assessment of spinal inflammation based on SPARCC in axial SpA.

Background: Knee ligament injuries are among the most frequent musculoskeletal conditions resulting from high-velocity trauma, sports activities, and road-traffic accidents. Damage to structures such as the anterior cruciate ligament (ACL), medial collateral ligament (MCL), and meniscus can severely impair joint stability, mobility, and overall functional capacity. Although surgical reconstruction is a common therapeutic approach, it does not always guarantee complete biomechanical recovery and may be associated with postoperative stiffness, prolonged rehabilitation, and variable success rates. In Ayurveda, such traumatic injuries can be correlated with Abhighātaja Snāyugata Vāta, where Abhighata leads to vitiation of Vāta and Rakta affecting Snāyu, Sandhi, and Asthi, producing pain, swelling, stiffness, and restricted movement. Case History: A 48-year-old male presented with pain, swelling, restricted movements of the right knee, and difficulty in walking for 5 months following a road-traffic accident. MRI revealed a partial tear of the ACL, PCL sprain, grade-3 medial meniscal tear, bone marrow edema, superficial MCL injury, and joint effusion. Treatment included Sthānika Taila Dhāra with Pinda Taila, Kṣīrabala Taila, Māṣha Taila, and Daśhaṅga Kumāri Upanāha for 7 days in 3 sittings, along with internal medications. Results: The patient showed significant pain relief, restored mobility, improved gait, and negative stability tests, with VAS reducing from 6 to 0. Conclusion: Ayurvedic Bahirparimarjana therapies combined with internal medication effectively managed a complex knee ligament and meniscal injury without surgical intervention. This case demonstrates the potential of Ayurveda as a safe, cost-effective, and non-invasive approach for treating ligament injuries and improving quality of life. Keywords: ACL injury, Snāyugata Vāta, Meniscal tear, Sthānika Taila Dhāra, Daśhāṅga Kumāri Upanāha, Abhighāta

Bone marrow edema (BME) of the femoral head is a prevalent condition that can cause hip pain and is observed in patients as a standalone finding or in conjunction with degenerative or inflammatory conditions. There has been a lack of extensive study on the effectiveness of combining surgery with biological treatment for BME. The objective of this study was to evaluate the efficiency of core decompression (CD) with bone marrow aspirate concentrate (BMAC) augmentation in alleviating pain and enhancing the quality of life in patients with BME in the hip. We conducted a retrospective analysis of patients who underwent treatment for BME of the hip using CD combined with BMAC between June 2021 and July 2023. Inclusion criteria consisted of patients diagnosed with BME in the hip (presence of BME on T2-weighted MRI in the femoral head or neck with pain corresponding to the same compartment as the BME). The patients' demographic information, presence of other medical conditions, body mass index (BMI), etiology, and assessments using the visual analog scale (VAS) and Harris hip score (HHS) were recorded. Pre- and postoperative radiographic imaging (XR) and magnetic resonance imaging (MRI) were analyzed. This study included 28 patients (40 femoral heads) who underwent CD with BMAC grafting at our institution. Among these patients, 9 had normal or non-diagnostic radiographs, 11 were at ARCO stage Ⅰ, and 8 were at ARCO stage Ⅱ. The mean age at the time of operation was 45.21 years (SD 13.17, range 21-75), and the mean BMI was 24.61 (SD 3.75, range 16.6-32.05). The area of BME showed a significant decrease from 954.21 ± 224.68 mm2 to 162.21 ± 189.05 mm2 3 months following surgery (P < 0.001). The VAS showed a substantial reduction from 4.86 ± 1.24 points to 1.86 ± 1.27 points at 3 months post-surgery, and further decreased to 1 ± 1.68 points at 12 months post-surgery (P < 0.001). HHS increased from 48.14 ± 4.4 points to 72.79 ± 8.96 points at 3 months after surgery and further increased to 86.39 ± 11.82 points at 12 months after surgery (P < 0.001). Two patients experienced the resolution of BME 3 months following surgery, whereas 3 femoral heads of 3 patients with ARCO 2 stage collapsed. Treatment of BME of the hip using CD combined with BMAC is effective and provides short-term pain relief for BME.

IntroductionTraumatic anterior hip dislocations are rare compared to posterior dislocations. We managed a case of traumatic anterior dislocation caused by high-energy injury. This report describes the treatment strategy, arthroscopic findings, and presumed injury mechanism.Case DescriptionA 17-year-old male sustained an anterior dislocation of the left hip after falling from a motorcycle and being struck by a following vehicle. Closed reduction was performed under general anesthesia. He was treated conservatively with non-weight-bearing for five weeks and achieved full weight-bearing ambulation eight weeks post-injury. Despite this, he remained symptomatic with persistent left hip pain for five months. Clinical evaluation showed a positive impingement sign. Imaging demonstrated a Cam deformity on radiographs and CT, and an anterior-superior labral tear with a Hill-Sachs-like lesion of the femoral head on MRI. He was diagnosed with femoroacetabular impingement (FAI).ResultsHip arthroscopy performed five months post-injury revealed a labral tear with adjacent cartilage delamination and a femoral head depression. No osteochondral fragments were observed. Arthroscopic labral repair and femoral osteoplasty were performed. Postoperatively, the patient experienced significant pain relief and returned to sports, including futsal and bowling, from three months after surgery.DiscussionMRI identified a depression and bone marrow edema at the anterolateral femoral head (1-o’clock position) and at the anterior medial femoral condyle. It is presumed that high-energy force in abduction, external rotation, and extension caused anterior-inferior hip dislocation toward the pubis. Arthroscopic repair and femoral osteoplasty eliminated impingement and improved symptoms.ConclusionThis case highlights the importance of recognizing labral and bony pathology after anterior hip dislocation in adolescents. Hip arthroscopy enabled identification and treatment of intra-articular lesions, facilitating rapid recovery. The surgery may benefit selected young patients with post-traumatic FAI.

A 21-year-old woman presented with a six-month history of right hip pain, which was notably exacerbated at night. Plain radiographs revealed no specific abnormalities. However, computed tomography (CT) identified a 5-mm nidus located at the anterior aspect of the right acetabulum. Magnetic resonance imaging (MRI) demonstrated a well-defined, low signal intensity lesion on T1-weighted images and high signal intensity surrounding bone marrow edema on T2-weighted images, findings consistent with osteoid osteoma. Whole-body bone scintigraphy (WBBS) showed a focal area of intense radiotracer uptake at the corresponding site.Based on CT findings, the lesion site was preoperatively marked on X-ray, and arthroscopic tumor excision was planned. Under C-arm guidance, an anterolateral portal was established, followed by an anterior portal. Extensive capsulotomy was performed to enhance device mobility. Although the osteoid osteoma was not directly visualized during arthroscopy, excision, including the overlying articular cartilage, was performed while confirming the lesion location with intraoperative C-arm imaging.Postoperatively, the patient’s right hip pain and night pain showed significant improvement. However, she developed meralgia paresthetica symptoms due to lateral femoral cutaneous nerve (LFCN) injury. This was managed with two ultrasound-guided LFCN blocks at the anterior superior iliac spine (ASIS) level at one-week intervals, resulting in symptom resolution.

Displaced fragments in meniscal flap tears may be challenging to detect radiologically but are clinically relevant for treatment planning. This study aimed to characterize fragment migration patterns on MRI and evaluate associated intra-articular pathologies. In this retrospective analysis of 89 knee MRIs performed between January 2018 and May 2022, patients with confirmed meniscal flap tears were assessed for tear location, fragment displacement direction, and associated findings, including cartilage defects, ligament injuries, bone marrow edema, osteophytes, osteochondral lesions, and joint effusion. Statistical associations between tear features and accompanying pathologies were evaluated. Inferior coronary recess was the most frequent displacement site, especially in medial tears (68.8%, P=0.007). Medial tears more often had cartilage defects (66.3%, P=0.024) and osteochondral lesions (55.0%, P=0.015). Posterior horn involvement predominated, and ACL tears were strongly associated with intercondylar notch displacement (77.8%, P=0.001). Meniscal flap tears are most commonly located in the posterior horn of the medial meniscus and tend to displace into the inferior coronary recess. Their frequent association with cartilage damage, osteochondral lesions, and ACL injuries underscores the importance of careful MRI evaluation to support surgical decision-making.

Polymyalgia rheumatica (PMR) is an age-related inflammatory disease with shoulder/hip girdle involvement. Magnetic resonance imaging (MRI) reveals extracapsular/entheseal soft tissue involvement in both PMR and spondyloarthritis (SpA), with sacroiliac joint and perientheseal spinal bone marrow edema (BME) being characteristic of SpA. Therefore, some shared anatomic topography might be expected to result in similar clinical features. Herein, we describe the clinical and imaging features of SpA initially diagnosed as PMR. Patients observed at Leeds Teaching Hospitals NHS Trust with a diagnosis of psoriatic arthritis (PsA) or axial SpA were screened to identify those initially diagnosed with PMR from 2002 to 2024. Only those patients who retrospectively fulfilled the 2012 EULAR/American College of Rheumatology classification criteria or the Bird et al criteria for PMR were included. Clinical data relevant to initial PMR diagnosis, imaging features, follow-up, and treatment data were collected, as well as radiographic or MRI features that established the final diagnosis. Thirty-one patients (median age 62 [interquartile range (IQR) 58-69] years; 17 women and 14 men) presenting with typical PMR shoulder/hip girdle pain were subsequently classified as having SpA spectrum disorders. The SpA diagnosis was made in 12 patients within three months of presentation and in 19 patients during the remaining follow-up period (median 3 [IQR 1-4] years). Four of 27 tested patients were HLA-B27 positive. BME on MRI was detected in the spine and/or sacroiliac joints in 20 of 25 patients (80%) who underwent imaging (sacroiliac joint: 17 patients [68%]; spine: 15 patients [60%]). Clinical resolution with C-reactive protein (CRP) level normalization occurred in 21 of 31 patients following initial glucocorticoid (GC) therapy, but 7 of these 21 initial responders experienced disease flares or elevations in CRP levels. Therapy-wise, disease-modifying antirheumatic drugs (DMARDs) were used in 21 of 31 patients: 8 received conventional synthetic DMARDs, and 11 received biologic agents (8 anti-tumor necrosis factor agents, 3 interleukin-17 inhibitors), whereas the remaining 10 patients were treated with ≤10 mg/day of GCs. Late-onset SpA with PMR clinical presentations is characterized by failure to respond to or taper GC therapy and is often identified by SpA-specific osteitis patterns on MRI. We propose that a PMR-SpA overlap may account for biologic therapy efficacy in steroid-refractory PMR.

Undifferentiated small round cell sarcoma of bone and soft tissue are rare, malignant neoplasms, often presenting diagnostic challenges due to its overlapping features with other conditions such as osteomyelitis and Brodie abscess. Accurate diagnosis requires a combination of imaging studies, histopathology, and genetic testing. Delayed or misdiagnosis can impact the prognosis and treatment outcomes. We present the case of a 34-year-old female who initially presented with persistent left upper thigh pain. Initial imaging raised suspicion of chronic osteomyelitis, with subsequent MRIs showing abnormal bone marrow edema and a lytic lesion in the left femoral diaphysis. Despite undergoing multiple biopsies, results remained inconclusive, with differential diagnoses including Brodie's abscess. The patient experienced temporary improvement, but her symptoms recurred, prompting further investigations. A repeat MRI showed the progression of intramedullary lesions and the appearance of new focal lesions. A biopsy eventually confirmed the presence of a malignant round cell tumor, identified as Ewing sarcoma through immunohistochemical evaluation and detection of EWSR1 gene rearrangement on FISH analysis and further NGS confirming EWSR1-NFATC2 fusion, diagnostic of the rare entity - round cell sarcoma with EWSR1-NFATC2 fusion. This case highlights the diagnostic complexities of round cell sarcoma of bone, which can mimic other benign bone lesions. It underscores the importance of multidisciplinary evaluation, genetic testing, and timely oncological intervention to improve patient outcomes.

Moderate-to-Severe Varus Deformity Is Associated With Conversion to Arthroplasty in Patients Who Have Subchondral Insufficiency Fracture of the Knee.

Avascular necrosis of the femoral head (AVN) describes an ischemia-induced necrosis of the subchondral bone of the femoral head. Early diagnosis is crucial to initiate appropriate treatment and achieve the longest possible preservation of the native joint. Pathophysiologically, AVN results from impaired blood supply to the subchondral bone, promoted by various risk factors or underlying pathologies. The most relevant include prolonged or high-dose corticosteroid therapy and chronic alcohol abuse. Magnetic resonance imaging (MRI) is regarded as the key modality for early detection, enabling identification of characteristic changes before radiographic abnormalities become apparent. The earliest MRI finding is aband-like, T1-hypointense line demarcating the necrotic area from surrounding viable bone. The characteristic double-line sign-comprising an outer hypointense and an inner hyperintense rim-reflects reparative processes at the necrosis margin. Bone marrow edema occurs only after the development of asubchondral fracture and thus indicates an advanced stage, rather than, as previously assumed, an early manifestation of AVN. Differential diagnosis should primarily include transient bone marrow edema syndrome and subchondral insufficiency fracture. The Association Research Circulation Osseous (ARCO) classification provides amultimodal, internationally established system for standardized staging. It distinguishes four clinically relevant stages: isolated MRI detection (stageI), radiographic changes without fracture (stageII), subchondral fracture (stageIII), and secondary osteoarthritis (stageIV). This system allows reproducible stage-based assessment, supports therapeutic planning, and facilitates interdisciplinary communication. Consequently, radiologic imaging plays apivotal role in diagnosis, disease monitoring, and treatment decision-making for patients with AVN.

Pustulotic arthro-osteitis (PAO) is a sterile osteoarticular inflammation associated with palmoplantar pustulosis (PPP) that affects the anterior chest wall, spine, and peripheral joints. Guselkumab, an anti-interleukin (IL)-23p19 antibody, has shown to be effective for PPP and PAO and has been widely used for these conditions in Japan. Brodalumab, an anti-IL-17 receptor A antibody, has demonstrated efficacy against PPP. However, its usefulness in PAO is not well understood. Herein, we report three patients with guselkumab-resistant PAO who were successfully treated with brodalumab. In these three cases, switching from guselkumab to brodalumab resulted in improved disease activity scores, such as the modified Bath Ankylosing Spondylitis Disease Activity Index, modified Ankylosing Spondylitis Disease Activity Score, and pain numerical rating scale. In addition, imaging findings, such as bone marrow edema on magnetic resonance imaging, improved in two cases. As a result, the doses of inflammatory analgesics and/or antirheumatic drugs were reduced in two patients. Notably, clinical responses were observed as early as 2 weeks after switching in one case. The remission of PPP lesions achieved by guselkumab was maintained during brodalumab treatment, and no adverse events were observed in any of the three cases. Our observations suggest that brodalumab may be an effective therapeutic option for patients with PAO who have intractable osteoarticular symptoms despite treatment with IL-23 inhibitors.

Deep-learning reconstructed 3D MRI for comprehensive knee assessment: Comparison with a multisequence 2D protocol at 1.5T.

Background. Fibromyalgia (FM) is a chronic widespread pain condition associated with multiple and heterogeneous systemic manifestations. It is currently regarded as a paradigmatic example of nociplastic pain, specifically a pain not attributable to direct nociceptive stimuli or neuropathic mechanisms, but rather to altered pain modulation processes due to peripheral and central sensitization (hyperalgesia and allodynia). FM may therefore present as a primary condition or coexist with other disorders that can influence its onset, course, and activity. We report two clinical cases of patients with refractory FM in whom an comprehensive diagnostic assessment revealed underlying osteoarticular disorders that responded to targeted treatment, leading to overall symptomatic improvement. Materials and Methods. The first patient, a 27-year-old woman diagnosed with FM two years earlier (according to the 2016 ACR/EULAR criteria: WPI 9, SSS 11) and with concomitant endometriosis and spasmophilia, complained of mixed low back pain poorly responsive to conservative therapy (amitriptyline, NSAIDs, neurotrophic supplements) and rehabilitation. Lumbosacral MRI revealed a left-sided L5 hemisacralization with hypertrophic transverse process articulating with the sacral ala (Castellvi type IIa), associated with subchondral bone marrow edema—findings consistent with Bertolotti’s syndrome (a lumbosacral transitional anomaly causing chronic low back pain). Intravenous neridronate treatment was initiated (100 mg per infusion, 4 infusions over 12 days). The second patient, a 73-year-old woman with a five-year history of FM (2016 ACR/EULAR criteria: WPI 8, SSS 10) under duloxetine therapy, presented with right hip pain initially attributed to myofascial iliopsoas syndrome in an osteoarthritic context. After failure of local infiltrative therapy, MRI demonstrated early avascular necrosis of the femoral head with subchondral bone edema. Combined treatment was started with intravenous neridronate and hyperbaric oxygen therapy (28 consecutive daily sessions). Results. In the first patient, pain intensity decreased from 8 to 4 on the VAS scale, with reduced need for NSAIDs and overall improvement in diffuse pain symptoms. In the second patient, VAS pain decreased from 8 to 5, with reduction in nocturnal pain, hyperalgesia, and allodynia, and partial resolution of bone marrow edema. A second combined treatment cycle was planned. Conclusions. These cases highlight the importance of a complete differential assessment in fibromyalgia patients presenting with refractory localized pain. The identification of coexisting structural conditions, as in the cases reported, can provide specific therapeutic targets, contributing to symptomatic improvement and better control of central sensitization. An integrated clinical approach—combining fibromyalgia diagnosis with the detection of concomitant somatic pathologies—represents a key strategy to optimize outcomes in patients with complex chronic pain.

Background. Neurological involvements in axial spondyloarthritis (axSpA) are uncommon but can lead to serious complications. Among these, the occurrence of an epidural fluid–cellular collection is extremely rare and scarcely reported, representing a significant diagnostic challenge in differentiating infectious, neoplastic, and inflammatory etiologies. We describe the case of a patient with radiographic axSpA complicated by dorsal myelopathy secondary to an inflammatory epidural collection. Materials and Methods. A 29-year-old man with a history of inflammatory back pain and family history of spondyloarthritis presented with worsening thoracolumbar pain, sphincter dysfunction, and progressive lower limb paraparesis. Laboratory investigations revealed elevated CRP (22.6 mg/L), HLA-B27 positivity, and a positive TB Quantiferon test. Contrast-enhanced spinal MRI demonstrated a large posterior epidural fluid–cellular collection extending from D4 to D6, causing spinal cord compression and signal alterations consistent with myelopathy. Bone marrow edema was also observed in the cervical, thoracic, and lumbar vertebrae, as well as in the sternal manubrium. Radiographic imaging showed syndesmophytes, bilateral sacroiliac ankylosis, and thoracolumbar Romanus lesions. The patient underwent neurosurgical decompression with laminectomy and paravertebral tissue biopsy. Results: Histopathological analysis revealed compact and trabecular bone with preserved architecture, surrounded by fibro-adipose tissue showing inflammatory infiltrates occasionally organized into small B- and T-cell germinal-like centers, consistent with a reactive inflammatory process. Microbiological studies, including cultures and PCR for Mycobacterium tuberculosis, were negative. PET-CT did not reveal hypermetabolic foci suggestive of lymphoproliferative disease. Given the high disease activity (ASDAS-CRP 4.76; BASDAI 7.4), HLA-B27 positivity, and characteristic radiological features of axSpA, an inflammatory etiology for the epidural collection was strongly supported. Conclusions. We report an atypical complication of radiographic axial spondyloarthritis presenting as dorsal myelopathy due to an inflammatory epidural collection. To our knowledge, similar cases have not been previously described. Early recognition and multidisciplinary management are essential to ensure appropriate diagnosis and treatment.