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Osteoid Osteoma

Osteoid Osteomas

Osteoid osteoma is a benign tumor of the skeletal system which primarily targets younger individuals, and most commonly develops in long bones. Clinical presentation involves intense localized pain, which is often not relieved by analgesics. Diagnosis can be made by imaging studies such as CT scanning, and permanent effective treatment can be achieved through percutaneous surgical techniques.


Presentation

The classical clinical presentation of patients with osteoid osteoma involves the presence of localized pain (at the site of the tumor), and it is described as continuous, deep, and intense [10]. Depending on the localization of the tumor, patients may report pain in their arms [11], legs, feet, or hands in rare cases. In the majority of patients, pain is intensified during night time, and can sometimes wake the patient up, while other symptoms, such as restricted range of motion or local swelling may be observed. This tumor can present as arthritis in cases of phalangeal or wrist involvement [12], as well as macrodactyly and clubbing [13] [14]. In rare cases, if the tumor is located near the growth plate, limb overgrowth and discrepancy may be observed in young children. Sometimes the pain is considered to be of different origin, especially since this tumor occurs in teenagers and young adults, in whom pain can be prescribed to growth or some form of trauma, which can delay the diagnosis for weeks, and possibly years.

Physical examination will highly likely reveal the location of the tumor, and atrophy of surrounding muscles may be observed in patients who are experiencing severe pain, which can cause muscle misuse.

Increased Energy
  • One patient had a recurrence of symptoms after 2 wk and underwent a new successful treatment with increased energy levels.[ncbi.nlm.nih.gov]
Increased Sweating
  • Symptoms and Presentation Symptoms include dull pain, increase in skin temperature, increased sweating and tenderness.[bonetumor.org]
Back Pain
  • The possibility of osteoid osteoma should be kept in mind when examining adolescents with low back pain.[ncbi.nlm.nih.gov]
  • In this case report, we presented an unusual case of lumbar osteoid osteoma in a 38-year-old male, who experienced low back pain and sciatica as initial symptoms.[ncbi.nlm.nih.gov]
  • The patient, a young male athlete, presented with severe chronic nightly left low-back pain radiated to the ipsilateral lower extremity who failed to respond to physical therapy and analgesic medications.[ncbi.nlm.nih.gov]
  • Lateral view of the lumbar spine in a 52-year-old man who had a biopsy-proven giant osteoid osteoma (osteoblastoma) and who presented with severe low back pain.[emedicine.medscape.com]
  • A 33-year-old man with back pain View Case[ajnr.org]
Bone Pain
  • Osteoid osteomas are benign bone lesions that present with bone pain in children and young adults. Over the last 2 decades, radiofrequency ablation has become the mainstay of treatment and is now preferred over surgical resection.[ncbi.nlm.nih.gov]
  • OBJECTIVES: To assess the efficacy of bisphosphonate therapy on bone pain in patients with osteoid osteoma (OO) (main objective), and to describe bisphosphonate-induced changes in nidus mineralisation and regional bone-marrow oedema (BMO).[ncbi.nlm.nih.gov]
  • CONCLUSION Osteoid osteoma is a relatively common benign bone lesion in children and young adults that can present with nontraumatic bone pain. Depending upon the location of the lesion, it may be difficult to diagnosis.[appliedradiology.com]
  • The nidus causes considerable pain and can often provoke reactive sclerosis in contagious tissue of the host bone.[jomfp.in]
  • Bone scan – a nuclear imaging method to evaluate any degenerative and/or arthritic changes in the joints; to detect bone diseases and tumors; to determine the cause of bone pain or inflammation.[web.archive.org]
Thigh Pain
  • Osteoid osteoma is a disease that need to be considered to differential diagnosis in pediatric patients with chronic thigh pain. Keywords : Osteoma, osteoid; bone neoplasms 1. TERMS OF USE 1.1.[turkiyeklinikleri.com]
Osteopenia
  • Regional osteoporosis may appear as an area of osteopenia around a joint. With spinal involvement, alignment abnormalities may be obvious, such as scoliosis, kyphosis, or hyperlordosis.[emedicine.medscape.com]
  • […] intramedullary-located osteoid osteomas may not exhibit surrounding bone sclerosis. 14 Indirect manifestations of synovial inflammation and joint effusion may be evident, or symptoms that mimic osteoarthritis may be present. 13,15 When treatment is delayed, secondary osteopenia[healio.com]
Monoarthritis of the Knee
  • Herein we report the case of a girl who presented with chronic monoarthritis of the knee mimicking JIA. After 1 year, OO of the femoral distal metaphysis was diagnosed.[ncbi.nlm.nih.gov]
Neglect
  • In neglected cases, it may also present as growth disturbance, scoliosis, osteoarthritis, and if located within the capsule of a joint, swelling, synovitis, restricted movement, and contracture.[ijri.org]
Unable to Walk
  • She was then referred to our hospital approximately 1 year after first symptom presentation, where she presented with severe left hip pain and was completely unable to walk.[ncbi.nlm.nih.gov]
Forgetful
  • Minimally invasive surgical techniques have recently emerged but orthopaedic surgeons must not forget that open excision remains the most safe and documented method for pediatric foot osteoid osteomas. Copyright 2015 European Foot and Ankle Society.[ncbi.nlm.nih.gov]

Workup

Clinical examination, as well as patient history, should point to a localized issue of the musculoskeletal system, and in all cases, imaging techniques are required to establish the diagnosis. Usually, a radiolucent area between 1-2 cm in diameter can be observed on plain X-ray, which can be surrounded by a halo ring that occurs as a result of bone sclerosis and cortical hypertrophy, which are hallmarks of osteoid osteoma. However, subperiosteal lesions may not be apparent, while both epiphyseal and metaphyseal lesions can show minimal or no sclerosing changes around the nidus, which is why CT scanning is recommended as the imaging technique of choice - to obtain a better view of the soft tissues, to exclude the presence of other types of tumors, and to serve as a guide to excision [15]. CT is superior to MRI, while radionuclide bone scanning with technetium-99m can be performed, since osteoid osteoma causes an uptake of isotope activity [16].

The definite diagnosis is achieved through a biopsy, which can be performed percutaneously, although results can be obtained in only 50% of the cases when samples through percutaneous techniques are obtained. For these reasons, a combination of clinical symptoms, as well as radiographic findings, is the key in order to diagnose osteoid osteoma. It is important to distinguish this benign bone tumor from other potentially debilitating, or sometimes life-threatening bone and joint illnesses such as osteomyelitis, arthritis, stress fractures, or osteoblastoma, which is also a benign tumor, and has almost identical features as osteoid osteoma.

Soft Tissue Calcification
  • We describe a case of an osteoid osteoma of the scaphoid bone associated with calcific tendinitis of the adjacent flexor carpi radialis tendon and periarticular soft tissue calcifications in a 21-year-old man presenting with radial-sided wrist pain.[ncbi.nlm.nih.gov]

Treatment

Treatment strategies include pain-relieving therapy and localized surgical techniques to remove the tumor.

NSAIDs are the drugs of choice for the management of pain caused by osteoid osteoma, such as aspirin, presumably through inhibition of prostaglandin synthesis. Contraindications for use of NSAIDs exist, such as peptic ulcer disease, and for most patients, the pain becomes too intense and chronic [17], in which case other forms of treatment are necessary. However, pain management with NSAIDs can significantly defer surgical treatment.

Surgical excision of the nidus is the treatment of choice for patients in whom NSAIDs are insufficient. Localized percutaneous techniques provide immediate relief, and are curative in the vast majority of cases, with very low rates of recurrence. Curettage and unroofing of the nidus encompasses the gradual removal of the overlying bone that is covering the central part of the tumor and its subsequent removal. This procedure is preferred for patients whose tumor is located in more complicated locations, such as the femoral neck, and can help maintain structural support for the area, without disrupting the underlying bone.

In the majority of cases, however, radiofrequency ablation is the treatment of choice, through heat production and use of energy current, and has a very high rate of success [18]. Open surgery is reserved for patients in whom percutaneous techniques are not possible, for ex. if the tumor is in close proximity to other important structures (Such as the spinal canal, tumors that are located in hands, wrists, or feet), or because heat caused by ablation may damage the surrounding structures.

Prognosis

The prognosis of osteoid osteoma is good, since this tumor presents as a solitary lesion, has a relatively small diameter, and poses no metastatic potential. Treatment can be delayed, sometimes significantly, through the use of NSAIDs, but curative rates are very high with excision and localized percutaneous techniques, with the most effective one being radiofrequency ablation.

Etiology

Osteoid osteoma is a benign bone-forming tumor that histologically appears as interlacing trabeculae of woven bone [6]. It is still unknown what the cause of the tumor is, and why are young adults in their second and third year most commonly affected.

Epidemiology

This benign tumor comprises between 8-10% of all symptomatic benign bone tumors, and about 5% of all primary bone tumors. Osteoid osteoma is most commonly diagnosed in teens and young adults (between 10 and 30 years), but it can affect individuals of any age, while about 3% of cases occur in children younger than 5 years [7]. It is established that male individuals are more commonly affected, with a 2-3:1 ratio, while a racial predilection of this tumor has not been observed.

Sex distribution
Age distribution

Pathophysiology

Osteoid osteoma is a tumor that usually involves the cortex of the bone, and is characterized by a central area called the nidus, which can potentially become sclerotic and mineralized, while the surrounding structures include interlacing trabeculae of woven bone and osteoblasts, as well as vascular connective tissue.

The pathogenesis of this tumor is still not completely understood, and several theories have been proposed, such as an inflammatory process (intracellular viral particles were observed on electron microscopy). The pain that is present in patients with this tumor includes generation of prostaglandins (which can account for intensifying pain during night time because of increased activity of prostaglandins during the night) [8], bradykinin, as well as vasodilation and edema, all contributing to stimulation of intraosseous nerve endings [9].

Prevention

Having in mind the fact that the cause of this tumor is unknown, there is little to be done in terms of prevention, but it is a relatively benign lesion that can be successfully managed, and poses no threat for the patient.

Summary

Initially described in the 1930s [1], osteoid osteoma is a benign bone tumor, usually between 1.5-2 cm in diameter, that is characterized by a radiolucent central area - the nidus, and surrounding sclerosing bone, as well as loose vascular, connective and adipose tissue. It most commonly develops in young adults, usually in their second and third decades of life, with a 2:1 predilection towards the male gender, for unknown reasons [2]. It usually appears in the long bones, with the most common sites being the tibia and proximal femur [3], while other sites include the phalanges, bones of the foot, and the vertebrae. Clinical presentation almost universally involves the presence of intense localized pain that intensifies at night. The diagnosis is achieved through imaging techniques, such as plain radiography or computed tomography (CT), while magnetic resonance imaging (MRI) can also be used, while radionuclide scanning can be effective in distinguishing osteoid osteoma from other tumors of the skeletal system [4]. This benign tumor does not metastasize, and is usually treated by percutaneous techniques, such as local excision, curettage, or radiofrequency ablation, while open surgery is rarely indicated. Non-steroidal anti-inflammatory drugs (NSAIDs) can be helpful in relieving pain, and surgical treatment may be replaced through the use of these medications, as the tumor does not pose a threat to the patient [5].

Patient Information

Osteoid osteoma is a small benign solitary tumor of the bones which occurs in individuals during their second and third decade of life, and is diagnosed more frequently in males. It is still not known why this tumor appears. It usually develops in the bones of the lower extremities, but it can appear on any bone in the body, including the arms, hands, feet, and the spine. Virtually all patients report severe localized pain at the site of the tumor, because the central part of the tumor - the nidus - produces intense pain. The majority of patients describe the pain as sharp, intense, and more often during the night, which may even wake up the patient. Limb asymmetry and unequal growth may be observed if the tumor is located inside the growth plate, while muscle atrophy can occur in patients who avoid using their extremity because of severe pain.

The diagnosis of osteoid osteoma is made based on findings made during the clinical examination, and imaging techniques. A plain X-ray may reveal the tumor, while computed tomography (CT scan) is the recommended imaging technique, because it can provide a good view of the bone and surrounding soft tissues. Once the diagnosis is made, treatment principles primarily include pain relieving, through the use of non-steroidal anti-inflammatory drugs, such as aspirin, which can defer other forms of therapy for a prolonged period of time. However, since the majority of patients cannot tolerate pain even with appropriate medication, certain types of minimally invasive surgical techniques are performed, usually under local anesthesia. Excision of the tumor can provide permanent relief, and rates of recurrences are minimal. This tumor is benign in origin, has no potential to become malignant and metastasize, and can be successfully treated.

References

Article

  1. Bergstrand H. Uber eine eigenartige, warscheinlich bisher nicht beschriebene osteoblastische Krankheit in den langen Knochen in der Hand und des Fusses. Acta Radiol. 1930;11:596-613.
  2. Gonzalez G, Abril JC, Mediero IG, Epeldegui T. Osteoid osteoma with a multicentric nidus. Int Orthop. 1996;20(1):61-3.
  3. Greenspan A. Benign bone-forming lesions: osteoma, osteoid osteoma, and osteoblastoma. Clinical, imaging, pathologic, and differential considerations. Skeletal Radiol. 1993;22(7):485-500.
  4. Iceton J, Rang M. An osteoid osteoma in an open distal femoral epiphysis. A case report. Clin Orthop Relat Res. 1986;162-5. 
  5. Marcove RC, Heelan RT, Huvos AG, et al. Osteoid osteoma. Diagnosis, localization, and treatment. Clin Orthop Relat Res. 1991;197-201.
  6. Assoun J, Richardi G, Railhac JJ, LeGuennec P, Caulier M, Dromer C, et al. Osteoid Osteoma: MR imaging versus CT. Radiology. 1991;91:217–223,4.
  7. Frassica FJ, Waltrip RL, Sponseller PD, et al. Clinicopathologic features and treatment of osteoid osteoma and osteoblastoma in children and adolescents. Orthop Clin North Am. 1996;27(3):559-74.
  8. Healey JH, Ghelman B. Osteoid osteoma and osteoblastoma. Current concepts and  recent advances. Clin Orthop Relat Res. 1986;(204):76-85.
  9. Golding JS. The natural history of osteoid osteoma; with a report of twenty cases. J Bone Joint Surg Br. 1954;36-B(2):218-29.
  10. Cohen MD, Harrington TM, Ginsburg WW. Osteoid osteoma: 95 cases and a review of the literature. Semin Arthritis Rheum. 1983;12(3):265-81.
  11. Bednar MS, McCormack RR Jr, Glasser D, Weiland AJ. Osteoid osteoma of the upper extremity. J Hand Surg Am. 1993;18(6):1019-25.
  12. Marcuzzi A, Acciaro AL, Landi A. Osteoid osteoma of the hand and wrist. J Hand Surg Br. 2002;27(5):440-3.
  13. Garcia-Vivar ML, Galindez E, Arostegui J, et al. Chronic monoarthritis caused by osteoid osteoma [in Spanish]. An Med Interna. 1996;13(7):344-6.
  14. Burger IM, McCarthy EF. Phalangeal osteoid osteomas in the hand: a diagnostic problem. Clin Orthop. 2004;427:198-203.
  15. Atar D, Lehman WB, Grant AD. Tips of the trade. Computerized tomography--guided excision of osteoid osteoma. Orthop Rev. 1992;21(12):1457-8.
  16. Rinsky LA, Goris M, Bleck EE, et al. Intraoperative skeletal scintigraphy for localization of osteoid-osteoma in the spine. Case report. J Bone Joint Surg Am. 1980;62(1):143-4.
  17. Barei DP, Moreau G, Scarborough MT, Neel MD. Percutaneous radiofrequency thermal ablation of osteoid osteoma. Operative Tech Orthop. 1999;9(2):72-8.
  18. Donkol RH, Al-Nammi A, Moghazi K. Efficacy of percutaneous radiofrequency ablation of osteoid osteoma in children. Pediatr Radiol. 2008;38(2):180-5.

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Last updated: 2019-06-28 12:11