The Aches and Pains of Bone Marrow Edema: An Educational Review

Purpose or Learning Objective: This educational review delves into the complexities surrounding bone marrow edema syndromes using the latest literature, shedding light on their potential causative factors, diagnostic approaches radiologically, and highlighting imaging findings that help differentiate the various entities.

Methods or Background: Hyperemia is likely the primary cause of extracellular bone marrow edema. Various clinical conditions can lead to localized bone marrow edema, such as trauma (bone contusions, stress fractures, and insufficiency fractures), transient hip osteoporosis, regional migratory osteoporosis, complex regional pain syndrome (reflex sympathetic dystrophy), early-stage osteonecrosis, tumors, and joint disorders like cartilage abrasion in degenerative joint disease.

Results or Findings: Transient osteoporosis presents with bone marrow edema on magnetic resonance imaging, predominantly affecting weight-bearing joints like the hip. It resolves spontaneously in 7 to 8 months. Regional migratory osteoporosis shares similar imaging features but shifts between joints over time, differentiating it from transient osteoporosis. Subchondral insufficiency fractures present with marrow edema and subchondral fractures, often progressing to osteonecrosis if vascular compromise occurs. Rapidly progressive osteoarthritis leads to severe joint destruction with rapid space loss, marrow edema, and femoral head deformation, including the “hatchet-like” deformity. A higher initial Tönnis angle was observed in rapidly progressing osteoarthritis patients compared with other conditions. In avascular necrosis, maximal depth on mid-coronal magnetic resonance imaging aids prognosis; the Kerboul angle quantifies lesion severity. Magnetic resonance imaging is the gold standard for chronic recurrent multifocal osteomyelitis, detecting marrow edema. Whole-body magnetic resonance imaging identifies multifocal lesions. Phenotypic patterns guide prognosis, and isotope bone scans detect active inflammation. In complex regional pain syndrome, magnetic resonance imaging should be used to exclude other conditions rather than for diagnosis. However, three-phase bone scintigraphy and osteoprotegerin levels may aid diagnosis, but specificity and sensitivity vary. Magnetic resonance imaging plays a key role in diagnosing and distinguishing these conditions for optimal management.

Conclusion: Bone marrow edema syndrome should be considered in patients with musculoskeletal pain of unknown origin, particularly when magnetic resonance imaging reveals a characteristic increase of fluid-sensitive signal intensity. Early diagnosis can help avoid unnecessary investigations and invasive treatments while also preventing the progression of certain disease processes.

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Artikel online veröffentlicht:
02. Juni 2025