How we manage painful bone marrow edema – an interdisciplinary consensus at LMU Munich

Introduction:

In many patients, who present with musculoskeletal pain to a general or specialized physician, further workup by MRI reveals the diagnosis of “bone marrow edema syndrome” (BMES). Nevertheless, BMES has to be considered a diagnosis of exclusion. Up to now we are still missing an interdisciplinary diagnostic algorithm accounting for all of those conditions. Several experts from the DVO certified Osteology Center at LMU Munich developed an interdisciplinary expert recommendation for a diagnosic algorithm for painful BME.

Methods:

Nine osteology experts from six different medical specialities (Trauma Surgery, Endocrinology, Rheumatology, Paediatrics, Orthopaedics, Radiology) at the University Hospital Munich (LMU) met regularly over nine months and discussed available literature and common practise in different fields of medicine. They developed an interdisciplinary workup algorithm for patients with painful BME, which was finally approved by all members.

Results:

BMES is a diagnosis by exclusion, which cannot be made solely based on one single MRI examination. First of all, traumatic causes (e.g. fracture, post surgical BME, CRPS and traumatic BME) must be separated and treated accordingly. Secondly, inflammatory causes (e.g. primary inflammatory like CNO, spondylitis/sacroiliitis, enthesitis, inflammatory and non-inflammatory arthritis or septic like septic arthritis and osteomyelitis) need to be excluded by evaluating medical history, physical examination, a basic laboratory workup, and joint aspiration, if necessary. If the aetiology is still unknown, we recommend RX/CT scan to differentiate mechanic, degenerative, ischemic and neoplastic causes (e.g. bone stress injuries, osteoarthritis, avascular necrosis, charcot neuroosteoarthropathy, osteochondrosis dissecans). The fourth step includes DXA densitometry and extended laboratory work-up for diagnosis of primary and secondary osteoporosis and other metabolic bone diseases (e.g. osteomalacia, indolent systemic mastocytosis, adult hypophopshatasia). In all secondary BME treatment should follow the underlying cause. Only in cases of “primary” BMES off label treatments, like bisphosphonates or ilomedin should be considered.

Discussion:

To our knowledge, this is the first workup algorithm worldwide for the management of painful BME. As it is only based on expert opinion further clinical studies are required to develop an evidence based guideline in the future. Until then we suggest scientific evaluation and validation of the proposed algorithm.