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The Healing Pattern of Osteoid Osteomas on Computed Tomography and Magnetic Resonance Imaging After Thermocoagulation

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The Healing Pattern of Osteoid Osteomas on Computed Tomography and Magnetic Resonance Imaging After Thermocoagulation Skeletal Radiol (2007) 36:813–821 DOI 10.1007/s00256-007-0319-1 SCIENTIFIC ARTICLE The healing pattern of osteoid osteomas on computed tomography and magnetic resonance imaging after thermocoagulation Geert M. Vanderschueren & Antoni H. M. Taminiau & Wim R. Obermann & Annette A. van den Berg-Huysmans & Johan L. Bloem & Arian R. van Erkel Received: 16 December 2006 /Revised: 17 February 2007 /Accepted: 23 March 2007 / Published online: 11 May 2007 # ISS 2007 Abstract unsuccessful in 27% (23/86) of patients followed by CT. Objective To compare the healing pattern of osteoid Thermocoagulation was successful in 72% (13/18) of patients osteomas on computed tomography (CT) and magnetic followed by MRI. After treatment, the healing of the nidus on resonance imaging (MRI) after successful and unsuccessful CT was evaluated using different healing patterns (complete thermocoagulation. ossification, minimal nidus rest, decreased size, unchanged Materials and methods Eighty-six patients were examined size or thermonecrosis). On MRI the presence of reactive by CT and 18 patients by dynamic gadolinium-enhanced MRI changes (joint effusion, “oedema-like” changes of bone before and after thermocoagulation for osteoid osteoma. marrow and soft tissue oedema) and the delay time (between Thermocoagulation was successful in 73% (63/86) and arterial and nidus enhancement) were assessed and compared before and after thermocoagulation. G. M. Vanderschueren (*) Results Complete ossification or a minimal nidus rest was Department of Diagnostic Radiology, observed on CT in 58% (16/28) of treatment successes University Hospital of Ghent, De Pintelaan 185, (with > 12 months follow-up), but not in treatment Ghent 9000, Belgium failures. “Oedema-like” changes of bone marrow and/or e-mail: [email protected] soft tissue oedema were seen on MR in all patients before thermocoagulation and in all treatment failures. However, A. H. M. Taminiau “ ” Department of Orthopaedics, Leiden University Medical Center, residual oedema-like changes of bone marrow were also Albinusdreef 2, P.O. Box 9600, Leiden, RC 2300, The Netherlands found in 69% (9/13) of treatment successes. An increased e-mail: [email protected] delay time was observed in 62% (8/13) of treatment : : successes and in 1/5 of treatment failures. G. M. Vanderschueren W. R. Obermann Conclusion Complete, or almost complete, ossification of A. A. van den Berg-Huysmans : J. L. Bloem : A. R. van Erkel Department of Radiology, Leiden University Medical Center, the treated nidus on CT correlated with successful treat- Albinusdreef 2, P.O. Box 9600, Leiden, RC 2300, The Netherlands ment. Absence of this ossification pattern, however, did not W. R. Obermann correlate with treatment failure. CT could not be used to e-mail: [email protected] identify the activity of the nidus following treatment. The A. A. van den Berg-Huysmans value of MR parameters to assess residual activity of the e-mail: [email protected] nidus was limited in this study. J. L. Bloem e-mail: [email protected] Keywords Osteoma . Osteoid . Electrocoagulation . A. R. van Erkel Tomography. X-ray computed . Magnetic resonance e-mail: [email protected] imaging . Bone neoplasms 814 Skeletal Radiol (2007) 36:813–821 Introduction Table 1 Anatomical location of osteoid osteomas in relation to the treatment outcome (97 patients) Thermocoagulation is an effective and safe treatment for Location Successful treatment Unsuccessful treatment osteoid osteoma [1, 2]. The typical clinical and imaging (n=74) (n=23) features of osteoid osteoma on plain radiographs, bone scintigraphy and computed tomography (CT) have been Femur 32 10 – Tibia 13 1 described in detail [3 5]. The radiolucent nidus is best seen Pelvis 6 2 on thin slice (1 mm to 2 mm) axial CT images, because Talus 4 1 there is no overlap of surrounding reactive sclerosis and/or Humerus 3 1 periosteal reaction [3–5]. More recent papers have focused Ulna 3 1 on the appearance of osteoid osteoma on magnetic Carpus 2 2 resonance imaging (MRI), describing the morphology of Metacarpal 2 1 the nidus, the surrounding bone, and the adjacent soft Lumbar spine 2 1 Tarsal 2 1 tissues, as well as the enhancement pattern of the nidus Fibula 1 1 during dynamic MRI imaging [6, 7]. Cervical spine 1 1 The healing pattern of the nidus of osteoid osteomas has Thoracic spine 1 0 been described by Lindner et al. [8] and Martel et al. [9]. Radius 1 0 Since these imaging features have been reviewed in only Phalanx 1 0 successfully treated patients, it is unclear whether the imaging features during follow-up correlate with the clinical results of the thermocoagulation. The purpose of the initial thermocoagulation procedure (97 procedures), this study was, therefore, to compare the healing pattern of 22/23 treatment failure patients underwent a second osteoid osteomas on CT and MRI in patients after procedure. After this second procedure, two treatment failure successful and unsuccessful thermocoagulation. patients underwent an additional third thermocoagulation session (one of these patients had recurrence of pain after 44 months) and two other patients had subsequent surgery. Materials and methods Thus, a total of 121 thermocoagulation procedures was performed in our patient group of 97 patients. The clinical Patients outcome, and definitions of diagnosis and outcome, have been previously reported [1]. Anatomical location is listed The records of 110 consecutive patients diagnosed with in Table 1. Of these 97 patients 51% (49/97) had osteoid osteoid osteoma and treated with thermocoagulation be- osteomas that were located extra-articularly and 49% (48/ tween June 1994 and April 2000 were retrieved from our 97) intra-articularly. As to the location of the nidus within database. All patients gave informed consent for imaging bone, 65% (63/97) were cortical lesions, 23% (22/97) studies and treatment. Our local institutional review board endosteal lesions, 10% (10/97) were intramedullary does not require informed consent for retrospective analysis lesions and, in 2% (2/97), the location relative to the of clinical data. Thirteen patients were excluded from this cortex was not documented. analysis because of incomplete follow-up data. Four of As part of the initial diagnostic work-up of osteoid these 13 patients were excluded because of incomplete osteoma prior to thermocoagulation, 50/97 patients under- follow-up data, and nine of 13 patients were excluded went MRI, 59/97 patients underwent scintigraphy, 94/97 because of a short (fewer than 3 months) but symptom-free patients had radiographs performed and all patients under- follow-up. In the nine patients with fewer than 3 months’ went CT scanning. After the radiological diagnosis was follow-up, no further follow-up data after 3 months were made using plain radiography, CT, bone-scintigraphy and available. Of these 110 patients, 97 had complete clinical MRI, CT-guided thermocoagulation was performed under follow-up data. In these 97 patients a total of 121 regional or general anaesthesia by a radiologist and/or thermocoagulation procedures were performed. A treatment orthopaedic surgeon. The nidus was localised using incre- failure was defined as the presence of residual symptoms mental CT (Tomoscan CXQ or LX; Philips Medical persisting at least 2 weeks after thermocoagulation or Systems, Best, The Netherlands) or helical CT (Tomoscan recurrence of symptoms resembling the initial symptoms SR 7000 or AV E1; Philips Medical Systems). (pain and/or impaired function). Otherwise the treatment Through a small skin incision, the centre of the lesion was was considered successful. In 76% (74/97) of these patients engaged, initially by using a Steinmann pin (Synthes, treatment was successful, and in 24% (23/97) of patients Bettlach, Switzerland) during the first 40 procedures and treatment failed after one thermocoagulation session. After later by using a 14-gauge “Bonopty” needle system (Radi Skeletal Radiol (2007) 36:813–821 815 Medical Systems, Uppsala, Sweden) during the other 81 12 months after thermocoagulation was used to evaluate procedures. A biopsy (including cultures) was performed if this bone healing. Thermocoagulation treatment was suc- the clinical or radiographic appearance of the lesion was cessful in 63 patients (73%). In 27% (23/86) of patients atypical, in clinical practice mainly to rule out a Brodie’s thermocoagulation did not result in a significant clinical abscess. If a biopsy were needed, a needle system (Jamshidi; improvement. The 63 successfully treated patients had a Sherwood Medical, Belfast, Northern Ireland) was intro- mean CT follow-up period of 15 months (range 6–32 months) duced over the K wire of the Steinmann pin, or the after the only thermocoagulation performed, and the 23 “Bonopty” needle system drill was removed and exchanged treatment failures had a mean CT follow-up time of 10 months for a 16-gauge biopsy needle. The position of the biopsy (range 2–28 months) after the first or only thermocoagulation needle was always monitored with CT. After the biopsy performed (as mentioned before, one of 23 treatment-failure needle had been removed, a dedicated cannula and, patients had only one thermocoagulation procedure). The subsequently, a radio-frequency probe [Sluijter-Metha can- mean clinical follow-up after the only or last thermocoagula- nula (20-gauge, length 145 mm, active tip 5 mm) for tion for this group of 86 patients was 44 months (range 6– radiofrequency probe, and a radiofrequency probe, both by 81 months). In all patients the duration of the clinical follow- Radionics, Burlington, Massachusetts, USA] were intro- up was at least as long as the duration of the CT follow-up. duced through the penetration cannula. CT follow-up examination was performed by incremental or The temperature at the tip of the thermocoagulation helical CT scanning. Incremental CT scanning was performed electrode was monitored during the procedure. The lesions with a 1–2 mm slice-by-slice thickness (Tomoscan CXQ or LX; were routinely heated to 90°C for 4 min (RFG-3C FF Philips Medical Systems).
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