AlbertLeung,HMSIII

GillianLieberman,M.D.
BIDMCRadiologyClerkship
February22,2010
Overview
IndexPatient
PeriostealReactions
DifferentialDiagnosis
PrinciplesofOsteoid Osteomas
BoneAnatomy
MenuofTests
RadiologicImages
Treatments
http://peakrunningperformance.com/webpages/images/stories/skeleton.gif
LearningObjectives
Recognizetheclinicalpresentationofosteoid osteoma
Understandthedifferentialdiagnosisforthisclinical
presentation
Reviewtheprinciplesofosteoid osteoma andits
classificationwithinthecontextofboneanatomy
Learnthemenuofappropriateradiologicimagingstudies
andtheindications
Studytheradiologicpresentationsandrecognizeclassic
findings
Knowhowtomedicallyandsurgicallymanageosteoid
osteomas
IndexPatient:PresentingHistory
ChiefComplaint
Rightwristpain
History
18yroldRhanddominantmalewithpersistentRwristpainfor4
months
Painisworseatnight,wakingpatientfromhissleep
Painreliefwithibuprofen
Nohistoryoftraumaorrepetitivemotionswithhand
ReviewofSystems
Deniesnumbness/tingling,fevers,chills,nightsweats
Past,Family,SocialHistories
Nonsignificant
IndexPatient:PhysicalExam
Palpablenodule(3.5x3cm)overtheradialaspectoftheRdistal
radiuswithfocaltendernessandswelling
Noerythema,discoloring,ecchymosis,ordrainage
FullrangeofmotionofRshoulder,elbow,wrist,andfingers;no
strengthdeficits
Normalsensationinalldistributions
+2pulsesbilaterally
Nopalpableaxillary lymphnodes
OurPatient:Radiographofcorticalosteoid

osteoma

inRdistalradius
Fusiform

corticalthickening
Ovoidscleroticlesionwith

centralradiolucency
1.1x1.3cm
APRadiograph
Image from BIDMC PACS
OurPatient:Rdistalradiusosteoid

osteoma

onCTImaging
Focalareasofradiolucency

surroundedbysclerotic

regionsthatoccupythecortexandinvadethemedulla
AxialC

CT
Image from BIDMC PACS
OurPatient:Periostealreactionon

CTImaging
Periostealreaction:elevatedcortex

frombonyexpansion
Image from BIDMC PACS
Coronal C- CT of R distal radius
PeriostealReaction:

NonaggressiveTypes
Rana RS, Wu JS, and Eisenberg RL. Periosteal Reaction. American Journal of Roentgenology. Oct 2009. 193(4): W259-272.
PeriostealReaction:

AggressiveTypes
Rana RS, Wu JS, and Eisenberg RL. Periosteal Reaction. American Journal of Roentgenology. Oct 2009. 193(4): W259-272.
PartialDifferentialDiagnosisfor

WristPain/BoneMass
Masses
BenignNeoplasms
Osteoid Osteoma
Osteoblastoma
Osteoma
Enostosis (boneisland)
Ganglioncyst
Infection
Brodie abscess(subacute
osteomyelitis)
Osteomyelitis
Inflammation
Tenosynovitis
Rheumatoidarthritis
DegenerativeConditions
Osteoarthritis
Stressfracture
Neurological
Carpaltunnelsyndrome
OurPatientsDifferentialDiagnosis
Unlikely given patients history and presentation
DistinguishingCharacteristicson

RadiologicImaging
Masses
BenignNeoplasms
Osteoid Osteoma <2cm;radiolucentnidus withsurrounding
sclerosis;mayspontaneouslyregress
Osteoblastoma large(>2cm);noregressioninsizeovertime
Osteoma coldbonescan;absent periostealreaction&
radiolucentnidus
Enostosis coldbonescan;thornyradiations;lowsignalonT2w
MRI
Infection
Brodie abscess corticaldestructionwithalinear,serpentinetract
extendingawayfromabscess
DegenerativeConditions
Stressfracture linearradiolucency perpendicular,ratherthan
parallel,tocortex
Background:Osteoid

Osteoma
Demographics
Majorityofpatientsareyoung(<35yrold)
Males>females(23:1)
Benign skeletalneoplasm
Consistsofasphericalnidus ofosteoid tissue&bonytrabeculae
superimposedonhighlyvascularized connectivetissue
Mayinitiallyappearonradiographasasmallscleroticboneisland
withinacircularlucency
NOmalignantpotential
Size
Rangesfrom0.52cm(avg 1.5cm)
Nogrowthprogression
Mayregressspontaneouslyoveryears
Background:Osteoid

Osteoma

(continued)
Mechanism
Unknownetiology
Nidus consistsofhighlyvascularosteoblastic proliferation,surroundedby
asecondaryzoneofsclerosis
ElevatedprostaglandinE2levelsinnidus responsibleforbonepain&
vasodilation
Tumorinfarctionmaybeinvolvedduringcasesofspontaneousregression
Locations
Typicallyaffectstheappendicular skeleton
Metaphysis/diaphysis oflongbones:70%
Femur/tibia:55%
Phalangesofhands/feet:20%
Spine:10% Causespainful scoliosiswithconcavitytowardsthelesion
Posteriorelements:90%
Extremelyrareinskull&facialbones
Osteoid

osteoma

vs

Osteoblastoma
Osteoid

osteoma Osteoblastoma
Usually<2cmdiameter
Presentswithintensepain,
oftensharplylocalizedand
worseatnight
Paincharacteristicallyrelieved
byaspirin/NSAIDs
Nonaggressivebehavior
Variablelocations:femur,tibia,
fibula,humerus,hands/feet,
vertebrae
Neuralstaining revealsaxons
throughoutthetumor(may
explainbonepain)
Usually>2cmdiameter
Lackofintensepain
Aggressivebehavior
Typicallyinthevertebraeor
majorbonesofthelower
extremity
Oftenaffectsthespongiosa
ofthebone
Absenceofneuralaxons
uponstaining
ReviewofBoneAnatomy
tsagalis.net/bones/anatomy.jpg
tsagalis.net/bones/anatomy.jpg
ClassificationofOsteoid

Osteomas
Cortical
Mostcommonlocation(80%)
Radiolucentnidus seenwithinthebonecortexandsurroundedby
fusiform corticalthickening/laminatedperiostealformation
Cancellous
Intramedullary lesion;mildreactivesclerosis&difficulttoidentify,
significantlydelayingthediagnosis
Commonsites:femoralneck,posteriorspine,hands&feet
Intraarticular
Jointeffusionorsynovitis
Subperiosteal
Roundmassadjacenttocortex
Absentperiostealreaction
Veryrare
Gitelis

S,WilkinsR,andConradEU,III.BenignBoneTumors.

JournalofBone&JointSurgery(Am).1995;77:17561782.
Osteoid Osteomas
ClassicClinicalPresentation
Focalbonepainthatworsensatnight&increaseswithactivity
Painisrelievedbyaspirinwithin30minutes(75%ofcases)
Localswellingandpointtenderness
Exacerbationofpainwithalcohol
http://library.thinkquest.org/08aug/01036/Imagini/Sleep.jpg
http://paddyk.files.wordpress.com/2009/11/5-aspirin.jpg
MenuofRadiologicTests
PlainRadiographs*
ComputedTomography*
MRI
Ultrasonography
NuclearImaging*
Angiography
*Usuallyusedforevaluatingosteoid

osteomas
PlainRadiographs
Mainimagingtechnique
Diagnosticin75%ofcases
ClassicAppearance
Welldefinedradiolucentnidus with
surroundingzoneofsclerosis
Centralnidus istypically<1.5cmindiameter
CompanionPatient#1:Radiograph

ofLtibial

osteoid

osteoma
21 yr old male with 4 months of
atraumatic left calf pain, worse at
night; osteoid osteoma eventually
removed by percutaneous RF
ablation
Periosteal reaction with cortical thickening in posterior tibia
Sagittal Radiograph
Image from BIDMC PACS
CTImaging
Bestimagingtoolforosteoid osteoma
Studyofchoiceforlocalizingthenidus
Goodatevaluatingcomplexanatomy(e.g. spinal
pedicles,laminae,femoralneck,hands,feet)
CompanionPatient#1:Ltibial

osteoid

osteoma

onCTImaging
Sagittal C- CT Axial C- CT
Mature periosteal reaction and
thickening with central radiolucency
Image from BIDMC PACS Image from BIDMC PACS
BackToOurIndexPatient:Rdistal

radiusosteoid

osteoma

onCT
Centralradiolucentnidus

withinascleroticzone
Osteoid

osteoma

eventuallyremovedby

opensurgicalcurettage
Image from BIDMC PACS
Sagittal C- CT
MRI
Advantages
Easilydetectsedemainthesofttissues&bonemarrow
Betteratdiagnosingcancellous/intramedullary osteoid
osteomas
Goodforevaluatingjointeffusion/synovitis for
intraarticular lesions
Appearance
T1w:nidus isisointense tomuscle
T2w:radiolucentareasofnidus withintermediateto
highsignalintensity
CompanionPatient#2:Radiograph

ofLtibial

osteoid

osteoma
18 yr old male with nocturnal focal pain
in L proximal tibia for 2 years; relief with
NSAIDs; osteoid osteoma eventually
removed by percutaneous RF ablation
Non-aggressive thick periosteal reaction of
the L medial tibial metaphysis
AP Radiograph
Image from BIDMC PACS
CompanionPatient#2:Ltibial

osteoid

osteoma

onAxialCT
5 mm radiolucent nidus
Thick periosteal reaction (10 mm)
Axial C- CT
Image from BIDMC PACS
CompanionPatient#2:Ltibial

osteoid

osteoma

onCoronalCT
Oval-shaped radiolucent lesion within the medial
tibial cortex
Dimensions: 4 x 4 x 18 mm
Coronal C- CT
Image from BIDMC PACS
CompanionPatient#2:Ltibial

osteoid

osteoma

onMRISTIR
Edema appears as high signal intensity
within the bone marrow
Coronal C- MRI STIR
Image from BIDMC PACS
CompanionPatient#2:Ltibial

osteoid

osteoma

onMRIT1w
Axial C- MRI T1w Coronal C- MRI T1w
Low signal intensity edema in soft tissue structures surrounding the cortical lesion
Image from BIDMC PACS Image from BIDMC PACS
NuclearImaging:BoneScan
Usestechnetium99mphosphonates
Tumorsitedemonstratesfocalareaofintenseuptake
Doubledensitysign:smallfocusofincreasedactivity
(nidus)surroundedbyalargerareaoflessintenseactivity
(reactivesclerosis)
Tracerisexcretedthroughkidneysandurinarybladder
CompanionPatient#3:Sacrococcygeal

osteoid

osteoma

onCTImaging
19 yr old male with 1 yr hx of
pain at coccyx, worse at night
pain & relieved with
ibuprofen; osteoid osteoma
eventually removed by
percutaneous RF ablation
Small curvilinear lucency (6 mm) with
focal sclerosis in adjacent posterior
cortex
Image from BIDMC PACS
Axial C- CT
CompanionPatient#3:CTguidedbiopsyof

asacrococcygeal

osteoid

osteoma
CT guided needle core biopsy of the
radiolucent nidus
Image from BIDMC PACS
Axial C- CT
CompanionPatient#3:Coronalbonescan

ofasacrococcygeal

osteoid

osteoma
Small intense focus of tracer uptake in the coccyx
with double density sign
Coronal Bone Scan
Image from BIDMC PACS
CompanionPatient#3:Sagittal

bonescanof

asacrococcygeal

osteoid

osteoma
Abnormally increased focal area of intense
tracer uptake
Image from BIDMC PACS
Sagittal Bone Scan
Ultrasonography
Maybeusedforguidanceofpercutaneous biopsies
DopplerU/Sdetectsthehighlyvascularnidus
Usefulfordetectingintraarticular osteoid osteomas
Angiography
Centralnidus ishighlyvascular
Intensecircumscribedblushthatdevelopsduringthe
earlyarterialphaseandpersistsintovenousphase is
diagnostic
Angiographyisusefulfordistinguishingosteoid osteoma
fromaBrodie abscess
Treatments
MedicalManagement
NSAIDS
SurgicalManagement
Opensurgicalcurettage
CTguided
Percutaneous radiofrequency(RF)ablation,laser,ethanol,
orthermocoagulation therapy
Anesthesia
Generalorspinal
Summary
Osteoid osteoma (OO)isalatentbenignbonetumorthat
classicallypresentsasfocalpainthatisworseatnightand
relievedbyNSAIDs
Corticalosteoid osteomas areoftenassociatedwithnon
aggressiveperiostealreactions
OOs andosteoblastomas arehistologically similarbutdifferin
size,painintensity,location,aggressiveness,andneuralstaining
patterns
OOs areclassifiedbytheirrelativepositiontothebone:
cortical,cancellous,intraarticular,andsubperiosteal
SummaryContinued
OOs haveaclassicappearanceonplainradiographsandCT
imaging:centralradiolucentnidus withsurroundingzoneof
sclerosis
CTimagingisthebestimagingtoolforOOs andisthestudyof
choiceforlocalizingthenidus
MRIisusefulfordetectingsofttissue/bonemarrowedemaand
intramedullary OOs
Nuclearbonescansmaylocalizethetumoranddemonstrate
focalareasofintensetraceruptake;doubledensitysignis
occasionallyseen
DopplerU/Scandetectthehighlyvascularnidus
AngiographymaydistinguishOOs fromaBrodie abscess:
intenseblushthatpersistsintovenousphaseisdiagnosticof
OO
References
Assoun

J,Richardi

G,Railhac

JJ,etal.Osteoid

osteoma:MRimagingversusCT.

Radiology1994;191(1):21723.
Bilchik

T,Heyman

S,SiegelA,andAlavi

A.Osteoid

osteoma:theroleofradionuclideboneimaging,conventional

radiographyandcomputedtomographyinitsmanagement.

TheJournalofNuclearMedicine.Feb1992;33(2):269

271.
DaviesAMandWellings

RM.Imagingofbonetumors.

CurrentOpinioninRadiology.1992;4(6):3238.
Dorfman

HDandCzerniak

B.BoneTumors(1
st

ed).St.Louis,MO,Mosby,1998.
GilS,MarcoSF,ArenasJ,etal.Dopplerduplexcolorlocalizationofosteoid

osteomas.

SkeletalRadiology.Feb1999;

28(2):107110.
Gitelis

S,WilkinsR,andConradEU,III.BenignBoneTumors.

JournalofBone&JointSurgery(Amed).1995;77:1756

1782.
GrecoF,Tamburrelli

F,Ciabattoni

G.Prostaglandinsinosteoid

osteoma.

InternationalOrthopedics.1991;15(1):3537.
GreenspanAandRemagen

W.DifferentialDiagnosisofTumorsandTumorlikeLesionsofBonesandJoints(1
st

ed).

Philadelphia,PA,Lippencott

Williams&Wilkins,1998.
PerkinsACandHardyJG.Intraoperativenuclearmedicineinsurgicalpractice.

NuclearMedicineCommunications.

Dec1996;17(12):10061015.
Rana

RS,WuJS,andEisenbergRL.PeriostealReaction.

AmericanJournalofRoentgenology.Oct2009.193(4):W259

272.
Acknowledgements
Dr.GillianLieberman
Dr.JimWu
Dr.EricaGupta
Dr.JayCatena
SpecialThanksTo:
Dr.Corrie Yablon
Dr.Aarti Sekhar
MariaLevantakis
Patients