Osteoid Osteoma Treatment & Management

Updated: Aug 08, 2019
  • Author: Gerard Librodo, MD; Chief Editor: Harris Gellman, MD  more...
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Treatment

Approach Considerations

Initial treatment of osteoid osteoma is nonoperative. Surgical intervention is generally indicated for patients whose pain is unresponsive to medical therapy, those who cannot tolerate prolonged use of nonsteroidal anti-inflammatory drugs (NSAIDs), and those who are not amenable to activity restrictions.

Lesions in anatomically inaccessible areas, such as the femoral head and neck, result in considerable surgical morbidity, and their removal may cause complications or disability more severe than that associated with the original condition.

Other disadvantages of surgical treatment include difficulties in identifying and localizing the nidus at the time of surgery, postoperative restriction of activity that may be required after bone is removed, and an awkward anatomic location of the tumor that may require an extensive surgical approach.

Localization of lesion

Preoperative

Regardless of the method of treatment, its success highly depends on preprocedural localization of the nidus. In fact, most authors agree that exact localization of the lesion is the most important determinant of successful operative removal.

Careful radiographic imaging is necessary to plan surgical treatment. However, radionuclide scanning and computed tomography (CT) have been most helpful in localizing the tumor. Radionuclide scanning assists in the localization and diagnosis of osteoid osteoma in its early stages. It is also used in ruling out multicentric processes, which can occur in osteoid osteoma. On the other hand, CT can assist in preoperative localization, and it is useful in precise localization of the nidus in the hip or the spine.

Intraoperative

Various methods have been used for intraoperative localization and identification of osteoid osteomas to minimize bone resection and to help ensure complete excision of the tumor.

Klonecke et al reported that intraoperative scanning has evolved because of the excessively wide excision necessary in the past that had to be planned to help guarantee complete removal of the lesion. [53]  However, even with the use of frozen sections, adequate excision is not ensured.

Tetracycline fluorescence under ultraviolet (UV) light requires patients to take tetracycline before surgery (4 mg/kg body weight by mouth four times daily for 1-2 days). The difficulty of intraoperative identification of the nidus often leads to nonexcision of the lesion. Information must therefore be obtained from the excised bone with pathologic examination. If the nidus is not in the specimen, further resection of the bone is required, resulting in unnecessary and excessive removal of bone.

Intraoperative radiography can be helpful in localizing the lesion in reference to a guide pin inserted into the bone. Multiplanar fluoroscopy can help in localizing the nidus if it is in cancellous bone, where sclerotic reactions are minimal. By comparison, cortical lesions contain reactive sclerosis that may obscure the nidus, leading to incomplete removal of the lesion and resulting in recurrence.

Rinsky et al first described intraoperative radioisotope scanning for osteoid osteoma. [35]  Advantages of this approach are that it employs a a radionuclide scintillation probe that is easy to use and reliable, it minimizes bone resection, and it does not prolong surgery. It can help the surgeon and pathologist confirm resection of the tumor and localize the lesion for histologic examination. Intraoperative radioisotope scanning is the only technique that aids in verifying complete surgical excision of the lesion (success rate, 94%). Furthermore, it keeps procedural morbidity at its lowest level.

CT is helpful for precise localization of the nidus in the hip or spine. It is also helpful in precisely defining the location of the tumor and the extent of osseous involvement.

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Medical Therapy

Initial treatment of osteoid osteoma remains nonoperative, with medications consisting of aspirin or other NSAIDs. In fact, Barei et al suggested that patients with osteoid osteoma should be treated with NSAIDs if they can tolerate them, because many patients may achieve lasting pain relief with NSAIDs. [10]

The response to salicylates is not universal, however; it can vary and is therefore not as reliable a sign as it was previously thought to be. Healey et al noted improved symptoms in 73% of patients, with patients taking only aspirin 650-3250 mg/day to control pain. [22]  Kirchner et al also reported that the response to salicylates can vary, ranging from 30% to 75%. [54]  Pettine et al described substantially decreased pain with aspirin or NSAIDs, with positive responses in 90% of patients. [12]

Response to other NSAIDs, such as naproxen, has also been reported in the literature. Saville et al noted good responses to therapeutic doses of naproxen after trials with aspirin, indomethacin, ibuprofen, and fenoprofen. [55]  They noted resolution of pain after 22 months of treatment, with complete resolution of pain after 33 months. Carpintero-Benitez et al noted a good response of pain to cyclooxygenase-2 (COX-2) inhibitors, as compared with conventional NSAIDs. [56]

Several authors have suggested that because the general mechanism of action of aspirin and NSAIDs is inhibition of prostaglandin synthesis leading to pain relief, any intervention that decreases the concentration of prostaglandins in the osteoma will also decrease the related pain.

If medical management is selected, blood counts and serum chemistries should be periodically monitored in all patients. Sequential radiographs should also be obtained at 3- to 6-month intervals during treatment. Observed radiographic changes that suggest healing of the lesion are ossification of the nidus and increased bone formation around the nidus.

Most patients are unable to continue this regimen of treatment. According to Barei et al, [10] the most common reasons for treatment failure were as follows:

  • Little tolerance for ongoing pain among young, active patients, who opt for an aggressive surgical alternative
  • Initial effect of anti-inflammatory medications that diminishes over time
  • Persistent pain

Kneisl et al mentioned several contraindications for NSAID use, including sensitivity to the medications, progressive deformity of the limb, and uncertainty about the diagnosis. They added the relative contraindications of patient preference, breakthrough pain with therapeutic doses of medications, and adverse effects (including gastrointestinal toxicity, central nervous system symptoms, and dermatologic manifestations). [57]

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Traditional Open Surgical Therapy

Timing of surgery

Timing of surgery has not been an issue for osteoid osteoma anywhere in the body except for the spine.

Mehta and Murray reported that patients with scoliosis reach a critical point after which the continuing discharge of painful stimuli leads to a structural change in the spine that precludes resolution of the deformity after the tumor is removed. [58]  In their study, painful symptoms that were present during the patient's growth spurt were most likely to cause progression of the scoliosis. Furthermore, the patient's age at the onset of symptoms and the duration of symptoms were the most important determinants at this critical point.

Pettine et al observed that 15 months was the critical duration of symptoms for antalgic scoliosis to correct spontaneously after excision. [12]  In patients with symptoms lasting less than 15 months, scoliosis is decreased or completely corrected within a short time after excision alone. Age was a less important factor than symptom duration, but patients who were relatively old at the onset of symptoms and those who were young at the time of surgery were most likely to have spontaneous correction of the curve.

Surgical options

Complete surgical excision of the nidus, even if it is intralesional, is the treatment of choice for patients with osteoid osteoma in whom conservative management fails. It provides immediate relief and is usually curative. Complete surgical excision is the most predictable way to cure osteoid osteoma and should be the goal of surgical intervention. Pettine et al added that the most important determinant for successful surgical removal is exact localization of the lesion. [12]

The data from one study noted that whereas conventional excision therapy is effective and reliable, a minimally invasive approach via video-assisted endoscopy, microscopy, or percutaneous radiofrequency coagulation results in less tissue trauma and collateral damage and may be an alternative method of treatment. [59]

Campanacci et al suggested two main approaches in open surgical treatment of osteoid osteoma: wide en-bloc resection and unroofing and excision. [60]

En-bloc resection

En-bloc resection of the lesion with surrounding bone is recommended in the treatment of osteoid osteoma, but this is not always possible. The purpose is to ensure complete removal of the nidus to minimize the risk of recurrence.

Disadvantages of this procedure include excessive resection of normal bone in the effort to achieve complete excision of the lesion. The procedure is contraindicated in patients with lesions in areas difficult to access, such as the acetabulum or femoral head and neck, where it leads to substantial morbidity.

Kruger et al suggested that en-bloc excision under imaging intensification is the treatment of choice for epiphyseal lesions. [61]

Unroofing and curettage

The procedure of unroofing and curettage entails unroofing of the nidus by gradually removing the overlying reactive bone, followed by excision with curettes and burrs. It is effective and has a cure rate of 75-100%. Unroofing and curettage is especially helpful in treating lesions in a structurally vital location, such as the femoral neck, wherein the tumor is eradicated without disrupting the underlying central sclerotic bone. This approach helps maintain structural support for the area.

Prophylactic internal fixation

Healey et al reported that prophylactic internal fixation is indicated if substantial cortex is resected and if the remaining bone is weakened. [22]

Spinal fusion

Healy et al reported that spinal fusion should be performed only if instability results from excision of the lesion. [22]

Intraoperative findings and appearance

Subperiosteal lesions may be visible as a superficial deformation a few millimeters in size. Changes on the bone surface in the form of a focal increase in the diameter of the superficial bone vessels, a pink area of millimetric dimensions, or both may reveal the presence of such lesions.

Intracortical lesions are difficult to localize solely through scrutiny of the bone surface if the bone is covered by thick periosteum. However, these lesions cause extensive bone reaction that typically surrounds the nidus of the tumor.

Intra-articular or medullary types cause little or no periosteal reaction; therefore, they are difficult to identify visually.

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Minimally Invasive Surgical Therapy

Radionuclide-guided excision

The use of radionuclides in surgery started in 1949, when attempts were made to facilitate surgical treatment by taking advantage of the property of certain lesions to concentrate radiopharmaceuticals.

For radionuclide-guided excision, patients undergo bone scintigraphy at diagnosis with the use of technetium-99m-labeled hydroxymethylene diphosphonate (HMDP) and dichloromethylene diphosphonate (DMDP). Three hours before surgery, the radionuclide is given to the patient, and 1 hour after the injection, control scanning encompassing the hot spot is carried out. A radiation detector probe is then used to locate the hot spot on the basis of the signal produced. [37, 62, 63, 64, 65, 66]

This method can be used to locate the projection of the nidus with a precision of 2 mm, facilitating excision of lesions with minimal damage to normal bone. Furthermore, it can reveal the progress of the excision and the absence of residual pathologic tissue at the end of the operation. [63, 64, 65, 67, 68]

Disadvantages of this method include the narrowness and depth of the operative field, which causes difficulty in positioning the probe perpendicular to the bone surface. In addition, narrow probes can cause false-negative readings and thereby yield imprecise localization of the lesion. Also, at the end of the operation, confirmation of complete removal of the lesion is difficult because of the altered anatomy of the site. Finally, the surgeon might be unsure if the lesion is completely excised because the probe detects high radioactivity in perilesional sclerosis. [66]

CT-guided percutaneous excision

Preoperative insertion of a needle under CT guidance is important for localizing the nidus of an osteoid osteoma during surgery. Proper insertion of the needle reduces the amount of bone removed during surgery and reduces the risk of postoperative fracture. [69]  Another advantage of this procedure is immediate verification of complete removal of the nidus with histologic confirmation of the diagnosis. [43]

The technique is done with the patient under local anesthesia. It entails identification of the lesion on the CT scan. Then, with CT guidance, a Kirschner wire (K-wire) is inserted and drilled through the cortex into the nidus. A small incision is created, a biopsy punch is inserted over the K-wire, and the specimen is completely removed. Postoperative CT is performed to confirm complete evacuation of the nidus. Finally, pathologic examination is done to confirm the diagnosis.

CT-guided percutaneous resection has a success rate of 83-100%. Campanacci et al noted a primary cure rate of 83% after a percutaneous procedure, with an additional 9% cured after a second procedure; however, they reported a failure rate of 2%, with no change in pain, after percutaneous treatment. [60]

Donohue et al observed that preoperative pain resolved within 1-2 weeks after percutaneous treatment, with no clinical or radiographic evidence of recurrence at a mean follow-up of 17 months (range, 9-43 months). [70]

Engel et al studied 15 patients who underwent CT-guided percutaneous drilling and concluded that the procedure is reliable and safe, with a lower cost. [71] However, the negative points included weakening of the bone and the need to have an orthopedic surgeon, a radiologist, and an anesthetist present simultaneously in the tomography room.

Raux et al reported on 42 cases of osteoid osteoma located in the neck of the femur or the lesser trochanter that were treated by means of CT-guided percutaneous bone resection and drilling (PBRD); patients were followed for a minimum of 1 year (range, 12-56 months). [72]  In 35 cases, PBRD resulted in cure, with complete and permanent pain relief.

Complications associated with this procedure include postoperative fracture, limitation of activity and impaired weight bearing for as long as 3 months after surgery, skin burns due to high rotation speed of the instrument, muscle hematoma, irritation of adjacent nerves with transient paresis, and osteomyelitis. Sans et al noted a complication rate of 24% in this procedure. [44]

Percutaneous laser photocoagulation

Bown et al first described percutaneous laser photocoagulation in 1983. [73]  The technique entails CT-guided localization of the nidus. A bare optical fiber or fibers are inserted directly into the target tissue, followed by treatment with low levels of power or laser energy (2-4 W) for several minutes. This causes a relatively predictable area of coagulative necrosis secondary to thermal destruction of the nidus. [74, 75]

Witt et al quantified the amount of coagulation in relation to the amount of power applied over the lesion. [76]  With 2 W of constant power, the mean axial diameter of coagulation was 3.4 mm with 200 J and 9.2 mm with 1000 J; the mean longitudinal diameter of coagulation was 4 mm with 200 J and 11.1 mm with 1400 J. Maximal effect was reached with delivery of 1000-1200 J; application of more energy yielded no alteration in the area of coagulation. Complete relief of pain was noted within 24-48 hours; at 72 hours, the patients could stop taking analgesics.

Lindner et al described a primary cure rate of 93% and a 96% cure rate after the second ablation. [77]

Percutaneous radiofrequency coagulation

Percutaneous radiofrequency coagulation is performed by using an electrode placed in the lesion, coupled with a radiofrequency generator that produces local tissue destruction by converting radiofrequency current into heat.

The technique involves CT-guided insertion of a trocar, followed by application of an electrode. Electrode placement is then confirmed with CT, and after confirmation, the lesion is heated to 90°C for 4 minutes. Lesions that are larger than average are treated with two passes of radiofrequency current. [78]

Tillotson et al showed reproducible zones of necrosis of 0.9-1.3 cm in diameter when lesions were heated to 80°C. Neither varying the duration of heating from 30 seconds to 4 minutes nor increasing the size of the tip altered the area of necrosis. Furthermore, the extent of the lesion and, therefore, tissue necrosis did not increase over time (3 weeks after the procedure). [79]

Lundskog et al showed that osteocyte necrosis occurs at 50°C sustained for 30 seconds. [80] Blood flow limited heat transmission in bone; therefore, lethal temperature to the tissues could not be sustained over great distances. Microscopic examination showed hemorrhage (radius, ~5 mm) extending from the probe tract. Adjacent bone was intact, and viable cells were seen. Over the next 6 weeks, marrow fat necrosis and reactive fibrosis replaced this hemorrhage. After 6 weeks, a thin, circular rim of intramedullary reactive bone surrounded this area of fat necrosis.

Complete or nearly complete relief of pain often occurs within 3 days. Patients are sent home on the day of surgery, and they have no limitations in weightbearing, though aggressive athletics are restricted for 2-3 months. Patients may then return to normal activities immediately or within 24-48 hours after surgery. Pain resolves immediately, and limping resolves within 24 hours. Furthermore, this procedure requires only a small osseous access to allow insertion of the electrode; therefore, no substantial structural weakening of the bone occurs.

Primary cure rates are 83-94%. Cure with a second ablation procedure is approximately 100%. Rosenthal et al noted no recurrences in their patients at more than 1 year after the procedure. [81, 82]

Vanderschueren et al reported factors that decrease or increase risk of treatment failures. Advanced age (mean, 24 years) and increased number of needle positions during thermocoagulation decrease the risk of treatment failure. However, young age (mean, 20 years) and a lesion of 10 mm or larger increases the risk of treatment failure. [83]

Rehnitz et al used a questionnaire to follow-up with 72 patients who underwent CT-guided radiofrequency ablation (RFA). They concluded that the long-term outcome was excellent and that findings from CT and magnetic resonance imaging (MRI) do not always correlate with the clinical outcome. [84]

Lassalle et al, in a single-center retrospective study aimed at evaluating long-term outcomes (mean follow-up, 34.6 months; range, 3-90) of CT-guided RFA in patients with suspected osteoid osteoma, reported an overall success rate of 94.3%. [85]  Primary success was achieved in 79 of the 88 patients (89.8%), and secondary success was achieved in four (4.5%). The few complications that occurred included mild reversible peripheral nerve injury (n=2), brachial plexus neuropathy (n=1), broken electrode tip fragment (n=1), and muscular hematoma (n=1).

Perry et al reported that the use of cone-beam CT (CBCT) with two-axis fluoroscopic navigational overlay, as compared with conventional CT guidance, yielded similar technical and clinical success rates, used lower doses of radiation, and was associated with increased total room utilization time. [86]

Percutaneous radiofrequency coagulation is currently the preferred treatment for osteoid osteoma because it does not require hospitalization, is not associated with complications, and is associated with rapid convalescence.

The main disadvantages of this procedure are recurrence or persistence of the osteoid osteoma and the lack of histologic verification. Recurrent lesions can be managed with repeat percutaneous RFA, but lesions should be confirmed histologically by means of needle biopsy before ablation. [87, 88]  Lesions that are resistant to percutaneous RFA can easily be treated with open surgery. Another complication is local skin burns.

Computer-assisted surgery

Computer-assisted surgery is a collection of techniques in which imaging and the use of three-dimensional (3D) tracking devices are combined to improve surgical performance. This surgery is based on initial diagnostic CT scans that are processed into 3D images. The volume or surface is then extracted to produce a computational model of the anatomy. [70, 78, 89]

The technique entails intraoperatively registering the patient to the preoperative image by determining a rigid-body transformation. Optical trackers mounted on modified surgical instruments are attached to the patient to allow intraoperative tracking with an optical system. Given the transformation between patient and image, the computer displays the 3D location and orientation of an instrument by superimposing a graphical representation of the instrument on the preoperative computer-generated image.

The advantage of this technique is that it can provide precise and accurate localization of lesions in bone. It is useful for small lesions located deep in the cortical bone, in which where there may be no surface changes to guide the surgeon or there may be only very subtle surface changes. The procedure is conducted without fluoroscopy; fluoroscopy is used only at the completion of the operation to document bone-tunnel placement. The percutaneous technique can be used in tandem with this procedure.

Magnetic resonance–guided focused ultrasound

Magnetic resonance–guided focused ultrasound (MRgFUS) is a novel imaging-guided surgical technique that allows the performance of noninvasive and radiation-free ablation. In a prospective multicenter study by Geiger et al, 29 patients with a nonspinal osteoid osteoma were treated with MRgFUS. [90]  At 12-month follow-up, technical success was achieved in all cases: complete clinical success in twenty-six (90%) and partial success in three (10%). No complications were observed.

A small safety and feasibility clinical trial by Yarmolenko et al found that this approach appeared to be both feasible and safe in children with painful osteoid osteoma. [91]

Arthroscopy

Osteoid osteomas that occur intra- or juxta-articularly are often more difficult to treat by means of open surgery or RFA. Accordingly, some have described the use of arthroscopy to treat such lesions at the knee and ankle. [92, 93]

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Complications

Open surgery

En-bloc surgical resection of the tumor can lead to the following:

  • Extended hospital stay
  • Perioperative fractures
  • Need for bone grafts, internal fixation, or both
  • Periarticular stiffness
  • Delayed functional recovery

About 9-28% of osteoid osteomas recur after surgical extirpation, the rate of local recurrence being inversely proportional to the aggressiveness of the surgery. Healey et al noted that intralesional resection or curettage had the highest recurrence rate and that en-bloc resection had the lowest rate. [22]  Several authors linked this finding to incomplete removal of the nidus. Recurrence is typically observed within 1 year after excision; hence, the patient should be monitored for a minimum of 1 year.

Proper preoperative and intraoperative localization of the tumor is critical to ensure adequate resection of the tumor and minimize the likelihood of recurrence. The use of these techniques dramatically reduce the recurrence rate.

Failure to relieve pain is associated with a bad prognosis, and it most probably indicates incomplete removal of the tumor. Rosenthal et al noted persistence of symptoms in 30% of cases. [81, 82]

Minimally invasive surgery

Incomplete resection is a real complication of minimally invasive procedures. Roger et al observed incomplete resection in 35.7% of patients, as assessed by immediate follow-up scintigraphy following CT-guided percutaneous excision. [94] These patients needed an immediate second resection to extirpate the lesion and relieve pain.

Recurrence is frequently linked to incomplete resection of the tumor. Rosenthal et al [81, 82]  and Barei et al [10]  noted a 12% recurrence rate in patients who underwent percutaneous radiofrequency ablation (RFA). This rate was not significantly different from that associated with surgical excision of the nidus. Atar et al stated that this was also the case with CT-guided percutaneous excision. [25]  Rosenthal et al noted that in 23% of patients, symptoms persisted following percutaneous RFA. This was significantly lower than the 30% rate associated with operative excision. [81, 82]

Other complications associated with CT-guided RFA have included skin burns, skin infections, hematomas, and fractures. [95]

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