Osteoid Osteoma

Author: Colin Woon

Topic updated on 04/28/13 11:37pm

Introduction

A self limited benign bone lesion usually in younger patients
- presents with pain unrelated to activity
Epidemiology
- demographics
  - 5-30 years (mostly in the second decade of life)
  - 2:1 male to female ratio
- location
  - 50% in diaphysis or metaphysis of long bones of lower extremity (tibia, femur)
    - proximal femur > tibia diaphysis > posterior elements of the spine > fingers and carpus > feet
  - the most common location is the proximal femur
  - the most common intra-articular location is the hip joint
  - the most common locations in the hand are the scaphoid and proximal phalanx
Pathophysiology
- thought to be from nerve fibers associated with blood vessels within the nidus
- pain is secondary to prostaglandin secretion and COX1/2 expression
  - COX1/2 expression in tumor makes it sensitive to NSAID therapy
Associated conditions
- orthopaedic manifestations
  - painful scoliosis
  - growth disturbance
  - flexion contractures
Prognosis
- pain from lesions usually resolves after an average of 3 years
- the lesion spontaneously resolves in 5-7 years
- in the spine, early resection (within 18 months) leads to resolution of scoliosis in young children (<11years)

Anatomy

Posterior elements of the spine include
- facet joints
- pedicles
- lamina

Symptoms

Symptoms
- pain that
  - increases with time
  - worse at night and with drinking ETOH
  - relieved by NSAIDS
  - may be adjacent to joint and mimic arthritis
- hand lesions may present with painless swelling
Physical exam
- joint effusions
- contractures
- limp
- muscle atrophy
- may present as painful nonstructural scoliosis
  - as a result of paravertebral spasm
  - the osteoid osteoma is located on the concave side at the apex of the curve

Imaging

Radiographs
- intensly reactive bone around radiolucent nidus
  - nidus is < 1.5 cm (otherwise osteoblastoma)
  - nidus may be difficult to see on plain xray
    - because intense periosteal reaction may obscure the nidus
CT
- study of choice
- to identify nidus surrounded by a sclerotic rim
Bone scan
- always hot with intense focal uptake

Histology

Characterized by
- distinct demarcation between nidus and reactive bone
- nidus contains uniform osteoid seams of immature osteoid trabeculae (woven bone) with a sharp border of osteoblastic rimming
  - uniform plump osteoblasts have regularly shaped nuclei with abundant cytoplasm
- reactive bone seen in region of sclerotic border
- similar appearance to osteoblastoma
- no pleomorphic cells, and does not infiltrate surrounding bone

Differentials

Long bone osteoid osteomas need to be differentiated from
- stress fx
- osteomyelitis
- Ewing's sarcoma
Posterior spinal element lesions need to be differentiated from
- aneurysmal bone cyst
- osteoblastoma (see table below)

	Osteoid Osteoma	Osteoblastoma
Size	<1.5cm	>1.5cm
Site	Long bone diaphysis	Posterior elements of the spine, long bone metaphysis
Location	Proximal femur > tibia diaphysis > spine	Spine > proximal humerus > hip
Natural History	Self-limited	Progressive
Symptoms	Nocturnal pain, relieved by NSAIDS	Dull ache, not relieved by NSAIDS. >50% of spine tumors have neurologic symptoms.
Management of Spine Lesions	Nonsurgical management is 1st line. Surgery is 2nd line	Surgery is always indicated as they don't respond to nonsurgical treatment.

Treatment

Nonoperative
- clinical observation and NSAID administration
  - indications
    - NSAIDS are 1st line and will lead to a dramatic decrease in symptoms
      - ~50% can be treated with NSAIDS alone
    - also indicated for painful spine lesions without scoliosis
    - fingertip lesions (distal phalanx) may not respond to NSAIDS
Operative
- percutaneous radiofrequency ablation
  - relative indications
    - failure of medical management
    - periarticular lesions, which increase the risk of cartilage injury and premature degenerative disease.
    - spinal lesions (controversial) - depends on the location of the lesion and proximity to neural elements
  - contraindications
    - lesions close to spinal cord or nerve roots
  - technique
    - done under CT guidance
    - probe at 80-90 deg C for 6 minutes to produce a 1cm zone of necrosis
  - outcomes
    - 90% of patients are successfully treated with 1-2 sessions of RFA
    - 10-15% recurrence rate
- surgical resection
  - indications
    - location of lesion is not amenable to CT guided percutaneous radiofrequency ablation
    - spine lesion associated with painful scoliosis
  - technique
    - successful treatment depends on complete marginal resection of nidus (scelotic bone is normal and can be left behind)
      - percutaneous approach
      - open approach
  - outcomes
    - depending on the child's age and duration of symptoms, removal of the osteoid osteoma will allow resolution of scoliosis without further treatment

Image Bank

	Location	Xray	CT	Bone scan	MRI	MRI	Histo
Case A	tibia
Case B	prox. femur
Case C	tibia
Case D	prox tibia

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Qbank (5 Questions)

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(SBQ04.40) A 6-year-girl continues to complain of pain for 8 months in the mid-tibia region that persists despite a trial of nonsteroidal anti-inflammatory medications. The pain is severe enough that it limits her activities of daily living, such as going to school and sleeping. She is afebrile and laboratory studies, including an ESR, C-reactive protein, and CBC are within normal limits. Radiographs and computed topography are shown in Figure A and B. Figure C shows the histology from a needle biopsy. What is the next step in management? Topic

Review Topic

FIGURES: A

1. Observation with repeat radiographs in 6 months
2. Percutaneous radiofrequency ablation
3. Wide surgical resection
4. Chemotherapy
5. Broad spectrum parenteral antibiotics for 6 weeks.

PREFERRED RESPONSE ▶

DISCUSSION: Osteoid osteomas are painful bone lesions that symptomatically respond to NSAIDs. Radiographs reveal a dense sclerotic cortex surrounding a small radiolucency or nidus. Symptoms often are worse at night and usually are not activity related. While treatment in the past has consisted of open en bloc excision, current means of removal include percutaneous drilling under CT guidance as described by Donahue et al and percutaneous radiofrequency ablation for extraspinal lesions as described by Rosenthal et al.

Donahue et al demonstrated 100% successful nidus excision with CT guided percutanous drilling confirmed by postexcision CT, histologic evaluation, and absence of symptoms on clinical and radiographic followup.

Success rates of percutaneous radiofrequency ablation are between 88% and 77% depending on defining failure by requiring revision or subjective outcome according to Rosenthal et al. Because the lesion is not caused by pyogenic organisms, antibiotics are not indicated.

REFERENCES:

1. Donahue F, Ahmad A, Mnaymneh W, Pevsner NH: Osteoid osteoma: Computed tomography guided percutaneous excision. Clin Orthop 1999;366:191-196. PMID:10627735 (Link to Abstract)

2. Rosenthal DI, Hornicek FJ, Wolfe MW, et al: Percutaneous radiofrequency coagulation of osteoid osteoma compared with operative treatment. J Bone Joint Surg Am 1998;80:815-821. PMID:9655099 (Link to Abstract)

Question Authors:

Charles Jobin MD, John Badylak MD, Michael Hughes MD,

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(OBQ09.6) A 27-year-old male presents with an acute onset of low back and right leg pain following a water skiing accident two weeks ago. His physical exam shows no neurological deficits. Lumbar spine radiographs are normal. An axial and coronal CT scan are shown in Figure A and B. What is the first line of treatment? Topic

Review Topic

FIGURES: A

1. Magnetic Resonance Imaging (MRI)
2. CT guided percutaneous biopsy
3. CT guided radiofrequency ablation
4. Open surgical curettage with chemical cauterization and cementing
5. Continued clinical observation

PREFERRED RESPONSE ▶

DISCUSSION: The radiographic findings are consistent with an osteoid osteoma. This lesion is likely an incidental finding, and not likely to be causing the patients symptoms. Continued clinical observation is the most appropriate treatment.

Considering the patient has a recent history of a water skiing accident with acute onset of back and leg pain, his symptoms possibly represent an acute muscle sprain and radiculopathy. Of note, the lesion is on the left while his radicular symptoms are on the right. Therefore, the first line of treatment should be clinical observation.

Volkmer et al discuss the use of radiofrequency ablation for lesions such as osteoid osteomas. They report that osteoid osteomas are usually a self-limited phenomenon and the first line of treatment should be observation and NSAID administration. They report the relative indications for radiofrequency ablation of osteoid osteomas are when medical management fails, or the lesion is periarticular placing the patient at increased risk of cartilage injury and premature degenerative disease.

Image A and B is a CT scan showing a nidus surrounded by sclerotic bone involving the neural arch of L5.

Incorrect Answers:
Answer 1: An MRI is not yet indicated for his radicular symptoms as they have only been present for two weeks and he had no neurologic deficits.
Answer 2,3 &4: The ostoid osteoma is not likely causing the patients symptoms, so treating it would not be appropriate.

REFERENCES:

1. Ross JS, Bell GR: Spine imaging, in Herkowitz HN, Garfin SR, Eismont FJ, et al (eds): Rothman-Simeone The Spine, ed 5. Philadelphia, PA, Saunders Elsevier, 2006, pp 187- 217

2. Volkmer D, Sichlau M, Rapp TB. The use of radiofrequency ablation in the treatment of musculoskeletal tumors. J Am Acad Orthop Surg. 2009 Dec;17(12):737-43. PMID:19948698 (Link to Abstract)

Question Authors:

Derek Moore, Patrick McCulloch MD, Michael Hughes MD,

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(OBQ09.197) A 17-year-boy has had chronic hip pain for the last 8 months that no longer responds to nonsteroidal anti-inflammatory medications. He reports that the pain is worse at night. He is afebrile and laboratory studies, including an ESR, C-reactive protein, and CBC are within normal limits. Radiographs, computed topography, and a bone scan are shown in Figure A, B, and C respectively. What is the next step in management? Topic

Review Topic

FIGURES: A

1. CT guided biopsy
2. CT of chest , abdomen, and pelvis
3. CT guided radiofrequency ablation
4. En bloc surgical resection resection
5. Open surgical curettage with chemical cauterization and cementing

PREFERRED RESPONSE ▶

DISCUSSION: The clinical and radiograhic presentation are consistent with osteoid osteoma. The first line of treatment, which should include observation and NSAID administration, has failed so the next step in treatment should be CT guided radiofrequency ablation.

Volkmer et al discusses the use of radiofrequency ablation and state indications for radiofrequency ablation of osteoid osteomas are when medical management fails, the lesion is leading to a scoliotic deformity, or the lesion is periarticular placing the patient at increased risk of cartilage injury and premature degenerative disease.

Moser et al present a therapeutic case series (level IV evidence) that shows an overall clinical success rate of 98% (of 68 patients) when using image-guided laser ablation to treat osteoid osteomas in pediatric patients.

The final reference by Lee et al is a review article of osteoid osteomas.

Incorrect Answers:
Answer 1: A CT guided biopsy alone is not indicated as the clinical and radiographic presentation are diagnostic and it is not worth the added risks of an additional procedure.
Answer 2: Based on imaging studies alone we can establish the diagnosis, and therefore a workup for a malignant process is not required.
Answer 4 & 5: The osteoid osteoma in this case does not meet any surgical indications.

REFERENCES:

1. Volkmer D, Sichlau M, Rapp TB. The use of radiofrequency ablation in the treatment of musculoskeletal tumors. J Am Acad Orthop Surg. 2009 Dec;17(12):737-43. PMID:19948698 (Link to Abstract)

2. Moser T, Giacomelli MC, Clavert JM, et al: Image-guided laser ablation of osteoid osteoma in pediatric patients. J Pediatr Orthop 2008;28:265-270 PMID:18388727 (Link to Abstract)

3. Lee EH, Shafi M, Hui JH: Osteoid osteoma: A current review. J Pediatr Orthop 2006;26:695-700 PMID:16932114 (Link to Abstract)

Question Authors:

Derek Moore, Patrick McCulloch MD, Michael Hughes MD,

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(OBQ08.85) A 17-year-old runner presents to your office with shin pain of 6 months duration. The pain is not activity related and is made better by NSAIDS. The pain is not changed with cessation of running. Based on the clinical picture, you are concerned about an osteoid osteoma. Which of the following histology slides would confirm your diagnosis. Topic

Review Topic

FIGURES: A

1. Figure A
2. Figure B
3. Figure C
4. Figure D
5. Figure E

PREFERRED RESPONSE ▶

DISCUSSION: The histology in Figure E is most consistent with an osteoid osteoma.

Osteoid osteomas are benign bone forming neoplasms that are characterized by their small size (less than 2 cm) and self-limited growth. They occur most commonly in adolescence and have a slight male predominance. The lesion classically presents with severe pain at night that is dramatically relieved by NSAIDs. The tumor has been shown to express very high levels of prostaglandins, particularly PGE2 and PGI2, which are presumed to be the cause of the intense pain seen in patients with this lesion.

Mungo et al. investigated the role of cyclooxygenases in the production of prostaglandins in osteoid osteomas. They found strong immunohistochemical staining for COX-2 in osteoid osteomma surgical samples. They conclude that the increased production of prostaglandins by osteoid osteomas implicates that COX-2 is one of the mediators of this condition. For this reason, they hypothesize that selective that COX-2 inhibitors could be used to more safely treat osteoid osteomas.

Rosenthal et al. compared percutaneous radiofrequency coagulation with operative treatment in patients with osteoid osteomas. They found percutaneous ablation with radiofrequency is equivalent to operative excision for the treatment of an osteoid osteoma in an extremity. They suggest the percutaneous method is preferred for the treatment of extraspinal osteoid osteoma because it does not necessitate hospitalization, has decreased complications, and leads to a quicker recovery time.

Figure E shows the characteristic findings of an osteoid osteoma which includes woven bone surrounded by osteoblasts, without neoplastic cells or cellular atypia. Illustration A shows a high powered view of osteosarcoma. Notice the high nuclear to cytoplasmic ratio with cellular atypia of the neoplasmic stromal cells

Incorrect Answers:
Answer 1: Figure A shows hypocellular with bland hyaline cartilage consistent with an enchondroma.
Answer 2: Figure B is a chordoma given the diagnostic clear physaliphorous cells.
Answer 3: Figure C is a high grade osteosarcoma as can be seen with the woven bone and the high nuclear to cytoplasmic ratio with cellular atypia of the neoplasmic stromal cells.
Answer 4: Figure D is normal lung tissue.

Illustrations: A

REFERENCES:

1. Mungo DV, Zhang X, O'Keefe RJ, Rosier RN, Puzas JE, Schwarz EM. COX-1 and COX-2 expression in osteoid osteomas. J Orthop Res. 2002 Jan;20(1):159-62. PubMed PMID: 11853083. PMID:11853083 (Link to Abstract)

2. Rosenthal DI, Hornicek FJ, Wolfe MW, Jennings LC, Gebhardt MC, Mankin HJ. Percutaneous radiofrequency coagulation of osteoid osteoma compared with operative treatment. J Bone Joint Surg Am. 1998 Jun;80(6):815-21. PubMed PMID: 9655099. PMID:9655099 (Link to Abstract)

Question Authors:

Derek Moore,

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COX-1 and COX-2 expression in osteoid osteomas. Includes Poll

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Evidence & References Show References

Level of Evidence 3 (Retrospective Cohort Study or Case-Control Study)

Rosenthal DI, Hornicek FJ, Wolfe MW, Jennings LC, Gebhardt MC, Mankin HJ. Percutaneous radiofrequency coagulation of osteoid osteoma compared with operative treatment. J Bone Joint Surg Am. 1998 Jun;80(6):815-21. PubMed PMID: 9655099. PMID:9655099 (Link to Abstract)

Level of Evidence 4 (Case Series)

Donahue F, Ahmad A, Mnaymneh W, Pevsner NH: Osteoid osteoma: Computed tomography guided percutaneous excision. Clin Orthop 1999;366:191-196. PMID:10627735 (Link to Abstract)
Rosenthal DI, Hornicek FJ, Wolfe MW, et al: Percutaneous radiofrequency coagulation of osteoid osteoma compared with operative treatment. J Bone Joint Surg Am 1998;80:815-821. PMID:9655099 (Link to Abstract)
Lindner NJ, Ozaki T, Roedl R, Gosheger G, Winkelmann W, Wörtler K. Percutaneous radiofrequency ablation in osteoid osteoma. J Bone Joint Surg Br. 2001 Apr;83(3):391-6. PMID:11341426 (Link to Abstract)
Mungo DV, Zhang X, O'Keefe RJ, Rosier RN, Puzas JE, Schwarz EM. COX-1 and COX-2 expression in osteoid osteomas. J Orthop Res. 2002 Jan;20(1):159-62. PMID:11853083 (Link to Abstract)
Volkmer D, Sichlau M, Rapp TB. The use of radiofrequency ablation in the treatment of musculoskeletal tumors. J Am Acad Orthop Surg. 2009 Dec;17(12):737-43. PMID:19948698 (Link to Abstract)
Moser T, Giacomelli MC, Clavert JM, et al: Image-guided laser ablation of osteoid osteoma in pediatric patients. J Pediatr Orthop 2008;28:265-270 PMID:18388727 (Link to Abstract)
Mungo DV, Zhang X, O'Keefe RJ, Rosier RN, Puzas JE, Schwarz EM. COX-1 and COX-2 expression in osteoid osteomas. J Orthop Res. 2002 Jan;20(1):159-62. PubMed PMID: 11853083. PMID:11853083 (Link to Abstract)

Level of Evidence 5 and Other Journal Articles (includes Case Reports, Expert Opinions, Personal Observations, and Biomechanic Studies)

Kan P, Schmidt MH. Osteoid osteoma and osteoblastoma of the spine. Neurosurg Clin N Am. 2008 Jan;19(1):65-70. Review. PMID:18156049 (Link to Abstract)
Volkmer D, Sichlau M, Rapp TB. The use of radiofrequency ablation in the treatment of musculoskeletal tumors. J Am Acad Orthop Surg. 2009 Dec;17(12):737-43. PMID:19948698 (Link to Abstract)
Lee EH, Shafi M, Hui JH: Osteoid osteoma: A current review. J Pediatr Orthop 2006;26:695-700 PMID:16932114 (Link to Abstract)

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Cronen GA, Emery SE. Benign and malignant lesions of the spine. In: Spivak JM, Connolly PJ, eds. Orthopaedic Knowledge Update: Spine 3. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2006:351-366.
Ross JS, Bell GR: Spine imaging, in Herkowitz HN, Garfin SR, Eismont FJ, et al (eds): Rothman-Simeone The Spine, ed 5. Philadelphia, PA, Saunders Elsevier, 2006, pp 187- 217

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Osteoid Osteoma

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