Osteomyelitis In Children Research Articles

Aspects of the epidemiology, diagnosis and management of sickle cell osteomyelitis in children in Africa

IntroductionSickle cell osteomyelitis in children is one of the complications of osteoarthritis in sickle cell disease.ObjectiveTo describe the epidemiology, diagnosis and treatment of sickle cell osteomyelitis in children in Africa to improve management.Tools and methodA review of records showed that from April 2004 through September 2009, eleven cases of osteomyelitis in children aged 0 to 15 years who carried the sickle cell trait were treated in the surgical and pediatric unit of the Women's and Children's Hospital of Yaounde.ResultThe children's mean age was 7 years, but frequency was highest for those aged 1 to 5 years. The sex ratio was 2:1 male. The portal of entry was found for only 30% of cases. The predilection of the disease for long bones, the non-fistulated forms, the homozygous type, and the frequency of Salmonella were all remarkable. Medical and preventive treatment, always applied, were followed by orthopedic treatment. The usefulness of surgery, on the other hand, is subject to debate. Healing was obtained in 80% of cases.ConclusionThe authors describe the profile of osteomyelitis in children with sickle cell disease in Africa.

Acute Haematogenous Metacarpal Osteomyelitis in Children: A Case Report and Review of Literature

Metatarsal osteomyelitis in children is a very uncommon disease, and this can make diagnosis difficult leading to a delay in treatment that can cause complications like brachymetacarpia or loss of function. We present an infant affected by granulomatous chronic disease with acute haematogenous osteomyelitis of the fourth metacarpal. Serratia marcescens was found to be the pathogenic agent. Treatment was antibiotics and debridement. Bone healed with little length discrepancy but functional result was normal.

Ostemyelitis of the clivus due to Fusobacterium necrophorum

Introduction: Septic jugular thrombosis with secondary osteomyelitis of the clivus due to Fusobacterium necrophorum is a rare complication of Lemierres syndrome. Other complications that can occur include cavernous sinus thrombosis and cerebral arterial vasospasm. Case Report: We present a case of a young girl illustrating the clinical findings of Lemierre's syndrome in addition to other complications that may occur. Retropharyngeal infection with internal jugular venous thrombosis was present in this case along with Fusobacterium necrophorum septicemia. Lemierre's syndrome consists of oropharyngeal infection with internal jugular vein thrombosis, anaerobic septicemia and septic embolization to multiple organ systems. Osteomyelitis of the clivus is a rare, but important complication associated with this syndrome. Fusobacterium necrophorum, the usual pathogen implicated in Lemierre's syndrome has rarely been known to be the sole pathogen implicated in childhood osteomyelitis secondary to septic jugular vein thrombosis. It is important to recognize some of the complications of septic jugular vein thrombosis to reduce morbidity and mortality. Conclusion: Awareness of the clinical and radiologic findings that may be seen in pediatric retropharyngeal infections along with awareness of the possible complications can help guide early treatment or surgical intervention.

Acute Hematogenous Osteomyelitis in Children

Acute Hematogenous Osteomyelitis in Children

Short- Versus Long-term Antimicrobial Treatment for Acute Hematogenous Osteomyelitis of Childhood

Considerable uncertainty exists on the optimal duration of antimicrobials for acute hematogenous osteomyelitis (AHOM) in children. Often they are administered for 1 to 2 months, the first 1 to 2 weeks intravenously, and decompressive surgery is usually added. No prospective, randomized, sufficiently powered comparative trial has been available. Children aged 3 months to 15 years with culture-positive AHOM were randomly assigned to receive clindamycin or a first-generation cephalosporin for 20 or 30 days, including an intravenous phase for the first 2 to 4 days. Surgery was kept at minimum. Illness was monitored with preset criteria. Antimicrobial was discontinued once most signs had subsided and serum C-reactive protein decreased ≤20 mg/L. The primary end point was full recovery without need for further antimicrobial therapy because of an osteoarticular indication during the 12 months after the primary therapy. Of the 131 cases, 18% also involved the adjacent joint. Staphylococcus aureus caused 89% of cases, and all strains were methicillin susceptible. The median duration of treatment was 20 days for 67 children, and 30 days for 64 children. Most children underwent only the diagnostic percutaneous aspiration or drilling, and 24% had no surgery. Except for 1 mild sequela in both treatment groups, all patients recovered entirely. Most cases of childhood AHOM can be treated for 20 days, including a short period intravenously, with large doses of a well-absorbed antimicrobial such as clindamycin or a first-generation cephalosporin, provided the clinical response is good and C-reactive protein normalizes within 7 to 10 days. Extensive surgery is rarely needed.

Acute Hematogenous Osteomyelitis

1. Dennis A. Conrad, MD* 1. *Professor of Pediatrics and Associate Chairman for Continuing Medical Education, Department of Pediatrics/Division of Infectious Diseases, University of Texas Health Science Center at San Antonio; Medical Director, Infection Control, CHRISTUS Santa Rosa Children's Hospital, San Antonio, Tex. After completing this article, readers should be able to: 1. Describe the pathophysiology of acute hematogenous osteomyelitis. 2. Correlate most common infectious causes of osteomyelitis with the age of the patient. 3. Recognize the typical clinical manifestations of acute hematogenous osteomyelitis. 4. Explain the appropriate use of ancillary information obtained by laboratory determinations and imaging studies to establish the diagnosis of acute hematogenous osteomyelitis. 5. Discuss the medical and surgical principles of management in the treatment of acute hematogenous osteomyelitis. The most common type of osteomyelitis, an infection of bone, that occurs in children is acute hematogenous osteomyelitis. Infection initially is established in the metaphyseal region of tubular bones, beginning as a metaphysitis following seeding by bacteria. The appendicular skeleton is the most common site of osteomyelitis. The lower extremity, especially the femur, is involved more often than the upper extremity, where the humerus is most likely to be infected. The pelvic bones or clavicles are less likely to be involved than the long bones of the extremities. The most common bone involved in acute hematogenous osteomyelitis in children is the femur. The axial skeleton is less likely to be the site of acute hematogenous osteomyelitis. Manifestations of osteomyelitis involving the axial skeleton are most commonly discitis, vertebral osteomyelitis, and infection involving the ribs and cranial bones. In most cases, the preceding bacteremia leading to acute hematogenous osteomyelitis is cryptic and asymptomatic, although osteomyelitis can be a focal complication of clinically symptomatic bacteremia and even overt septicemia. The nidus of infection begins in the valveless sinusoidal loops of the venules at their reflection at the epiphysis and is attributed to slow and nonlaminar blood flow through this vascular …

Cortical bone fenestrations with continuous antibiotic irrigation to mediate hematogenous tibial osteomyelitis in children

The objective of this study was to evaluate the results of drainage and continuous antibiotic irrigation of the medullary canal to mediate hematogenous osteomyelitis of the tibia in children. Data were analyzed from 376 patients (388 tibiae) treated from January 1982 to December 2004. The average age at the time of surgery was 5 years and 9 months. The diagnosis of mediate hematogenous osteomyelitis was based on clinical examination, plain radiographs, scintigraphy, ultrasound, and bacterial cultures. Treatment included two groups: (i) group I [from January 1981 to September 1984 in 108 patients (112 tibiae)] who were operated on according to traditional surgical procedure (pus drainage), (ii) group II [from October 1984 to December 2004 in 268 patients (276 tibiae)] who were operated on according to cortical bone fenestrations with continuous antibiotic irrigation. Postoperative antibiotic(s) with the intravenous antibiotic therapy were administered for 2 weeks and oral antibiotic therapy for 4 weeks. The total time of antibiotic therapy was 6 weeks. There were 152 (40.4%) female and 224 (59.6%) male patients. Unilateral involvement was the most common, with the left tibia affected in 119 (31.6%) patients, and the right in 245 (65.2%). Both tibiae were involved in 12 (3.2%) patients. The average age at the time of operation was 5 years 9 months (range: 22 days-13 years, 7 months). All patients were classified as having a mediate stage of osteomyelitis. We attained good results in 50.9% of the patients in the group I, fair results in 7.1%, and poor results in 42% with pathologic fracture in eight tibiae. In group II, there were good results in 77.9%, fair results in 21.4%, and poor results in 0.7% tibiae with the development of chronic osteomyelitis and without pathologic fracture. In conclusion, this technique is generally safe and effective. We suggest that similar management might also be applied for hematogenous osteomyelitis of femur and humerus.

Brodie’s abscess presenting in a young soccer player following ankle injury

Brodie’s abscess is a localized form of subacute osteomyelitis that typically occurs in the growing ends of long bones in the lower limbs of young adults. It is rare and potentially serious if the diagnosis is delayed. A high index of suspicion is required to diagnose the condition and persistent pain following an injury should alert the treating doctor to the possibility of this condition and not to simply attribute the pain to the original injury. This letter aims to highlight this rare occurrence with the case of an 11-year-old soccer player who suffered a noncontact eversion injury to his right ankle. At initial presentation he was found to have an avulsion fracture of the right medial malleolus on plain radiographic evaluation and was managed with below knee cast immobilisation for 4 weeks. Ten weeks following the injury he began to feel increasing discomfort in the anterior aspect of his right distal shin. Subsequent radiographs of his right ankle showed a lesion in the lower tibial metaphysis, which was of mixed sclerotic and lytic nature that did not appear to breach the cortex with no associated periosteal reaction. Subsequent magnetic resonance imaging (MRI) of the right ankle demonstrated a well-defined lesion crossing the growth plate in keeping with a Brodie’s abscess (Fig. 1). Contemporaneous haematological investigations revealed a raised C-reactive protein (CRP) at 19.5 mg/l (normal \ 5 mg/l) with a normal white cell count (WCC) and erythrocyte sedimentation rate (ESR). Aerobic and anaerobic blood cultures failed to grow any organisms. Despite antibiotic therapy, his blood tests showed a worsening picture of inflammation and he developed erythema over the lateral aspect of his right ankle. He was subsequently taken to theatre and 8 ml of pus was aspirated from his ankle joint. Culture of the pus aspirated from the ankle grew no organisms. He underwent further operative washout of his right ankle 4 days later and completed a 6-week course of antibiotics. Following this, he went on to make a good recovery and at 1-year follow up he is asymptomatic and back playing soccer. A Brodie’s abscess may be mistaken for a variety of neoplasms including Ewing’s sarcoma and osteoid osteoma. In as many as 50% of cases, subacute osteomyelitis is confused with tumour and biopsy is sometimes required for definitive diagnosis [1]. The incidence of osteomyelitis in children is 2.9 new cases per 100,000 population per year [2]. Pain is the most consistent symptom and constitutional symptoms are usually mild. C-reactive protein (CRP) has been found to be superior than ESR or WCC in monitoring the effectiveness of therapy and predicting recovery from acute haematogenous osteomyelitis [3]. Blood cultures are seldom positive and abscess culture may be negative in as many as 50% of cases [4]. This may in part be because the patient has already received antibiotic treatment. If cultures are positive then typically Staphylococcus aureus is isolated [4], although a number of other causative organisms such as streptococci, pneumococci, and Gram-negative bacteria have also been isolated [2]. Magnetic Resonance (MR) Imaging is a useful tool for evaluating patients with osteomyelitis and has been shown to be superior to bone scanning. MR provides better soft tissue resolution and is more useful in differentiating S. P. Edmundson (&) K. M. Hirpara P. O’Grady Department of Trauma and Orthopaedics, Mayo General Hospital, Castlebar, County Mayo, Ireland e-mail: stevenedmundson@yahoo.co.uk

Deep venous thrombosis associated with acute hematogenous osteomyelitis in children

Deep venous thrombosis (DVT) is rare in children. It may complicate acute hematogenous osteomyelitis (AHO). The present study assessed the incidence of DVT in community-acquired AHO, and compared clinical and laboratory characteristics with AHO without DVT. A prospective study included patients treated for community-acquired AHO between April 2007 and December 2009. Seventy patients were included: mean age, 7.7 years. Seven developed DVT. All involved Staphylococcus aureus. The isolated Staphylococcus aureus was significantly more often methicillin-resistant than methicillin-susceptible (p=0.04). C-reactive protein, erythrocyte sedimentation rate, positive blood culture and incidence of pulmonary staphylococcus were significantly higher in patients with DVT. These patients also had significantly more febrile days. One patient with DVT died from severe refractory respiratory failure. DVT was observed in 10% of cases of community-acquired AHO. DVT was associated with more severe onset, with extensive local disease. Surgery was often needed to drain a subperiosteal abscess. DVT can cause invasive and life-threatening infection through septic emboli, particularly to the lungs. Level III.

Systematic review of systemic antibiotic treatment for children with chronic and sub‐acute pyogenic osteomyelitis

There is a lack of consensus on the most appropriate antibiotics to treat children with chronic or sub-acute pyogenic bacterial osteomyelitis and on the optimal duration of antibiotic therapy. To review the published evidence on the duration of antibiotic therapy and outcomes in children with chronic and sub-acute pyogenic bacterial osteomyelitis. Systematic review of the literature. We found no randomised controlled trials comparing different antibiotic regimens or comparing duration of antibiotic treatment for chronic or sub-acute osteomyelitis in children. We found 14 observational case series published between 1973 and 2008. Most children with chronic osteomyelitis received 4-6 weeks of parenteral antibiotics followed by oral antibiotics to a total duration of 3-6 months. Small observational studies suggest that a shorter duration of parenteral and oral antibiotics may be equally effective. There is no high level evidence on the optimal duration of parenteral and oral antibiotics for children with chronic or sub-acute osteomyelitis. A large randomised controlled trial is needed comparing short course parenteral and oral antibiotics with longer antibiotic duration.

Pyogenic osteomyelitis of the vertebral arch in children

Vertebral infection represents 2% to 4% of all cases of osteomyelitis in children. Extension of vertebral osteomyelitis into the vertebral arch is rare; and exclusive pyogenic involvement is exceedingly rare, especially in children. A review of the literature revealed less than 25 combined cases, most of them reported in the beginning of the 20th century without cross-sectional imaging. The unusual location creates difficulties in distinguishing vertebral osteomyelitis from neoplasm and arthritic conditions. We present 2 cases of infection of the posterior vertebral elements. Most useful in identifying the presence and extent of infection were a sudden onset of nonspecific back pain, elevated inflammatory parameters, and magnetic resonance imaging. Antibiotic therapy with or without surgical intervention provided successful management. With the recurrence observed in 1 child, the most optimal treatment of this condition might still be unknown.

Chronic haematogenous osteomyelitis in children

We present a retrospective review of 167 patients aged 18 years and under who were treated for chronic haematogenous osteomyelitis at our elective orthopaedic hospital in Malawi over a period of four years. The median age at presentation was eight years (1 to 18). There were 239 hospital admissions for treatment during the period of the study. In 117 patients one admission was necessary, in 35 two, and in 15 more than two. A surgical strategy of infection control followed by reconstruction and stabilisation was employed, based on the Beit CURE radiological classification of chronic haematogenous osteomyelitis as a guide to treatment. At a minimum follow-up of one year after the end of the study none of the patients had returned to our hospital with recurrent infection. A total of 350 operations were performed on the 167 patients. This represented 6.7% of all children's operations performed in our hospital during this period. One operation only was required in 110 patients and none required more than three. Below-knee amputation was performed in two patients with chronic calcaneal osteomyelitis as the best surgical option for function. The most common organism cultured from operative specimens was Staphylococcus aureus, and the tibia was the bone most commonly affected. Polyostotic osteomyelitis occurred in four patients. We believe this is the largest reported series of patients treated for chronic haematogenous osteomyelitis.

Chronic Osteomyelitis in Children: Treatment by Intramedullary Reaming and Antibiotic-impregnated Cement Rods

Chronic osteomyelitis (CO) is rarely encountered in developed countries and is especially rare in children and adolescents. However, on occurrence, it can pose a difficult therapeutic challenge necessitating a combination of aggressive surgical treatment and prolonged antibiotic administration. Four patients were treated for CO in the Pediatric Orthopaedic Unit at Schneider Children's Medical Center between June 2005 and December 2006 and were reviewed retrospectively. Surgical treatment consisted of debridement and lavage, reaming of the intramedullary canal and insertion of gentamycin-impregnated polymetamethacrylate rods into the canal and beads around the infection site. At rod removal reaming and lavage were repeated. Antibiotic treatment was initiated with intravenous cephalothin, followed by prolonged oral treatment according to bacterial sensitivity. Cement rods and beads were removed 16 to 62 days after insertion. Intravenous antibiotics were continued for 6 weeks (3-13) and total antibiotic treatment length was 16 weeks (10-37). Total treatment time from presentation to full resolution averaged 8 months (2-18). One patient sustained a fracture requiring osteotomy and correction. At mean follow-up of 41 months from rod removal (36-46), all patients are asymptomatic and fully functional with no clinical signs of infection. C-reactive protein is within normal limits in all 4 patients. The method presented combining reaming, lavage and local and systemic antibiotic treatment was found to be safe and effective in the treatment of CO, eradicating the infection and preventing further tissue loss. Therapeutic study, clinical case series: level IV.

Some aspects of the pathogenesis of hematogenous osteomyelitis in children

Characteristic features of the pathogenesis of hematogenous osteomyelitis in children undergoing complex treatment are described. The data characterizing the development of an osteomyelitic focus are presented. Some of the causes of the protracted course of the disease and its transition into a chronic state, as well as aspects of immunobiological protection of the organism during treatment have been studied.

Invasive aspergillosis osteomyelitis in children—a case report and review of the literature

Immunocompromised patients are at high risk of secondary infection associated with high morbidity. In children these complications include fungal osteomyelitis due to continuous infiltration or hematogenous spread. The case of a 4-year-old boy is presented who developed lumbalgia and thigh pain during ongoing chemotherapy for acute lymphatic leukemia. MRI revealed infarct-like lesions in the femur and L5 vertebra, which were biopsied. The histologic diagnosis was consistent with angioinvasive aspergillosis. A multifocal osseous presentation has rarely been described in children and an overview of the literature is presented. Invasive aspergillosis is a rare complication to be considered in children with MRI-detected bony lesions of infarct-like appearance.

Acute osteomyelitis in children in Ibadan, Nigeria. Is surgical decompression necessary?

A total of 17 Children with acute osteomyelitis presenting to division of orthopaedics and trauma surgery is presented. The male:female ratio is 1:1:3, mean age of 6.12 years. The median time of illness before presentation is 8 days. The Tibia bone is the most common site of infection (52.9%) while multifocal infection occurs in 35.3% of the patient. Staphylococcus aureus is the most common isolate (47.1%) while Salmonella typhi occurred in 23.5% of the patients, all with sickle cell disease. There was positive bone aspirate in all the patients while all patient had surgical intervention with sequential intravenous - oral antibiotic therapy with an excellent outcome in 94.1%. Surgical intervention appears to be essential to cure of acute osteomyelitis in addition to antibiotic use.

Chronic Recurrent Multifocal Osteomyelitis as the First Presentation of Acute Lymphoblastic Leukemia in a 2-year-old Boy

We present herein a 2-year-old boy who suffered from chronic recurrent multifocal osteomyelitis for 6 months and was later diagnosed as acute lymphoblastic leukemia. In view of the rarity of bilateral symmetric and multifocal lesions in osteomyelitis in children, we suggest that leukemia should be investigated with bone marrow aspiration in such patients, even if complete blood count parameters are normal, and there is no hepatosplenomegaly.

Acute osteomyelitis in children: The pathogenesis revisited?

The present study reviews our experience of acute hematogenous osteomyelitis in 450 children over a period of 20 years from 1985 to 2004 at the Nouméa Territorial Hospital in New Caledonia. The objective was to formulate a new theory of the pathogenesis of this affection and to report our research on the disparity in the pathology between temperate countries and our own tropical Pacific area. Only children with an initially normal X-ray and showing symptoms for less than one week were included in the study. Subacute osteomyelitis, infant osteoarthritis and spinal and sacroiliac joint infections were all excluded. All children were treated according to a preestablished protocol including: clinical examination; blood tests; ultrasound, to determine the presence and size of the periosteal elevation and to exclude soft tissue abscess and frequent pyomyositis. Ultrasound was used in the decision to treat with antibiotics alone or with surgery. Computed Tomography was used for deep structures assessment and medical therapy guidance Surgery was limited to open drainage of the subperiosteal abscess only. Regular follow-up of outpatients was continued until normal blood test and X-ray results were achieved. Four hundred and fifty children with a diagnosis of acute hematogenous osteomyelitis were identified, giving an average incidence of 22 new cases per year (range, 12-35). This incidence was two to five times as high as found in Europe. Fifty-three percent of our cases required surgical drainage (vs. 20 % in Europe). Ethnically, 60 % of the children were Melanesian and 20 % Polynesian (both represented less than 50 % of the local population). A similar incidence, about four times as high as in the population of European descent, was reported in Polynesians by our neighbors in New Zealand. The limbs were affected in 90 % of cases, and specifically lower limbs in 70 %. Multiple osseous lesions and systemic infection were recorded in 43 children (9.5 %). Blood cultures and surgical samples were positive in 80 % of cases, and otherwise negative. All the children were successfully treated, without chronic evolution or sequelae needing secondary surgery. The predominant microorganisms isolated were Staphylococcus aureus, in 81 % of cases, none of which were methicillin-resistant, and group A Streptococcus in 7.5 % of cases. A previous study of soft-tissue S. aureus infection showed the presence of Panton-Valentine Leukocidin (PVL) genes in 89 % of cases. These very infrequent genes are responsible for leukotoxic apoptosis, producing leukocidin, causing local acute aggressiveness. A parallel study, in progress for more than a year, is focusing on detecting PVL genes in S. aureus isolated from acute osteomyelitis: in the first nine children analyzed, PVL genes were likewise detected in 89 % of the S. aureus isolated, with no methicillin resistance. Ultrasonography allowed positive diagnosis in 64 % of cases on the day of admission and 84 % by the second day. Because of this very early presence of subperiosteal abscess at the beginning of the disease, and several other issues raised in the present study, we believe that Trueta's theory of acute osteomyelitis pathogenesis does not provide any logical explanation for our anatomoclinical observations. We believe that the primary focus of infection is in the osteoperiosteal area rather than under the growth plate in the metaphyseal bone. The term of Acute Osteo-Periostitis would therefore be much more suitable. A history of blunt trauma was found in 63 % of cases in the present series, and often reported in the literature. We speculate that two forms of infection fixation may develop: a local form, where bacteria carried by the blood stream reach a subperiosteal edema or hematoma secondary to blunt trauma, which is in our opinion the most frequent cause; and a general form, where fixation occurs as single or multifocal osteoperiostitis, and multivisceral locations in severe forms of septicemia. The disparity in this pathology between temperate countries and our own tropical Pacific area is certainly due to PVL-positive S. aureus and ethnic factors. The high prevalence of Melanesian and Polynesian patients confirms that they are at high risk of musculoskeletal infection in New Caledonia as in other Pacific countries, and it is possible that these ethnic groups are genetically susceptible to PVL-positive strains. Level IV. Retrospective case series.

Biologic therapy in refractory chronic non-bacterial osteomyelitis of childhood

To date there is no uniformly effective treatment for either chronic recurrent multifocal osteomyelitis (CRMO) or synovitis, acne, pustulosis, hyperostosis and osteitis (SAPHO) syndrome. We report on our clinical experience of using biologic therapy to treat children with these conditions. Retrospective descriptive case series of four children with refractory disease treated with biologics. Disease activity was assessed at predetermined time points (T = 0, T = 6 weeks and T = 12 months after the start of biologic therapy, and at latest follow-up) using a combination of clinical examination and radiological findings: a 10 cm pain and physician visual analogue scale; the Childhood Health Assessment Questionnaire as an assessment of disability; and changes in markers of systemic inflammation. There was an initial improvement in all parameters assessed for all three children treated with TNF-alpha blockade, although the third case had to discontinue the therapy due to a suspected (but unconfirmed) fungal skin infection. Anakinra treatment alleviated the symptoms in the fourth patient at 6 weeks, but there was no sustained response to treatment at 1-year follow-up. We present our preliminary experience of using biological therapies to treat children with CRMO and SAPHO in conjunction with other immunosuppression. Further studies are needed to establish the role of these therapies in refractory CRMO and SAPHO.

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.