Introduction A small, discrete, painful, benign bone lesion 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) 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 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 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) Classification Enneking Classification of Benign Lesions Stage Grade Examples Images Stage 1 Latent lesions enchondroma, non-ossifying fibroma Stage 2 Active lesions osteoid osteoma, UBC Stage 3 Aggressive lesions giant cell tumor of bone, ABC, chondroblastoma, chondromyxoid fibroma, 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 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 vetebral 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, not relieved by 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 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 with currettage 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 Image Bank Location Xray CT Bone scan MRI MRI Histo Case A tibia Case B prox. femur Case C tibia Case D prox tibia
QUESTIONS 1 of 16 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Previous Next (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? Review Topic QID: 2819 FIGURES: A B 1 Magnetic Resonance Imaging (MRI) 8% (192/2519) 2 CT guided percutaneous biopsy 4% (99/2519) 3 CT guided radiofrequency ablation 14% (361/2519) 4 Open surgical curettage with chemical cauterization and cementing 7% (184/2519) 5 Continued clinical observation 66% (1673/2519) ML 3 Select Answer to see Preferred Response PREFERRED RESPONSE 5 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 (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? Review Topic QID: 3010 FIGURES: A B C 1 CT guided biopsy 8% (129/1709) 2 CT of chest , abdomen, and pelvis 5% (79/1709) 3 CT guided radiofrequency ablation 81% (1378/1709) 4 En bloc surgical resection resection 2% (30/1709) 5 Open surgical curettage with chemical cauterization and cementing 5% (85/1709) ML 2 Select Answer to see Preferred Response PREFERRED RESPONSE 3 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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? Review Topic QID: 37 FIGURES: A B C 1 Observation with repeat radiographs in 6 months 4% (28/775) 2 Percutaneous radiofrequency ablation 84% (653/775) 3 Wide surgical resection 7% (56/775) 4 Chemotherapy 2% (19/775) 5 Broad spectrum parenteral antibiotics for 6 weeks. 1% (5/775) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 2 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 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. Review Topic QID: 471 FIGURES: A B C D E 1 Figure A 12% (78/634) 2 Figure B 8% (48/634) 3 Figure C 14% (91/634) 4 Figure D 9% (59/634) 5 Figure E 55% (351/634) ML 4 Select Answer to see Preferred Response PREFERRED RESPONSE 5 (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? Review Topic QID: 4408 FIGURES: A B C 1 Idiopathic scoliosis 3% (114/3927) 2 Giant cell tumor 3% (106/3927) 3 Osteoid osteoma 93% (3639/3927) 4 Vertebral osteomyelitis 1% (21/3927) 5 Metastatic osteosarcoma 1% (21/3927) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 3 (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? Review Topic QID: 4371 FIGURES: A B 1 Radiation and chemotherapy is required for definitive treatment 1% (43/4292) 2 An increase in cyclooxygenase activity has been demonstrated within these lesions 89% (3808/4292) 3 Spontaneous resolution does not occur 5% (222/4292) 4 A definitive diagnosis cannot be made without MRI 2% (98/4292) 5 Pain is most severe during the day, and typically improves at night 2% (93/4292) ML 1 Select Answer to see Preferred Response PREFERRED RESPONSE 2 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK
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