osteoma

Radiofrequency ablation for Spinal osteoid osteoma

Radiofrequency ablation for Spinal osteoid osteoma

Complete excision With osteoid osteomas, only complete surgical excision ensures the least risk of local recurrence, and effectively provides immediate pain relief and early mobilization. Newer, minimally invasive methods, including. percutaneous CT-guided radiofrequency ablation (RFA), are gaining popularity internationally for the treatment of extra spinal tumors 1).

Complete surgical excision of the nidus is curative, providing symptomatic relief, and is the traditionally preferred treatment. However, surgery has disadvantages, including the difficulty of locating the lesion intraoperatively, the need for prolonged hospitalization, and the possibility of postoperative complications ranging from an unsatisfactory cosmetic result to a fracture. Percutaneous radiofrequency (RF) ablation, which involves the use of thermal coagulation to induce necrosis in the lesion, is a minimally invasive alternative to surgical treatment of osteoid osteoma. With reported success rates approaching 90%, RF ablation should be considered among the primary options available for treating this condition 2).

Review

Sagoo et al. sought to systematically assess and summarize the available literature on the clinical outcomes and complications following radiofrequency ablation (RFA) for painful spinal osteoid osteoma (OO).

PubMed, Scopus, and CENTRAL databases were searched in accordance with PRISMA guidelines. Studies with available data on safety and clinical outcomes following RFA for spinal OO were included.

In the 14 included studies (11 retrospective; 3 prospective), 354 patients underwent RFA for spinal OO. The mean ages ranged from 16.4 to 28 years (Females = 31.3%). Lesion diameters ranged between 3 and 20 mm and were frequently seen in the posterior elements in 211/331 (64%) patients. The mean distance between OO lesions and neural elements ranged between 1.7 and 7.4 mm. The estimated pain reduction on the numerical rating scale was 6.85/10 (95% confidence intervals [95%CI] 4.67-9.04) at a 12-24-month follow-up; and 7.29/10 (95% CI 6.67-7.91) at a >24-month follow-up (range 24-55 months). Protective measures (e.g., epidural air insufflation or neuroprotective sterile water infusion) were used in 43/354 (12.1%) patients. Local tumor progression was seen in 23/354 (6.5%) patients who were then successfully re-treated with RFA or open surgical resection. Grade I-II complications such as temporary limb paresthesia and wound dehiscence were reported in 4/354 (1.1%) patients. No Grade III-V complications were reported.

RFA demonstrated safety and clinical efficacy in most patients harboring painful spinal OO lesions. However, further prospective studies evaluating these outcomes are warranted 3).

Case series

Percutaneous Radiofrequency Ablation Using a Navigational Bipolar Electrode System 4).

Between 2002 and 2012, a total of 61 patients (46 male and 15 female, mean age 26.4 ± 12.7 years) were subjected to RFA for spinal OO. The diagnosis of OO was made after a period of pain and symptoms of 20.6 ± 14.4 months. RFA was performed under conscious sedation and local analgesia. Clinical symptoms were evaluated at 3, 6, and12 months, and at the end of the time of the present investigation. Mean follow-up was 41.5 ± 7.1 months.

Results: The primary efficacy of RFA, complete regression of symptoms, was obtained in 57 out of 61 patients (93.4%). Four out of 61 (6.5%) patients showed a relapse of OO (after 3 months); 2 out of 4 were subjected to a second RFA, the remaining ones were subjected to surgery. There was one complication (case of lower limb paresthesia for 30 days after the ablation) and one possible complication (a disc herniation).

Conclusion: CT-guided RFA is an excellent treatment for spinal OO. Our data suggest that this procedure should be considered for the first stage of therapy for this disease 5)

Between March 2009 and July 2016, 8 consecutive patients with spinal osteoid osteomas were enrolled in the study and underwent 9 CT-guided RFA procedures. All patients presented with spinal pain (median preoperative visual analog scale [VAS] score 7.55, range 6-8.8) predominantly during the night, and they all had normal neurological examination results before the procedure. Pain (according to the VAS score) and neurological status were reassessed immediately before discharge, with further follow-up at 1, 6, and 12 months after the procedure. At the final follow-up, VAS score, neurological examination, patient satisfaction, and a radiological control (CT scan) were documented (median 48 months, range 12-84 months). VAS scores before and after the procedure were compared during the 3 days before surgery (D0), on the day of the surgery, Day 1 (D1), and at the final follow-up. RESULTS No neurological deficit was documented following the procedure or at the final follow-up. A statistically significant reduction in the VAS score was observed on Day 1 (mean 2.56 ± 0.68, p = 0.005) compared with D0. At the final follow-up, all patients reported a VAS score of 0 and a satisfaction rate of 100%. Only 1 patient had recurrent symptoms (pain, VAS score 8.1) 6 months after the initial RFA. A second procedure was performed, and the patient was subsequently symptom free at the final follow-up. CT scanning performed in all patients (12-84 months post-RFA) showed residual sclerosis in 4 patients and complete resolution of the radiological lesion in the remaining 4 patients. CONCLUSIONS CT-guided RFA appears to be a safe and effective method for the management of spinal osteoid osteoma and can be safely performed for lesions close to the dura or exiting nerve root based on the motor response threshold testing performed during the procedure. It should be considered the treatment of choice for spinal osteoid osteomas refractory to conservative treatment, thus avoiding more aggressive spinal approaches with subsequent potential morbidity 6).

The records of all patients with osteoid osteomas of the spine managed with thermal ablation at two academic centers from 1993 to 2008 were reviewed.

Results: Seventeen patients (13 male patients, four female patients; mean age, 25.9 years) had lesions in the lumbar (seven patients), thoracic (six patients), cervical (three patients), and sacral (one patient) regions of the spine. Two lesions were in the vertebral body, one was within the dens, and the others were in the posterior elements. The mean lesion diameter was 8.8 mm, and the mean distance between the lesion and the closest neural element was 4.3 mm. The lesions were managed with laser (13 lesions) or radiofrequency (four lesions) ablation. Special thermal protection techniques involving the epidural injection of gas or cooled fluid were used. Pain levels were assessed immediately before the procedure and on the day after the procedure. Long-term follow-up findings were available for 11 patients. No complications were encountered, and all patients reported relief of pain. The 11 patients who participated in long-term follow-up reported continued relief of pain.

Conclusion: Percutaneous thermal ablation can be used to manage spinal osteoid osteomas close to the neural elements. Special thermal protection techniques may add a margin of safety 7).

A prospective study on 24 patients with spinal osteoid osteoma treated with radiofrequency ablation (RFA).

Objective: To determine if and when computed tomography (CT)-guided RFA is a safe and effective treatment for spinal osteoid osteomas.

Summary of background data: Surgery has been considered the standard treatment for spinal osteoid osteomas. Surgery may cause spinal instability, infection, and nervous injury. We evaluated CT-guided RFA as an alternative treatment.

Methods: A total of 28 RFA procedures in 24 patients with spinal osteoid osteoma were performed, using a 5-mm noncooled electrode. Clinical symptoms and spinal deformity were evaluated before and after the procedure. Unsuccessful treatment was defined as the presence of residual or recurrent symptoms. The mean follow-up was 72 months (range: 9-142 months).

Results: Nineteen (79%) patients were successfully treated after 1 RFA, and all except one after repeat RFA. One patient with nerve root compression needed further surgery. No complications were observed. Spinal deformity persisted in 3 of 7 patients after successful RFA.

Conclusion: CT-guided RFA is a safe and effective treatment for spinal osteoid osteoma. Surgery should be reserved for lesions causing nerve root compression 8).

1)

Gasbarrini A, Cappuccio M, Bandiera S, Amendola L, van Urk P, Boriani S. Osteoid osteoma of the mobile spine: surgical outcomes in 81 patients. Spine (Phila Pa 1976). 2011 Nov 15;36(24):2089-93. doi: 10.1097/BRS.0b013e3181ffeb5e. PMID: 21304430.
2)

Motamedi D, Learch TJ, Ishimitsu DN, Motamedi K, Katz MD, Brien EW, Menendez L. Thermal ablation of osteoid osteoma: overview and step-by-step guide. Radiographics. 2009 Nov;29(7):2127-41. doi: 10.1148/rg.297095081. PMID: 19926767.
3)

Sagoo NS, Haider AS, Chen AL, Vannabouathong C, Larsen K, Sharma R, Palmisciano P, Alamer OB, Igbinigie M, Wells DB, Aoun SG, Passias PG, Vira S. Radiofrequency ablation for spinal osteoid osteoma: A systematic review of safety and treatment outcomes. Surg Oncol. 2022 Mar 25;41:101747. doi: 10.1016/j.suronc.2022.101747. Epub ahead of print. PMID: 35358911.
4)

Tomasian A, Jennings JW. Spinal Osteoid Osteoma: Percutaneous Radiofrequency Ablation Using a Navigational Bipolar Electrode System. AJR Am J Roentgenol. 2018 Oct;211(4):856-860. doi: 10.2214/AJR.17.19361. Epub 2018 Aug 7. PMID: 30085840.
5)

Albisinni U, Facchini G, Spinnato P, Gasbarrini A, Bazzocchi A. Spinal osteoid osteoma: efficacy and safety of radiofrequency ablation. Skeletal Radiol. 2017 Aug;46(8):1087-1094. doi: 10.1007/s00256-017-2662-1. Epub 2017 May 11. PMID: 28497160.
6)

Faddoul J, Faddoul Y, Kobaiter-Maarrawi S, Moussa R, Rizk T, Nohra G, Okais N, Samaha E, Maarrawi J. Radiofrequency ablation of spinal osteoid osteoma: a prospective study. J Neurosurg Spine. 2017 Mar;26(3):313-318. doi: 10.3171/2016.8.SPINE16462. Epub 2016 Dec 2. PMID: 27911227.
7)

Rybak LD, Gangi A, Buy X, La Rocca Vieira R, Wittig J. Thermal ablation of spinal osteoid osteomas close to neural elements: technical considerations. AJR Am J Roentgenol. 2010 Oct;195(4):W293-8. doi: 10.2214/AJR.10.4192. PMID: 20858792.
8)

Vanderschueren GM, Obermann WR, Dijkstra SP, Taminiau AH, Bloem JL, van Erkel AR. Radiofrequency ablation of spinal osteoid osteoma: clinical outcome. Spine (Phila Pa 1976). 2009 Apr 20;34(9):901-4. doi: 10.1097/BRS.0b013e3181995d39. PMID: 19360000.

Osteoid Osteoma of the Atlas

Osteoid Osteoma of the Atlas

Vertebral osteoid osteoma of the atlas has previously been reported very rarely in the published literature.

Valluzzi et al. reported the first case of osteoid osteoma involving the atlas associated with adverse local tissue reaction 1).

Diagnosis

Among the several etiologies mentioned for neck pain and torticollis, osteoid osteoma of the first 2 cervical vertebrae should be considered as a possible but rare cause 2). In the era before the MRI, if standard cervical spine radiographs are negative, isotope scanning and computed tomography can help to establish the diagnosis. 3).

Treatment

The traditional standard treatment has been a surgical resection of the nidus.

Even though different kinds of management have been mentioned for osteoid osteoma, resection of the lesion remains the best option for achieving a cure 4).

Computed tomography (CT)-guided radiofrequency ablation (RFA) has gained favor as a more precise alternative treatment. The technique might be contraindicated when the nidus is less than 2 mm away from the neural structures 5).

Case reports

Valluzzi et al. reported a case of an vertebral osteoid osteoma involving the atlas in a 6-year-old boy, who presented with suboccipital pain and torticollis. Initial radiological findings were ambiguous as magnetic resonance imaging showed mainly edema of upper cervical spine soft tissues. The subsequent computed tomography depicted a lesion of left lamina of C1. As conservative treatment failed, the lesion was surgically resected and the patient became pain free. This is the first case of osteoid osteoma involving the atlas associated with adverse local tissue reaction reported in literature 6).

A case of osteoid osteoma of the C1 lateral mass treated successfully using CT-guided RFA. A 30-year-old woman who presented with a four-month history of occipital and suboccipital pain was treated by CT-guided RFA. The visual analog scale (VAS) assessed the pain before and after RFA. The patient reported significant pain relief and normal activities. The VAS score reduced from 8/7 to 1/0 after the procedure. Therefore CT-guided percutaneous RFA of C1 vertebral osteoid osteoma is a safe and effective method. The technique might be contraindicated when the nidus is less than 2 mm away from the neural structures 7).

Amirjamshidi et al. reported 4 cases of upper cervical osteoid osteoma, 1 involving C-1 and the other 3 C-2, and they discuss different aspects of management in similar cases. The patients were 14, 17, 35, and 46 years old, and all presented with neck pain and various degrees of painful limitation of head rotation not ameliorated by ordinary analgesics. Radionuclide isotope bone scans, CT scanning, and MR imaging were helpful preoperative diagnostic modalities. The first attempt at eradication of the lesions failed in 2 cases and the lesions could be excised totally at a second approach. Postoperatively, the patients all became pain free and gained full range of neck motion. There has been no tumor recurrence and no sign of instability in short- to medium-term follow-up. Among the several etiologies mentioned for neck pain and torticollis, osteoid osteoma of the first 2 cervical vertebrae should be considered as a possible but rare cause. Even though different kinds of management have been mentioned for osteoid osteoma, resection of the lesion remains the best option for achieving a cure 8).

Occipital headache, which was relieved by salicylates, was the major symptom reported by two adolescents. In the first patient, a lesion of C1 was seen on plain radiographs. In the second patient, the diagnosis of osteoid osteoma was suggested by scintigraphic imaging and subsequently by computed tomography.

The pain disappeared in both cases after surgical excision of the lesion. Histologic examination disclosed characteristic features of osteoid osteoma.

Occipital pain in adolescents, which is relieved by aspirin, should raise suspicion about the possibility of an osteoid osteoma of the atlas. If standard cervical spine radiographs are negative, isotope scanning and computed tomography can help to establish the diagnosis. Complete excision eliminates the lesion and produces immediate relief for the patient 9).

Jones DA. Osteoid osteoma of the atlas. J Bone Joint Surg Br. 1987 Jan;69(1):149. doi: 10.1302/0301-620X.69B1.3818723. PMID: 3818723.

References

1) , 6)

Valluzzi A, Donatiello S, Gallo G, Cellini M, Maiorana A, Spina V, Pavesi G. Osteoid Osteoma of the Atlas in a Boy: Clinical and Imaging Features-A Case Report and Review of the Literature. Neuropediatrics. 2020 Oct 27. doi: 10.1055/s-0040-1715488. Epub ahead of print. PMID: 33111305.
2) , 4) , 8)

Amirjamshidi A, Roozbeh H, Sharifi G, Abdoli A, Abbassioun K. Osteoid osteoma of the first 2 cervical vertebrae. Report of 4 cases. J Neurosurg Spine. 2010 Dec;13(6):707-14. doi: 10.3171/2010.5.SPINE09297. PMID: 21121747.
3) , 9)

De Praeter MP, Dua GF, Seynaeve PC, Vermeersch DG, Klaes RL. Occipital pain in osteoid osteoma of the atlas. A report of two cases. Spine (Phila Pa 1976). 1999 May 1;24(9):912-4. doi: 10.1097/00007632-199905010-00014. PMID: 10327515.
5) , 7)

Yang J, Li W, Yin Y, Li Z, Ni C. Radiofrequency ablation of osteoid osteoma in the atlas: A case report. Interv Neuroradiol. 2018 Feb;24(1):88-92. doi: 10.1177/1591019917742889. Epub 2017 Nov 20. PMID: 29157057; PMCID: PMC5772548.

UpToDate: Subdural osteoma

Subdural osteoma

Subdural osteomas are benign neoplasms that are rarely encountered.

Case reports

Yang et al., report the case of a 64‑year‑old female patient with a left temporal subdural osteoma.

The patient presented with intermittent dizziness that first began two years earlier. Non-contrast computed tomography revealed a densely calcified left temporal extra-axial mass. Magnetic resonance imaging of the lesion revealed signal loss on T1-weighted and T2-weighted images and non-enhancement on Gadolinium enhanced T1-weighted images, and Diffusion weighted magnetic resonance imaging and ADC images demonstrated reduced values attributed to calcium-induced signal loss. Histologically, the lesion predominantly consisted of lamellar bone without bone marrow elements. The patient underwent stereotactic magnetic resonance imaging-guided neurosurgical resection and recovered without complication.

Subdural osteomas may not be enhanced on magnetic resonance imaging. Surgical tumourectomy can be considered for symptomatic patients with subdural osteomas 1).

A 29-year-old female presented with a 3-year history of headaches. Computed tomography scan revealed a homogeneous high-density lesion isolated from the inner table of the frontal bone (a lucent dural line) in the right frontal convexity. Magnetic resonance imaging revealed an extra-axial lesion with a broad base without dural tail sign and punctate enhancement pattern characteristic of abundant adipose tissue. Upon surgical excision, we found a hard bony mass clearly demarcated from the dura. The mass displayed characteristics of an osteoma upon histological examination. The symptom was relieved after operation 2).

Cheon JE, Kim JE, Yang HJ. CT and pathologic findings of a case of subdural osteoma. Korean J Radiol. 2002;3:211–213.

Kim JK, Lee KJ, Cho JK, et al. Intracranial intraparenchymal ostemoa. J Korean Neurosurg Soc. 1998;27:1450–1454.

Jung TY, Jung S, Jin SG, Jin YH, Kim IY, Kang SS. Solitary intracranial subdural osteoma: intraoperative findings and primary anastomosis of an involved cortical vein. J Clin Neurosci. 2007;14:468–470.

Lee ST, Lui TN. Intracerebral osteoma: case report. Br J Neurosurg. 1997;11:250–252.

Vakaet A, De Reuck J, Thiery E, vander Eecken H. Intracerebral osteoma: a clinicopathologic and neuropsychologic case study. Childs Brain. 1983;10:281–285.

Haddad FS, Haddad GF, Zaatari G. Cranial osteomas: their classification and management. Report on a giant osteoma and review of the literature. Surg Neurol. 1997;48:143–147.

Akiyama M, Tanaka T, Hasegawa Y, Chiba S, Abe T. Multiple intracranial subarachnoid osteomas. Acta Neurochir (Wien) 2005;147:1085–1089. discussion 1089.

Pau A, Chiaramonte G, Ghio G, Pisani R. Solitary intracranial subdural osteoma: case report and review of the literature. Tumori. 2003;89:96–98.

Aoki H, Nakase H, Sakaki T. Subdural osteoma. Acta Neurochir (Wien) 1998;140:727–728. [PubMed] 10. Choudhury AR, Haleem A, Tjan GT. Solitary intradural intracranial osteoma. Br J Neurosurg. 1995;9:557–559.

Constantinidis J. [Intrathalamic osteoma] Psychiatr Neurol (Basel) 1967;154:366–372.

1)

Yang H, Niu L, Zhang Y, Jia J, Li Q, Dai J, Duan L, Pan Y. Solitary subdural osteoma: A case report and literature review. Clin Neurol Neurosurg. 2018 Jul 2;172:87-89. doi: 10.1016/j.clineuro.2018.07.004. [Epub ahead of print] PubMed PMID: 29986201.
2)

Kim EY, Shim YS, Hyun DK, Park H, Oh SY, Yoon SH. Clinical, Radiologic, and Pathologic Findings of Subdural Osteoma: A Case Report. Brain Tumor Res Treat. 2016 Apr;4(1):40-3. doi: 10.14791/btrt.2016.4.1.40. Epub 2016 Apr 29. PubMed PMID: 27195262; PubMed Central PMCID: PMC4868817.