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Thoracic spine osteoid osteoma
European Journal of Radiology Extra 46 (2003) 74 /77 http://intl.elsevierhealth.com/journals/ejrx
Thoracic spine osteoid osteoma Kamel Bahloul a, Artur Xhumari a, Antoine Feydy b, Michel Kalamarides a, Aime´e Redondo a,*, Alain Rey a a
Department of Neurosurgery, Hoˆpital Beaujon, AP-HP, Faculte´ Xavier Bichat, Universite´ Paris 7, 92110 Clichy, France b Department of Radiology, Hoˆpital Beaujon, AP-HP, Faculte´ Xavier Bichat, Universite´ Paris 7, 92110 Clichy, France Received 15 May 2002; received in revised form 14 August 2002; accepted 19 August 2002
Abstract A case report of an adult patient with an osteoid osteoma of the lamina of 9th thoracic vertebra is presented. The long history of progressively worsening nocturnal dorsal pain which was relieved by non-steroid anti-inflammatory drugs, and an essentially clinical examination, are typical of this condition in which the CT and radionuclide bone scans are the investigation of choice. Complete relief was obtained following excision of the lesion. The literature is reviewed. # 2002 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Osteoid osteoma; Spine tumour; Back pain
1. Introduction Osteoid osteoma is a benign bony lesion, reported in virtually every bone in the human body. This tumour is rarely located on the spine. Pain is the most common symptom associated with scoliosis. Radionuclide bone scans and CT scans are useful to identify and precisely locate the nidus. Complete relief is obtained following total excision.
2. Case report This 27-year-old woman, without any previous medical history, started to complain of a dorsal pain with hemithoracic irradiation 1 month after her delivery in May 1997. Pain became progressively worse and began to affect her sleep pattern. The physical and neurologic examinations were unremarkable. Findings of routine laboratory studies, including a complete blood count with differential and limited chemistry panel, were within normal limits. The pain work-up was completed with a technetium 99 bone
* Corresponding author. Tel.: /33-1-40-87-51-16; fax: /33-1-4739-66-35 E-mail address: [email protected] (A. Redondo).
scan (Fig. 1) which showed a focus of fixation at the junction between the lamina and the facet at the Th9 level and a CT scan (Fig. 2) which demonstrated at the same level a ring-like image surrounded by dense reactive bone on the whole pedicle. These findings evoked an osteoid osteoma. As the patient complained of persisting pain not relieved by the medications, surgery was planned on March 2001. Using a unilateral intermyolaminar approach and under X-ray control we removed the lamina and articular facets at Th9 level. Pain disappeared as soon as the patient awakened from anaesthesia. The histological patterns were typical of an osteoid osteoma.
3. Discussion Osteoid osteoma were first described by Jaffe in 1935 as a true neoplasm, and histologically as a dense sclerotic overgrowth of bone, with a highly vascularised nidus consisting chiefly of fibrous tissue containing varying amounts of lymphocytic infiltration [1]. In a series of 8452 osseous tumours reported by Dahlin and Vnni [2], osteoid osteoma comprise 12% of the benign osseous tumours. Osteoid osteomas have been reported in virtually every bone in the human body, occurring
1571-4675/03/$ - see front matter # 2002 Elsevier Science Ireland Ltd. All rights reserved. doi:10.1016/S1571-4675(03)00050-6
K. Bahloul et al. / European Journal of Radiology Extra 46 (2003) 74 /77
75
Fig. 1. Bone scintigraphy reveal Th9 increased uptake.
most commonly in the femur (27.33%) and tibia (22.1%). Approximately 10% of all osteoid osteomas occur in the spine [1 /6], with 52% of these in the lumbar region, 25% in cervical, 17% in thoracic and exceptionally in the sacrum (5%) [1]. Generally only one vertebra is pathologic and mainly the posterior segment, i.e. lamina, spinous process, articular facets, transverse process, even pedicle. The localisation on a vertebral body is encountered in 10% of cases. A few cases of multiple osteoid osteomas on the same vertebra have been reported at Th7 [7] and at Th5 level [2]. This tumour is more frequent in childhood, teenagers and young adults. In the series of Jackson et al. [4], of 860 osteoid osteomas, 87% of patients are less than 25 years old. A few cases have been reported in patients beyond 60 [8]. There is a male predominance. Our case is consistent with most cases of the literature, concerning young man with localisation on the posterior segment. The pathogenesis of osteoid osteoma is still unclear [2]. The latency between the onset of symptoms and diagnosis is rather long; nearly 2 years in 80% of cases. The most striking symptom in usually localised spine pain with nocturnal paroxysm, lasting for months or years. This pain responds to AINS treatment. In 70% of cases [9] scoliosis is centred on the pathological process, which is due to contracture of the para-vertebral muscles and depends upon the localisation of the osteoma. The dorsal or the lumbar regions are more frequently concerned than the cervical one. Radicular pain is rare; in our patient it was the first symptom. Exceptionally the osteoid osteoma may act as a spinal cord compressive lesion. In the standard X-ray owing to the overlap of anatomical features osteoid osteomas may be difficult
to visualise. CT scan is the investigation of choice showing a small osteolytic lesion (B/1.5 cm in diameter) with a dense sclerotic ring which has in some cases (20 / 30%) central calcifications. Osteoid osteoma may be even completely calcified. Radionuclide bone scanning shows a hyper intense focus even in the very beginning of the clinical history. MRI may not be diagnostic for the appearance depends on the amount of calcification within the nidus, the size of the fibrovascular zone, reactive sclerosis and the amount of oedema in the bone [10]. However in case of radicular pain MRI is often performed at first to search for a disk disease. The presence of bone marrow and soft tissues changes are characterised by low signal on T1-weighted sequence, high signal on T2 and enhancement after gadolinium IV administration. These changes are not specific [11,12]. The pathology makes the definite diagnosis. Macroscopically the lesion is reddish, round or oval shaped, and of soft consistency. It is highly vascular. Microscopically this lesion is characterised by a hypervascularized stroma with osteoid boundary and calcifications in some instances. The main differential diagnosis is osteoblastoma which although sharing identical histological features with osteoid osteomas, differs in size (/20 mm), behaviour (locally invasive with destructive potential and enlarging) and recurrence rate (higher). Treatment is necessary when an osteoid osteoma is suspected even if few spontaneous cures have been reported. Aspirin or other NSAIDs have a dramatic but not long-lasting effect on pain. The surgical treatment is advocated as the treatment of choice. The purpose is to perform a total removal of the nidus, which needs in some cases removal of half the posterior segment; this was what we did in our case.
76
K. Bahloul et al. / European Journal of Radiology Extra 46 (2003) 74 /77
Fig. 2. (a) CT scan: Axial view showing a well delimited lesion at the junction between the lamina and the facet of right T9; (b) CT scan: Sagittal view showing a ring-like image surrounded by dense reactive bone on the whole T9 pedicle.
The peroperative localisation may not be easy; in a few cases the accurate localisation of the nidus has been possible under control of evoked potentials [13] or with a per operative scintigraphy with a portable camera, 2 or 3 h after intravenous injection of labelled technetium. Another alternative treatment is the percutaneous curettage of the nidus under CT control with local anaesthesia; the nidus is removed by curettage with a 7 mm biopsy needle. Percutaneous CT-guided thermo-coagulation has also been proposed: a radio- frequency thermode is directed percutaneously to the nidus. In this technique a hole was first cut into the bone with a cutter and a few biopsy specimens can be obtained, and a small radiofrequency electrode can be introduced into the bone through the
biopsy track. Sufficient current is used to heat the electrode tip to 85/90 8C with consequent thermal necrosis of the tissue. The heating is continued for 6 min. These different techniques allow a mini invasive technique and are of interest if the tumour is difficult to approach surgically. CT guided percutaneous radio-frequency ablation achieves the same clinical outcomes as the operative excision with significantly lower costs (pain relief was noted to occur very rapidly in 100% of cases) [17]. Following total removal, permanent cure is obtained and rapid recovery is documented in most of the series. Regrowth is due to incomplete removal rather than multiple nidus [3,14 /16]. X-ray control is mandatory coupled in certain cases with scintigraphy.
K. Bahloul et al. / European Journal of Radiology Extra 46 (2003) 74 /77
References [1] Guy G, Jan M, Lemonnier P, Rabehenoinia Ch, Mercier Ph. Oste´omes oste´oides rachidiens. A propos de 4 observations. Neurochirurgie 1989;35:41 /6. [2] Dahlin DC, Unni KK. In: Charles CT, editor. Bone tumors. General aspects and data on 8542 cases, 4th ed. Illinois: Springfield, 1986. [3] Blery M, Leroux B. Oste´ome oste´oide verte´bral. Ann Radiol 1978;21:59 /63. [4] Jackson RP, Reckling FW, Mantz FA. Osteoid osteoma and osteoblastoma. Similar histologic lesions with different natural histories. Clin Orthop 1977;128:303 /13. [5] Kattapuram SV, Kusher DC, Phillips WC, Rosental DI. Osteoid osteoma an unusual cause of articular pain. Radiology 1983;147:383 /7. [6] Maiuri F, Signorelli C, Lavano A, Gambarbella A, Simari R, D’Andrea F. Osteoid osteoma of the spine. Surg Neurol 1986;25:375 /80. [7] Calderoni P, Gusella A, Martucci E. Multiple osteoid osteoma in the 7th dorsal vertebral. Ital J Orthop Traumatol 1984;10:257 /60. [8] Capanna R, Boriani S, Mabit S, Donnati D, Savini R. L’oste´ome oste´oı¨de de localisation rachidienne. Revue de chirurgie orthope´dique 1991;77:545 /50. [9] Keim HA, Reina EG. Osteoid osteoma as a cause of scoliosis.
77
J Bone Joint Surg 1975;57:159 /63. [10] Hermann G, Abdelwaheb F, Casden A, Mosesson R, Klein MJ. Osteoid osteoma of a cervical vertebral body. Br J Radiol 1999;72:1120 /3. [11] Ben Abdallah N, Sarrazin JL, Soulie D, Cosnard G. Osteoid osteoma, neuralgia and MRI. J Radiol 1996;77:133 /6. [12] Assoun J, Richardi G, Railhac JJ, Baunin C, Fajadet P, Giron J, et al. Osteoid osteoma: MR imaging versus CT. Radiology 1994;191:217 /23. [13] Balasubramanian E, Keim HA, Hajdu M. Osteoid osteoma of the thoracic spine with surgical decompression aided by somatosensory evoked potentials. Spine 1985;10:396 /8. [14] Baunin C, Puget C, Assoun J, Railhac, Cahuzac, Clement JL. Sale de Gauzy. Percutaneous resection of osteoid osteoma under CT guidance in eight children. J Ped Radiol 1994;24:185 /8. [15] Jos A, Cove MD, Antoine H, Taminiau MD, Williem R, Obermann M, et al. Osteoid osteoma of the spine treated with percutaneous computed tomography */guided thermocoagulation. Spine 2000;10:1283 /6. [16] Osti OL, Sebben R. High-fre´quency radio-ware ablation of osteoid osteoma in the lumbar spine. Eur Spine J 1998;7:422 /5. [17] Gallazi MB, Arborio G, Garbana PG, Perruchini G, Dalio PA. Percutaneous radio-frequency ablation of osteoid osteoma: technique and preliminary results. Radiol Med 2001;102(5 /6):329 / 34.
Thoracic spine osteoid osteoma Kamel Bahloul a, Artur Xhumari a, Antoine Feydy b, Michel Kalamarides a, Aime´e Redondo a,*, Alain Rey a a
Department of Neurosurgery, Hoˆpital Beaujon, AP-HP, Faculte´ Xavier Bichat, Universite´ Paris 7, 92110 Clichy, France b Department of Radiology, Hoˆpital Beaujon, AP-HP, Faculte´ Xavier Bichat, Universite´ Paris 7, 92110 Clichy, France Received 15 May 2002; received in revised form 14 August 2002; accepted 19 August 2002
Abstract A case report of an adult patient with an osteoid osteoma of the lamina of 9th thoracic vertebra is presented. The long history of progressively worsening nocturnal dorsal pain which was relieved by non-steroid anti-inflammatory drugs, and an essentially clinical examination, are typical of this condition in which the CT and radionuclide bone scans are the investigation of choice. Complete relief was obtained following excision of the lesion. The literature is reviewed. # 2002 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Osteoid osteoma; Spine tumour; Back pain
1. Introduction Osteoid osteoma is a benign bony lesion, reported in virtually every bone in the human body. This tumour is rarely located on the spine. Pain is the most common symptom associated with scoliosis. Radionuclide bone scans and CT scans are useful to identify and precisely locate the nidus. Complete relief is obtained following total excision.
2. Case report This 27-year-old woman, without any previous medical history, started to complain of a dorsal pain with hemithoracic irradiation 1 month after her delivery in May 1997. Pain became progressively worse and began to affect her sleep pattern. The physical and neurologic examinations were unremarkable. Findings of routine laboratory studies, including a complete blood count with differential and limited chemistry panel, were within normal limits. The pain work-up was completed with a technetium 99 bone
* Corresponding author. Tel.: /33-1-40-87-51-16; fax: /33-1-4739-66-35 E-mail address: [email protected] (A. Redondo).
scan (Fig. 1) which showed a focus of fixation at the junction between the lamina and the facet at the Th9 level and a CT scan (Fig. 2) which demonstrated at the same level a ring-like image surrounded by dense reactive bone on the whole pedicle. These findings evoked an osteoid osteoma. As the patient complained of persisting pain not relieved by the medications, surgery was planned on March 2001. Using a unilateral intermyolaminar approach and under X-ray control we removed the lamina and articular facets at Th9 level. Pain disappeared as soon as the patient awakened from anaesthesia. The histological patterns were typical of an osteoid osteoma.
3. Discussion Osteoid osteoma were first described by Jaffe in 1935 as a true neoplasm, and histologically as a dense sclerotic overgrowth of bone, with a highly vascularised nidus consisting chiefly of fibrous tissue containing varying amounts of lymphocytic infiltration [1]. In a series of 8452 osseous tumours reported by Dahlin and Vnni [2], osteoid osteoma comprise 12% of the benign osseous tumours. Osteoid osteomas have been reported in virtually every bone in the human body, occurring
1571-4675/03/$ - see front matter # 2002 Elsevier Science Ireland Ltd. All rights reserved. doi:10.1016/S1571-4675(03)00050-6
K. Bahloul et al. / European Journal of Radiology Extra 46 (2003) 74 /77
75
Fig. 1. Bone scintigraphy reveal Th9 increased uptake.
most commonly in the femur (27.33%) and tibia (22.1%). Approximately 10% of all osteoid osteomas occur in the spine [1 /6], with 52% of these in the lumbar region, 25% in cervical, 17% in thoracic and exceptionally in the sacrum (5%) [1]. Generally only one vertebra is pathologic and mainly the posterior segment, i.e. lamina, spinous process, articular facets, transverse process, even pedicle. The localisation on a vertebral body is encountered in 10% of cases. A few cases of multiple osteoid osteomas on the same vertebra have been reported at Th7 [7] and at Th5 level [2]. This tumour is more frequent in childhood, teenagers and young adults. In the series of Jackson et al. [4], of 860 osteoid osteomas, 87% of patients are less than 25 years old. A few cases have been reported in patients beyond 60 [8]. There is a male predominance. Our case is consistent with most cases of the literature, concerning young man with localisation on the posterior segment. The pathogenesis of osteoid osteoma is still unclear [2]. The latency between the onset of symptoms and diagnosis is rather long; nearly 2 years in 80% of cases. The most striking symptom in usually localised spine pain with nocturnal paroxysm, lasting for months or years. This pain responds to AINS treatment. In 70% of cases [9] scoliosis is centred on the pathological process, which is due to contracture of the para-vertebral muscles and depends upon the localisation of the osteoma. The dorsal or the lumbar regions are more frequently concerned than the cervical one. Radicular pain is rare; in our patient it was the first symptom. Exceptionally the osteoid osteoma may act as a spinal cord compressive lesion. In the standard X-ray owing to the overlap of anatomical features osteoid osteomas may be difficult
to visualise. CT scan is the investigation of choice showing a small osteolytic lesion (B/1.5 cm in diameter) with a dense sclerotic ring which has in some cases (20 / 30%) central calcifications. Osteoid osteoma may be even completely calcified. Radionuclide bone scanning shows a hyper intense focus even in the very beginning of the clinical history. MRI may not be diagnostic for the appearance depends on the amount of calcification within the nidus, the size of the fibrovascular zone, reactive sclerosis and the amount of oedema in the bone [10]. However in case of radicular pain MRI is often performed at first to search for a disk disease. The presence of bone marrow and soft tissues changes are characterised by low signal on T1-weighted sequence, high signal on T2 and enhancement after gadolinium IV administration. These changes are not specific [11,12]. The pathology makes the definite diagnosis. Macroscopically the lesion is reddish, round or oval shaped, and of soft consistency. It is highly vascular. Microscopically this lesion is characterised by a hypervascularized stroma with osteoid boundary and calcifications in some instances. The main differential diagnosis is osteoblastoma which although sharing identical histological features with osteoid osteomas, differs in size (/20 mm), behaviour (locally invasive with destructive potential and enlarging) and recurrence rate (higher). Treatment is necessary when an osteoid osteoma is suspected even if few spontaneous cures have been reported. Aspirin or other NSAIDs have a dramatic but not long-lasting effect on pain. The surgical treatment is advocated as the treatment of choice. The purpose is to perform a total removal of the nidus, which needs in some cases removal of half the posterior segment; this was what we did in our case.
76
K. Bahloul et al. / European Journal of Radiology Extra 46 (2003) 74 /77
Fig. 2. (a) CT scan: Axial view showing a well delimited lesion at the junction between the lamina and the facet of right T9; (b) CT scan: Sagittal view showing a ring-like image surrounded by dense reactive bone on the whole T9 pedicle.
The peroperative localisation may not be easy; in a few cases the accurate localisation of the nidus has been possible under control of evoked potentials [13] or with a per operative scintigraphy with a portable camera, 2 or 3 h after intravenous injection of labelled technetium. Another alternative treatment is the percutaneous curettage of the nidus under CT control with local anaesthesia; the nidus is removed by curettage with a 7 mm biopsy needle. Percutaneous CT-guided thermo-coagulation has also been proposed: a radio- frequency thermode is directed percutaneously to the nidus. In this technique a hole was first cut into the bone with a cutter and a few biopsy specimens can be obtained, and a small radiofrequency electrode can be introduced into the bone through the
biopsy track. Sufficient current is used to heat the electrode tip to 85/90 8C with consequent thermal necrosis of the tissue. The heating is continued for 6 min. These different techniques allow a mini invasive technique and are of interest if the tumour is difficult to approach surgically. CT guided percutaneous radio-frequency ablation achieves the same clinical outcomes as the operative excision with significantly lower costs (pain relief was noted to occur very rapidly in 100% of cases) [17]. Following total removal, permanent cure is obtained and rapid recovery is documented in most of the series. Regrowth is due to incomplete removal rather than multiple nidus [3,14 /16]. X-ray control is mandatory coupled in certain cases with scintigraphy.
K. Bahloul et al. / European Journal of Radiology Extra 46 (2003) 74 /77
References [1] Guy G, Jan M, Lemonnier P, Rabehenoinia Ch, Mercier Ph. Oste´omes oste´oides rachidiens. A propos de 4 observations. Neurochirurgie 1989;35:41 /6. [2] Dahlin DC, Unni KK. In: Charles CT, editor. Bone tumors. General aspects and data on 8542 cases, 4th ed. Illinois: Springfield, 1986. [3] Blery M, Leroux B. Oste´ome oste´oide verte´bral. Ann Radiol 1978;21:59 /63. [4] Jackson RP, Reckling FW, Mantz FA. Osteoid osteoma and osteoblastoma. Similar histologic lesions with different natural histories. Clin Orthop 1977;128:303 /13. [5] Kattapuram SV, Kusher DC, Phillips WC, Rosental DI. Osteoid osteoma an unusual cause of articular pain. Radiology 1983;147:383 /7. [6] Maiuri F, Signorelli C, Lavano A, Gambarbella A, Simari R, D’Andrea F. Osteoid osteoma of the spine. Surg Neurol 1986;25:375 /80. [7] Calderoni P, Gusella A, Martucci E. Multiple osteoid osteoma in the 7th dorsal vertebral. Ital J Orthop Traumatol 1984;10:257 /60. [8] Capanna R, Boriani S, Mabit S, Donnati D, Savini R. L’oste´ome oste´oı¨de de localisation rachidienne. Revue de chirurgie orthope´dique 1991;77:545 /50. [9] Keim HA, Reina EG. Osteoid osteoma as a cause of scoliosis.
77
J Bone Joint Surg 1975;57:159 /63. [10] Hermann G, Abdelwaheb F, Casden A, Mosesson R, Klein MJ. Osteoid osteoma of a cervical vertebral body. Br J Radiol 1999;72:1120 /3. [11] Ben Abdallah N, Sarrazin JL, Soulie D, Cosnard G. Osteoid osteoma, neuralgia and MRI. J Radiol 1996;77:133 /6. [12] Assoun J, Richardi G, Railhac JJ, Baunin C, Fajadet P, Giron J, et al. Osteoid osteoma: MR imaging versus CT. Radiology 1994;191:217 /23. [13] Balasubramanian E, Keim HA, Hajdu M. Osteoid osteoma of the thoracic spine with surgical decompression aided by somatosensory evoked potentials. Spine 1985;10:396 /8. [14] Baunin C, Puget C, Assoun J, Railhac, Cahuzac, Clement JL. Sale de Gauzy. Percutaneous resection of osteoid osteoma under CT guidance in eight children. J Ped Radiol 1994;24:185 /8. [15] Jos A, Cove MD, Antoine H, Taminiau MD, Williem R, Obermann M, et al. Osteoid osteoma of the spine treated with percutaneous computed tomography */guided thermocoagulation. Spine 2000;10:1283 /6. [16] Osti OL, Sebben R. High-fre´quency radio-ware ablation of osteoid osteoma in the lumbar spine. Eur Spine J 1998;7:422 /5. [17] Gallazi MB, Arborio G, Garbana PG, Perruchini G, Dalio PA. Percutaneous radio-frequency ablation of osteoid osteoma: technique and preliminary results. Radiol Med 2001;102(5 /6):329 / 34.