summary Osteoid Osteomas are small, benign, osteogenic bone lesions most commonly found in the proximal femur. Patients typically present between ages 5 and 25 with regional pain that is worse at night and improves with NSAIDS. Diagnosis is made radiographically by a characteristic lesion that is less than 1.5 cm in diameter with a sclerotic margin and radiolucent nidus. Treatment is usually nonoperative with observation and NSAID for pain control. Radiofrequency ablation or surgical resection may be indicated in patients with progressive and severe symptoms. Epidemiology Incidence cause of painful scoliosis in the adolescent population Demographics 3:1 male to female ratio persons aged 5-25 years (>80% present before age of 30) Anatomic location most common lower extremity (>50%) proximal femur > tibia diaphysis usually found within the bone cortex spine (10-15%) thoracic and lumbar regions > cervical and sacral majority involve the posterior elements usually found on the side of concavity in scoliosis hand (5-10%) scaphoid and proximal phalanx foot (<5%) predominantly involves the talar neck Etiology Pathophysiology pathoanatomy nidus central nodule of woven bone and osteoid with osteoblastic rimming reactive zone area of thickened bone and fibrovascular tissue cellular biology pain attributed to increased local concentration of prostaglandin E2 and COX1 & 2 expression increased number and size of unmyelinated nerve fibers within the nidus Associated conditions orthopaedic manifestations painful scoliosis growth disturbance flexion contractures Classification Enneking Classification of Benign Lesions Grade Examples Stage 1 Latent lesions Enchondroma Non-ossifying fibroma Stage 2 Active lesions Osteoid osteoma, UBC, ABC Chondroblastoma Chondromyxoid fibroma Stage 3 Aggressive lesions Giant cell tumor of bone Symptoms Symptoms pain constant and progressive 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 inspection palpable bone deformity, swelling, erythema, tenderness proximity to a joint effusion, contracture, limp, muscle atrophy spine postural scoliosis, paravertebral muscle spasm Imaging Radiographs recommended views 3 views of affected bone or joint findings intensely reactive bone around radiolucent nidus CT indication cross-sectional imaging is the study of choice findings to help identify the location and size of nidus usually < 1.5 cm (otherwise think osteoblastoma) Bone scan indication concerning features on radiograph or advanced imaging findings intense hot area of focal uptake at the nidus low uptake in reactive zone known as the 'double-density sign' MRI indications usually not recommended as it can mimic aggressive lesions findings must be interpreted with reference to x-ray or CT scan Histology Histology 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 zone region surrounding the sclerotic border 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 vs. Osteoblastoma Osteoid Osteoma Osteoblastoma Incidence 10% of benign tumors 3% of benign tumors Size < 2 cm (typically <1.5cm) > 2 cm (average, 3.5 - 4.0 cm) Site > 50 % in long bone diaphysis > 35% in posterior elements of the spine Location Proximal femur > tibia diaphysis > spine Vertebral column > proximal humerus > hip Natural History Self-limited Progressive Histology Benign appearance. No growth potential.Central nidus composed of more organized osteoid and lined by osteoblasts. Benign appearance. Localized growth, with aggressive potential. Central lesion less organized, with greater vascularity. Symptoms Nocturnal pain, relieved by NSAIDS Dull ache, partial response to NSAIDS. >50% of spine tumors have neurologic symptoms. Management of Spine lesions Nonsurgical management is indicated as first-line treatment. Surgery is always indicated as they do not 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 in the fingers lesions close to nerves 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 MR-guided high-intensity focused ultrasound (MR-HIFU) indications failure of medical management contraindications any contraindication to anesthesia lesions in anatomic area which could not be directly accessed by ultrasound energy (ex. vertebrae) technique based on MR imaging, therapeutic ultrasound energy transferred transcutaneously causing thermal ablation to the periosteal nerves, which penetrates the medullary bone and coagulates the osteoma nidus outcomes less invasive than other modalities significant and persistent decreases in pain with low risk for adverse events improvements in quality of life scores decreased need for NSAID in treatment population improvement in follow-up imaging showing decrease or total absence in osteoid osteoma nidus vascularity surgical resection with curettage indications location of lesion is not amenable to CT guided percutaneous radiofrequency ablation e.g. close to skin or nerve spine lesion associated with painful scoliosis digital lesions RFA carries risk of thermal skin necrosis and injury to digital neurovascular bundle technique successful treatment depends on complete marginal resection of nidus (sclerotic bone is normal and can be left behind) percutaneous approach open approach outcomes 94% success with local excision associated scoliosis rarely requires treatment Complications Recurrence 10-15% recurrence rate with percutaneous radiofrequency ablation 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)
QUESTIONS 1 of 22 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (SBQ16SM.5) A 21-year-old collegiate distance runner presents with continued right hip and groin pain despite a 1-month cessation from running and impact activities. The pain bothers him at all times of the day. Ibuprofen has helped tremendously but he is taking it nearly four times a day. On exam, he endorses pain with flexion to 110 degrees but none with log-roll or in the flexed, adducted, and internally rotated position. Radiographs are shown in Figure A and his CT scan is in Figure B. What is the best next step in treatment? QID: 211161 FIGURES: A B Type & Select Correct Answer 1 Diagnostic intra-articular corticosteroid injection 2% (50/2031) 2 MR arthrogram 4% (73/2031) 3 MRI 15% (303/2031) 4 Percutaneous radiofrequency ablation 75% (1533/2031) 5 Physical therapy focusing on eccentric strengthening and core stability 3% (59/2031) L 2 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ12.11) A 24-year-old man has had pain in the right index finger for the past 9 months. The pain is completely relieved with ibuprofen. An AP radiograph and CT scan are shown in Figures A and B respectively. Which of the following is true regarding this lesion? QID: 4371 FIGURES: A B Type & Select Correct Answer 1 Radiation and chemotherapy is required for definitive treatment 1% (49/5174) 2 An increase in cyclooxygenase activity has been demonstrated within these lesions 89% (4602/5174) 3 Spontaneous resolution does not occur 5% (254/5174) 4 A definitive diagnosis cannot be made without MRI 2% (125/5174) 5 Pain is most severe during the day, and typically improves at night 2% (113/5174) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic (OBQ12.48) A 17-year-old female presents for re-evaluation of her diffuse thoraco-lumbar spine pain. She had previously been evaluated at the age of 14 for the same symptoms. At that time she was diagnosed with scoliosis and prescribed brace therapy which has offered her no relief. A current radiograph, CT scan, and bone scan of the affected area are shown in Figures A,B and C respectively. Lab workup including CRP, ESR, and WBC is normal. What is the most likely diagnosis and cause of persistent pain in this patient? QID: 4408 FIGURES: A B C Type & Select Correct Answer 1 Idiopathic scoliosis 3% (140/5189) 2 Giant cell tumor 3% (154/5189) 3 Osteoid osteoma 92% (4797/5189) 4 Vertebral osteomyelitis 0% (24/5189) 5 Metastatic osteosarcoma 1% (43/5189) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (SBQ10PE.71.1) A 12-year-old child was referred for spinal curvature and a 2-year history of back pain. Pain was initially responsive to nonsteroidal anti-inflammatory drugs but pain relief can no longer be achieved. Examination shows a mild spinal deformity. Figures A-D show radiographs, a bone scan, and a CT scan. What is the most appropriate treatment at this time? QID: 9102 FIGURES: A B C D Type & Select Correct Answer 1 Bracing with a thoracolumbosacral orthosis (TLSO) 2% (34/1784) 2 Observation with repeat radiographs of the scoliosis in 3 months 4% (74/1784) 3 Continued anti-inflammatory medications 3% (61/1784) 4 Removal via surgical excision 77% (1378/1784) 5 Phenol injection 13% (224/1784) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (SBQ09SP.14) A 20-year-old man presents with chronic neck pain for the last 2 years. Imaging studies are obtained and depicted in Figures A and B. His pain has worsened despite 5 years of taking high doses of non-steroidal anti-inflammatory medications, which initially provided symptomatic relief. What is the most appropriate next step in management? QID: 3377 FIGURES: A B Type & Select Correct Answer 1 Low-dose oxycodone 1% (18/3150) 2 Surgical resection 70% (2196/3150) 3 Radiofrequency ablation 19% (598/3150) 4 Open biopsy 9% (276/3150) 5 Vertebrectomy 0% (11/3150) L 3 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic (OBQ09.6) A 27-year-old male presents with an acute onset of low back and right leg pain following a water skiing accident one week 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? QID: 2819 FIGURES: A B Type & Select Correct Answer 1 Magnetic Resonance Imaging (MRI) 8% (263/3328) 2 CT guided percutaneous biopsy 4% (141/3328) 3 CT guided radiofrequency ablation 14% (454/3328) 4 Open surgical curettage with chemical cauterization and cementing 8% (250/3328) 5 Continued clinical observation 66% (2206/3328) L 3 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic (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 tomography, and a bone scan are shown in Figure A, B, and C respectively. What is the next step in management? QID: 3010 FIGURES: A B C Type & Select Correct Answer 1 CT guided biopsy 9% (225/2503) 2 CT of chest , abdomen, and pelvis 5% (132/2503) 3 CT guided radiofrequency ablation 78% (1950/2503) 4 En bloc surgical resection resection 1% (37/2503) 5 Open surgical curettage with chemical cauterization and cementing 6% (149/2503) L 3 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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. QID: 471 FIGURES: A B C D E Type & Select Correct Answer 1 Figure A 13% (149/1150) 2 Figure B 8% (88/1150) 3 Figure C 15% (171/1150) 4 Figure D 9% (108/1150) 5 Figure E 54% (626/1150) L 4 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic (SBQ04PE.63) A 17-year-old boy began having right leg pain several days after the start of football practice. The pain is worse at night and not activity-related. He denies any specific injuries. Radiographs were obtained and demonstrate cortical thickening in the proximal medial tibia. A CT scan was subsequently obtained and shown in Figures A and B. Laboratory analysis reveals a normal CBC, ESR, and CRP. You prescribe him an oral medication that greatly improves his symptoms. Which of the following mechanisms of action is responsible for this result? QID: 2248 FIGURES: A B Type & Select Correct Answer 1 Cyclooxygenase inhibition 98% (1696/1737) 2 Mu-opiod receptor agonist 0% (8/1737) 3 Bacterial protein synthesis inhibition by binding to the 30S ribosomal subunit 0% (8/1737) 4 Transpeptidase inhibition 1% (9/1737) 5 Acetylcholine receptor agonist 0% (7/1737) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic (SBQ04PE.40) A 6-year-girl continues to complain of pain for 8 months in the mid-tibia region that persists despite temporary relief with use 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? QID: 37 FIGURES: A B C Type & Select Correct Answer 1 Observation with repeat radiographs in 6 months 6% (72/1264) 2 Percutaneous radiofrequency ablation 82% (1041/1264) 3 Wide surgical resection 8% (95/1264) 4 Chemotherapy 2% (28/1264) 5 Broad spectrum parenteral antibiotics for 6 weeks. 1% (13/1264) L 1 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic
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