Osteoid Osteoma and Your Everyday Practice

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Instructions 1. Review the stated learning objectives at the beginning cme ARTICLE of the CME article and determine if these objectives match your individual learning needs. 2. Read the article carefully. Do not neglect the tables and other illustrative materials, as they have been selected to enhance your knowledge and understanding. 3. The following quiz questions have been designed to provide a useful link between the CME article in the issue Osteoid Osteoma and your everyday practice. Read each question, choose the correct answer, and record your answer on the CME Registration Form at the end of the quiz. Petros J. Boscainos, MD, FRCSEd; Gerard R. Cousins, MBChB, BSc(MedSci), MRCS; 4. Type or print your full name and address and your date of birth in the space provided on the CME Registration Form. Rajiv Kulshreshtha, MBBS, MRCS; T. Barry Oliver, MBChB, MRCP, FRCR; 5. Indicate the total time spent on the activity (reading article and completing quiz). Forms and quizzes cannot be Panayiotis J. Papagelopoulos, MD, DSc processed if this section is incomplete. All participants are required by the accreditation agency to attest to the time spent completing the activity. educational objectives 6. Complete the Evaluation portion of the CME Registration Form. Forms and quizzes cannot be processed if the Evaluation As a result of reading this article, physicians should be able to: portion is incomplete. The Evaluation portion of the CME Registration Form will be separated from the quiz upon receipt at Orthopedics. Your evaluation of this activity will in no way affect educational1. Discuss the clinical objectives presentation of and different imaging modality options the scoring of your quiz. for suspected osteoid osteomas. 7. Send the completed form, with your $15 payment (check or money order in US dollars drawn on a US bank, or credit card information) to: Orthopedics CME Quiz, PO Box 36, 2. Develop an insight into the histopathology and histochemistry of osteoid Thorofare, NJ 08086, OR take the quiz online. Visit www. Healio.com/EducationLab/Orthopedics for details. osteomas. 8. Your answers will be graded, and you will be advised whether you have passed or failed. Unanswered questions will be 3. Use diagnostic processes in the differential diagnosis of suspected osteoid considered incorrect. A score of at least 80% is required to pass. osteomas. If a passing score is achieved, Keck School of Medicine of USC will issue an AMA PRA Category 1™ certificate within 4-6 weeks. 9. Be sure to mail the CME Registration Form on or before 4. Apply current treatment depending on the location and accessibility of the deadline listed. After that date, the quiz will close. CME the lesion. Registration Forms received after the date listed will not be processed. CME ACCREDITATION This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through Abstract osteomas have wide variations in presen- the joint sponsorship of Keck School of Medicine of USC and Orthopedics. Keck School of Medicine of USC is accredited Osteoid osteoma is the third most com- tation and tend to present in the second by the ACCME to provide continuing medical education for mon benign bone tumor. The authors decade of life, with pain that is worse at physicians. Keck School of Medicine of USC designates this Journal- describe the clinical presentation, diag- night and is relieved by salicylates. Plain based CME activity for a maximum of 1 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate nostic investigations, differential diagno- radiographs and computed tomography with the extent of their participation in the activity. sis, histopathology, and treatment options scans are the mainstay of imaging; how- This CME activity is primarily targeted to orthopedic surgeons, hand surgeons, head and neck surgeons, trauma for this condition, including a compre- ever, bone scintigraphy, single-photon surgeons, physical medicine specialists, and rheumatologists. There is no specific background requirement for participants hensive review of the literature. Osteoid emission computed tomography, magnet- taking this activity. FULL DISCLOSURE POLICY In accordance with the Accreditation Council for Continuing Medical Education’s Standards for Commercial Support, all CME providers are required to disclose to the activity audience The authors are from the Department of Trauma and Orthopaedic Surgery (PJB, GRC, RK), Perth the relevant financial relationships of the planners, teachers, Royal Infirmary, NHS Tayside, Perth, Scotland; Department of Radiology (TBO), Ninewells Hospital, and authors involved in the development of CME content. An NHS Tayside, Dundee, United Kingdom; and the Department of Orthopaedics (PJP), Athens University individual has a relevant financial relationship if he or she has a financial relationship in any amount occurring in the last Medical School, Athens, Greece. 12 months with a commercial interest whose products or The authors would like to thank Dr Elaine MacDuff, Western Infirmary, Glasgow, United Kingdom, services are discussed in the CME activity content over which for providing the image of the hematoxylin-eosin stain. the individual has control. The authors have no relevant financial relationships to The material presented in any Keck School of Medicine of USC continuing education activity does not disclose. Dr Aboulafia, CME Editor, has no relevant financial necessarily reflect the views and opinions of Orthopedics or Keck School of Medicine of USC. Neither relationships to disclose. Dr D’Ambrosia, Editor-in-Chief, has Orthopedics nor Keck School of Medicine of USC nor the authors endorse or recommend any techniques, no relevant financial relationships to disclose. The staff of Orthopedics have no relevant financial relationships to disclose. commercial products, or manufacturers. The authors may discuss the use of materials and/or products that UNLABELED AND INVESTIGATIONAL USAGE have not yet been approved by the US Food and Drug Administration. All readers and continuing education The audience is advised that this continuing medical participants should verify all information before treating patients or using any product. education activity may contain references to unlabeled uses Correspondence should be addressed to: Petros J. Boscainos, MD, FRCSEd, Department of Trauma of FDA-approved products or to products not approved by the FDA for use in the United States. The faculty members have and Orthopaedic Surgery, Perth Royal Infirmary, NHS Tayside, Taymount Terrace, Perth, United King- been made aware of their obligation to disclose such usage. dom, PH1 1NX ([email protected]). doi: 10.3928/01477447-20130920-10

792 ORTHOPEDICS | Healio.com/Orthopedics Osteoid Osteoma | Boscainos et al cme ARTICLE ic resonance imaging, and sonography predominantly the talar neck. Flat bones Imaging are also used. Osteoid osteomas consist in the body and the skull are rarely af- Plain Radiographs of a nidus with surrounding sclerotic fected. Osteoid osteoma is usually local- Plain radiographs are the initial imaging bone. The differential diagnosis covers a ized within the bone cortex. Subcortical, study of choice. The osteoid osteoma ap- wide range of conditions due to the vari- intracortical, and intraperiosteal osteoid pears as a small, radiolucent nidus (usually able presentation of osteoid osteoma. The osteomas have been described. Osteoid less than 1 cm) surrounded by a variable natural history is for regression to occur osteomas of the spine account for ap- area of sclerotic bone or cortical thicken- within 6 to 15 years with no treatment; proximately 6% of cases and almost al- ing (Figure 1). The nidus can be difficult however, this can be reduced to 2 to 3 ways involve the posterior arch area close to detect when it is obscured by sclerotic years with the use of aspirin and non- to the pedicles.6,7 The lumbar spine is the cortical bone or in cases of intra-articular steroidal anti-inflammatory drugs. Com- most commonly affected region. Multiple lesions, where bone deposition from the in- puted tomography–guided percutaneous osteoid osteoma nidi in the same or dif- tracapsular periosteum is usually less.12,13 techniques, including trephine excision, ferent bones are rare.8,9 In addition, intramedullary-located oste- cryoablation, radiofrequency ablation, Pain is the most common clinical oid osteomas may not exhibit surrounding and laser thermocoagulation, are de- presentation. Its usual characteristics bone sclerosis.14 Indirect manifestations of scribed. are dull, unremitting, initially mild and synovial inflammation and joint effusion intermittent pain that increases in inten- may be evident, or symptoms that mimic steoid osteoma is a small, dis- sity and persistence over time. It tends osteoarthritis may be present.13,15 When tinctive, nonprogressive, be- to become increasingly severe at night treatment is delayed, secondary osteopenia Onign osteoblastic lesion that is and is usually relieved by salicylates and and changes in bone morphology may be usually accompanied by severe pain. nonsteroidal anti-inflammatory drugs observed.11 If the nidus is larger than 1.5 Jaffe1 was the first to report the iden- (NSAIDs). The indolent nature of early cm, the lesion is usually designated as an tification of this osteoblastic lesion in osteoid osteoma may result in delayed osteoblastoma.16,17 Osteoblastomas are 1935. As the third most common biopsy- presentation. Swelling, erythema, and seen radiologically as lesions with a lucent, analyzed benign bone tumor after osteo- tenderness may be present in bones in slow-growing, expansile area with irregu- chondroma and nonossifying fibroma, subcutaneous locations.5 Referred pain lar sclerosis and no definite nidus.18 osteoid osteoma is a relatively common and muscular atrophy may result in the lesion. It represents 11% to 14% of be- misdiagnosis of a neurological disor- Computed Tomography nign bone tumors. Two percent to 3% of der.10 This observation is common in The most common appearance of osteoid excised primary bone tumors are osteoid patients who have a painful osteoid os- osteoma on computed tomography (CT) is osteomas.2,3 teoma in posterior elements of the spine, as a small, well-delineated, low-attenuation where a postural scoliosis is found due to nidus surrounded by a dense sclerotic reac- Clinical Presentation paravertebral muscle spasm but is revers- tion (Figure 2). Foci of calcification may Osteoid osteoma can manifest at any ible after treatment.4 be visible. A recently described CT finding age, but the majority of patients are aged Osteoid osteomas in the region of is the presence of fine, linear, low-density between 5 and 20 years, with 50% of pa- the proximal femur or pelvis may pres- vascular channels that can surround oste- tients aged between 10 and 20 years.4,5 ent with symptoms of knee pain, and the oid osteomas. When present, such vascular Osteoid osteomas are 1.6 to 4 times more diagnosis may require a bone scan. Intra- grooves have high sensitivity and specificity prevalent in males.4 In the majority of cas- or juxta-articular lesions are commonly in the diagnosis of osteoid osteoma.19 es, osteoid osteoma occurs in long bones, associated with synovitis.11 Joint pain A CT scan is useful in diagnosing affecting the metaphysis or diaphysis. with flexion contracture, abated range of intra- or juxta-articular osteoid osteomas, The most common loci are the femur and motion, and antalgic gait can be a clini- and it has been proposed that CT must be the tibia, with the most characteristic site cal pattern of an intra-articular osteoid used in all patients with suspected osteoid being the femoral neck and the intertro- osteoma.5 In children, the most common osteomas because it has better diagnos- chanteric region.4 Rarely, it also involves presenting symptom is nocturnal pain. In tic accuracy compared with plain radio- the epiphyseal and intracapsular aspect of a young child with an osteoid osteoma, graphs or magnetic resonance imaging in long bones (known as intra-articular os- a limp may be the only symptom. If the these cases.20,21 Preoperative localization teoid osteomas). Less commonly affected lesion is close to an open physis, it can of osteoid osteomas can be facilitated us- are the spine and the small bones of the cause lengthening, angular deformity, or ing CT guidance.22,23 Percutaneous abla- hand and feet. It can involve the talus, both of the extremity.4 tion of lesions under CT guidance is well

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1B 1C Figure 1: An 11-year-old girl presented with chronic midtibial pain and localized warmth on examination. Lateral radiograph showing diffuse anterior cortical thickening (arrow) centered on a subtle lucency, which was diagnosed as an osteoid osteoma (A). Axial proton-density fat-saturated magnetic resonance image showing diffuse high-signal medullary edema and periostitis surrounding a markedly thickened low-signal cortex, within which a 3-mm osteoid osteoma lies (B). Axial computed tomography scan obtained during radiofrequency ablation showing the densely thickened cortex and an ablation needle 1A completely occupying the nidus (C).

used to demonstrate the nidus because the reactive bone uptake may obscure it.14 In children, increased uptake by active growth plates can obscure an adjacent osteoid osteoma. In this situation, compari- son with the contralateral unaffected site is helpful to identify the tumor.13 In situa- tions where radiofrequency ablation is not available, intraoperative radionucleotide imaging may be used to confirm complete resection of the tumor.14,33

Single-photon Emission Computed Tomography 2A 2B Although in most cases a conventional bone scan followed by thin-section CT Figure 2: A 23-year-old man presented after 18 months of knee pain due to medullary osteoid osteoma. Axial computed tomography scan from a treatment planning study showing the lucent osteoid osteoma, scan is sufficient, single-photon emission subtle central calcification, and surrounding medullary sclerosis. Note the vascular channel entering the computed tomography (SPECT) can be medial aspect of the lesion (A). Coronal proton-density fat-saturated magnetic resonance image showing helpful in diagnosing osteoid osteomas a zone of marrow edema centered on a high-signal nidus adjacent to the physeal scar (B). in cases in which bone scintigraphy uptake is subtle.34 A SPECT scan can detect smaller lesions by improved spatial reso- established and is discussed later (Figure usually shows intense uptake in the arterial lution of overlying normal tissue uptake 3).24-28 Computed tomography–guided ab- phase within the richly vascular nidus and and has been advocated as helpful in de- lation of osteoid osteomas has also been in the delayed phase within surrounding re- picting osteoid osteomas of the spine.14,35 described in technically challenging loca- active bone (Figure 4).31 Usually, an intense Transaxial anatomic imaging of SPECT tions, such as the spine.29,30 area of radiotracer uptake is found in the can further enhance its diagnostic ability region of the nidus and less in the reactive in positioning suspicious lesions.36 Bone Scintigraphy bone. This pattern, which is known as the Due to the correlation between osteo- double-density sign, is diagnostic of osteoid Magnetic Resonance Imaging blastic activity and the intensity of radio- osteoma.32 The area of uptake may be wide. The appearance of osteoid osteoma is pharmaceutical uptake, bone scintigraphy Historically, a pinhole collimator has been variable with magnetic resonance imaging

794 ORTHOPEDICS | Healio.com/Orthopedics Osteoid Osteoma | Boscainos et al cme ARTICLE

3A 3B 4 Figure 3: An 11-year-old boy presented with an osteoid osteoma in the right medial femoral neck that was Figure 4: A 16-year-old boy presented with a treated with radiofrequency ablation. Computed tomography (CT) scanogram image showing the lucent 1-year history of knee pain but normal clinical ex- osteoid osteoma surrounded by medullary sclerosis and overlying cortical thickening. An ablation needle amination. Radionuclide bone scan image showing has been placed in the lesion under CT guidance (A). Axial CT scan showing the needle traversing the a wide zone of increased uptake in the proximal tib- osteoid osteoma. A lateral approach was used to avoid the grossly thickened cortical bone (B). ia due to increased osteoblastic activity provoked by an osteoid osteoma.

(MRI). A primarily cellular nidus will dem- intravenous gadopentate dimeglumine, sistency may vary from soft and granular onstrate low to intermediate signal inten- both the central nidus and surrounding to hard and sclerotic. Older lesions dem- sity on T1-weighted images that increases edema show enhancement. This technique onstrate formation of defined trabeculae. on T2-weighted images (Figure 1B). A is not always necessary, but occasion- Intraoperatively, the tumor can be visu- heavily calcified nidus appears as low to ally it may assist the differential diagnosis alized protruding from the bone surface, or intermediate signal intensity on both T1- along with other modalities. it may be hidden under a thick cortical lay- and T2-weighted images.37A more striking er of hyperostotic reactive bone. Intracorti- finding is the presence of surrounding bone Sonography cal and subperiosteal lesions are often as- marrow edema or periostitis, best demon- Historically, the use of preoperative sociated with hyperemia and edema of the strated on fluid-sensitive sequences (Figure Doppler duplex color localization of os- surrounding soft tissues.4 In tubular bones 2B). Areas of densely sclerotic medullary teoid osteomas has been reported as a specifically, osteoid osteomas that present or cortical bone may retain low signal in- means of assessment of the vascularity subperiosteally tend to become intracorti- tensity on all sequences. In some cases, of the nidus or the nidus’ feeding artery.40 cal due to continuous bone remodeling and the bone marrow and soft tissue edema is Color Doppler sonography may show in- subperiosteal new bone apposition.43 florid and can mimic an aggressive process, creased blood supply and demonstrate the Histologically, the nidus appears as such as infection or malignancy. Reactive entering vessel at the site of the lesion.41 a small, well-defined area consisting of soft tissue mass with myxomatous change, Sonography is limited by its inability to interlacing, irregular bone trabeculae of cell-depleted juxtanidal bone marrow, and penetrate bone and has been replaced by varying mineralization (Figure 5). Size, proteinaceous material may be confused other imaging modalities. thickness, and mineralization diversity of with those of a malignant tumor or osteo- trabeculae are evident among different le- myelitis.38,39 Histopathology sions, as well as in different areas of the It has been suggested that MRI must Osteoid osteomas consist of a nidus same lesion. The nidus may demonstrate a not be interpreted without reference to that is surrounded by sclerotic bone, the zonal arrangement of trabecular architec- plain radiographs and CT scans because density of which usually varies with time ture, with the central part being more scle- the appearance of osteoid osteomas on from the onset of the lesion.42 Macroscop- rotic and the periphery less mineralized MRI can mimic that of an aggressive le- ically, the nidus is a distinct round or oval and with more cells. Osteoid trabeculae sion.25 Correlation with clinical infor- reddish area with little contact with its are surrounded mainly by osteoblasts.44 mation is the most important aspect of surrounding sclerotic bone. Depending on Osteoclast-like, multinucleated giant diagnosing osteoid osteomas. Following the degree of calcification, the nidus’ con- cells have also been reported to be pres-

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Nidus osteoblasts also display strong ing using CT, bone, and SPECT scans are diffuse staining for COX-2, a key enzyme useful in delineating the nature of the le- in the production of prostaglandins and sion. Patients with unexplained low-back in particular of prostaglandin E2.52 This pain and sciatic pain in the second decade enzyme appears to be a major factor in of life should be carefully examined to osteoid osteoma pain, and inhibition of rule out osteoid osteoma.58 COX-2 production enables control of symptoms.53 Treatment Moberg59 suggested that the natural 5 Differential Diagnosis history of osteoid osteoma is that of spon- Figure 5: Hematoxylin-eosin stain (original magni- The differentiation of osteoid osteomas taneous healing. In various studies, it has fication 3200) showing trabeculae of woven bone from other benign bone-forming lesions is been noted that if the osteoid osteoma is lined by osteoblasts surrounded by a loose vascular connective tissue stroma. based on the difference in size, location, not excised, complete resolution of symp- pathology, and clinical symptoms, pathol- toms occurs within 6 to 15 years.42,59 Ad- ogy, and clinical symptoms.5 In particular, ministering aspirin or other NSAIDs can ent.45 A reactive bone-formation zone with osteoblastomas are larger in size (usually reduce this time period to 2 to 3 years.50,53 thickened trabeculae and a loose fibro- more than 1.5 to 2 cm) and tend to expand Kneisl and Simon60 reported permanent vascular stroma surrounds the nidus. The instead of regress.45 Osteoblastomas are relief of symptoms and regression of the surrounding zones of soft tissue, skeletal also painful but generally without charac- nidus after prolonged NSAIDs treatment muscle, and bone show increased vascular- teristic night exacerbation seen with oste- for 30 to 40 months. Strict selection cri- ity, with vessels becoming smaller closer oid osteomas, and pain does not respond teria should be applied if nonoperative to the nidus.46 In chronic lesions, the fibro- dramatically to salicylates or NSAIDs. treatment is considered, given the poten- vascular stroma may be dense with chronic Osteoblastomas have a predilection for tial side effects of prolonged NSAIDs ad- inflammatory cell infiltration. vertebrae and can be accompanied more ministration. Nonoperative management Pain commonly induced by osteoid os- frequently with neurological symptoms or should be considered in patients where teomas is attributed to unmyelinated nerve paravertebral muscle spasm.6,7 Instances osteoid osteoma is not easily accessible fibers found within the nidus.47 Immunohis- of osteoid osteoma transition to osteo- by surgery. tochemical analysis has detected peripheral blastoma have been reported, although Various techniques have been de- nerve fibers in the reactive zone and the ni- they are rare.54,55 Radiographically, osteo- scribed for the preoperative localization dus, with the greatest number being at the blastomas appear larger with less reactive of osteoid osteomas, such as angiography interface between the reactive zone and the sclerosis.5 Plain radiographs alone may and placing wires and needles dipped in edge of the nidus.44 Increased local concen- not be distinctive enough to establish the methylene blue over the nidus while un- 23 tration of prostaglandins (PGE2, PGI2, PGF2- diagnosis, and CT scans can give more in- der CT guidance. Radioisotope imaging alpha) and increased urinary excretion of formation on the expansive nature of the with scintimetric guidance for intraop-

6-keto-PGF1 (the major urinary metabolite lesion. erative localization and excision has been 61-63 of PGI2) have been discussed in the literature When small in size, a Brodie’s abscess reported. Historically, in cases of in- in cases of osteoid osteoma.48,49 Pain medi- may appear similar to an osteoid osteoma tracortical lesions, preoperative oral tetra- ated by prostaglandins has been attributed to on plain radiographs.9 Imaging using cycline administration and examination of the vasodilatory and vascular proliferation MRI, CT, and scintigraphy can help dif- nidus’ fluorescence under ultraviolet light effect causing increased local pressure and ferentiate between osteoid osteomas and has been used to demonstrate the lesion thus stimulating the peripheral nerve fibers osteomyelitis, as well as other types of and to verify excision, but such techniques of the reactive zone, or through activation of tumors, including nonossifying fibromas, are not currently considered practical.64,65 the bradykinin system.50 Increased prosta- chondroblastomas, enchondromas, eosin- Osteoid osteoma was traditionally glandin values are reversible after osteoma ophilic granulomas, and malignant bone treated with excision of the nidus.6,16 Al- removal.49 Although the remodeling and os- tumors.32,39,56 though the nidus needs to be removed teolytic effect of prostaglandins is still under In children, infantile cortical hyperos- completely to achieve symptomatic relief, consideration, prostaglandins of the E series tosis, osteomyelitis, Perthes’ disease, leg- complete removal of the sclerotic bone stimulate osteoclastic bone resorption in vi- length discrepancy, healing stress frac- is not necessary. A well-planned surgical tro and may contribute to the formation of tures, tuberculosis, and neuromuscular approach is essential. Radiographs or CT osteoid osteoma.51 conditions should be considered.57 Imag- scans confirm identification of the nidus

796 ORTHOPEDICS | Healio.com/Orthopedics Osteoid Osteoma | Boscainos et al cme ARTICLE before and after en bloc removal, and then postoperative scintigraphy were effective polar radio frequency probe is adequate. A the nidus undergoes histological examina- in localizing and confirming removal of series of 21 patients with osteoid osteoma tion for confirmation. En bloc resection the nidus in an outpatient setting.26 In a in atypical locations (eg, hip, radioulnar has the disadvantages of a large surgical series of 38 patients, Sans et al71 reported joint, phalanx) showed radiofrequency exposure and excision of a large part of a cure rate of 84% at 3.7 years postopera- ablation to be successful, albeit with only sclerotic bone. Bone grafting or internal tively and 2 instances of femoral fracture short-term follow-up data available.78 A fixation may be necessary, depending on at 2 months. Muscolo et al72 reported su- 5-year review of radiofrequency ablation the size of the bone defect left by the re- perior outcomes of CT-guided minimally confirmed cure in 38 of 39 patients, with 1 section.5 Unroofing and curettage has a invasive surgery rather than open sur- case of a broken drill and 1 of infection as role in structurally critical locations, such gery. Overall, percutaneous CT-guided the only reported complications.79 Simi- as the neck of femur because the central procedures have profoundly modified the larly, a 5-year case series of 21 patients sclerotic structure is not disrupted.4 Mul- treatment of osteoid osteoma. Rosenthal confirmed a primary cure rate of 89.6% tiple articles report arthroscopic removal et al73 reported a statistically significant that increased to 93% if a second treat- of intra-articular osteoid osteomas.66-69 reduction in hospital stay over the past ment was required.80 Several methods have been described 20 years by using more conservative and With osteoid osteoma affecting the whereby osteoid osteomas may be treated intralesional procedures. spine, the efficacy and safety of this pro- percutaneously using CT guidance. These Gangi et al74 reported laser interstitial cedure has been assessed, especially con- include trephine excision, cryoablation, photocoagulation as a successful mini- sidering the effect of increased temperature radiofrequency ablation, and laser thermo- mally invasive procedure. In their case in the spinal canal. Dupuy et al81 reported coagulation.24-28 The use of 3-dimensional series of 114 patients, 112 patients had a that this technique has no cytotoxic ef- C-arm radiographs during percutaneous visual analog score of 0 at 1 week postop- fects into the spinal canal, especially with excision in the long bones of children eratively. Six patients had recurrence and internally cooled radiofrequency probes. has also been reported.70 However, most were successfully treated at the second Recently, Peyser et al82 and Neumann et patients in the literature undergoing per- attempt.74 A recent retrospective study re- al83 also concluded that CT-guided percu- cutaneous ablation or resection required ported 26 patients treated by percutaneous taneous radiofrequency ablation of osteoid general anesthesia for pain control. The trephine resection and 100 by percutane- osteomas is a safe, effective, and minimally need for a general anesthetic increases ous interstitial laser ablation.75 Percutane- invasive procedure with a high success rate the invasive nature and the cost of these ous trephine resection had a success rate and no recurrence. Rimondi et al84 reported procedures and reduces the advantages of 95% at 24 months. Two patients sus- a series of 557 patients and recommended of percutaneous treatment over surgical tained skin burns and 1 reported meralgia. modifications to electrode parameters, du- resection. Furthermore, these techniques Interstitial laser ablation had a success ration of ablation with regard to the size, require equipment not commonly avail- rate of 94% at 24 months, with compli- and morphology of the lesion. able in all hospitals. cations including infection, tendonitis, Recently, bipolar radiofrequency tech- Fine drills, bone trephine, or Tru-Cut hematoma, and common peroneal nerve nology has gained interest in the manage- needles (Medline Industries, Inc, Mun- injury. The outcome was worse regardless ment of osteoid osteoma. Some drawbacks delein, Illinois) have been described for of treatment method in patients younger of monopolar radiofrequency ablation use in precise and bone-sparing resec- than 18 years and in instances where the include skin burns at the site of neutral tion. With smaller instruments, the need nidus was 12 mm or larger.75 electrode and aberrant currents causing ir- for a general anesthetic is also reduced, Percutaneous thermocoagulation of regular areas of necrosis or inducing heat and the procedure can be performed the nidus has been used by de Berg et al,76 at metallic implants.85 Another innovative in the outpatient setting, reducing the who reported 17 patients treated success- approach with promising results, particu- overall cost. Roger et al26 reported 16 fully with this method. Percutaneous ra- larly for inaccessible lesions, has been patients who were treated using per- diofrequency ablation has been proposed described by Mylona et al,29 who success- cutaneous CT-guided excision and had as an alternative to the operative treatment fully performed radiofrequency ablation satisfactory results in 14 patients. The 2 of osteoid osteomas.77 The newer technol- using a probe needle with expandable failures were attributed to the proximity ogy radiofrequency probes allow thermo- electrodes. A retrospective review of 81 of the lesion to the articular margin and coagulation of a region as large as 5 cm patients treated either by conventional excessive periosteal reaction preventing using a single probe (Figure 1C). Gener- surgery or minimally invasive techniques access. The authors concluded that in- ally, osteoid osteoma nidus size is up to 1 for osteoid osteoma of the spine found no traoperative CT guidance and immediate cm; consequently, the conventional mono- difference in outcome.86

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In its 2004 issue, the National production of prostaglandins may lead to 15. Schlesinger AE, Hernandez RJ. Intracapsular 53 osteoid osteoma of the proximal femur: find- Institute of Clinical Excellence stated further treatment modalities. ings on plain film and CT.AJR Am J Roent- that “Current evidence on the safety and genol. 1990; 154(6):1241-1244. efficacy of CT-guided thermocoagulation References 16. Peyser AB, Makley JT, Callewart CC, Brack- of osteoid osteoma appears adequate to 1. Jaffe H. “Osteoid osteoma”: a benign osteo- ett B, Carter JR, Abdul-Karim FW. Osteoma of the long bones and the spine. A study of support its use, provided that the normal blastic tumor composed of osteoid and atypical bone. Arch Surg. 1935; 31:709-728. eleven patients and a review of the literature. arrangements are in place for consent, J Bone Joint Surg Am. 1996; 78(8):1172- 87 2. Unni KK. Osteoid osteoma. 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