Spinal osteoid osteoma: Surgical resection and review of literature
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How to cite this article: Mallepally AR, Mahajan R, Pacha S, Rustagi T, Marathe N, Chhabra HS. Spinal osteoid osteoma: Surgical resection and review of literature. Surg Neurol Int 2020;11:308.
Abstract
Background:
Osteoid osteoma (OO) is a rare benign tumor of the spine that involves the posterior elements with 75% tumors involving the neural arch. The common presenting symptoms include back pain, deformity like scoliosis, and rarely radiculopathy.
Methods:
From 2011 to 2017, we evaluated cases of OO managed by posterior surgical resection while also reviewing the appropriate literature.
Results:
We assessed five patients (three males and two females) averaging 36.60 years of age diagnosed with spinal OOs. Two involved the lumbar posterior elements, two were thoracic, and one was in the C3 lateral mass. All patients underwent histopathological confirmation of OO. They were managed by posterior surgical resection with/without stabilization. No lesions recurred over the minimum follow-up period of 24 months.
Conclusion:
Surgical excision is the optimal treatment modality for treating spinal OOs. The five patients in this study demonstrated good functional outcomes without recurrences. Further, the literature confirms that the optimal approach to these tumors is complete surgical excision with/without radiofrequency ablation.
Keywords
INTRODUCTION
Osteoid osteoma (OO) is a benign tumor which accounts for 10–40% of spine tumors; the majority involve the lumbar spine (59%), and especially the neural arch (75%). Typical clinical presentations include night pain/back pain/stiffness markedly relieved by nonsteroidal anti-inflammatory medications. Treatment options for OO include conservative management with anti-inflammatory agents, surgical curettage, partial excision, marginal or gross total en bloc excision, and with/without radiofrequency ablation.[1] Here, we reviewed five cases of OO, along with their clinical presentations, radiographic appearances, surgical management, and outcomes along with an appropriate focused review of the literature.
MATERIALS AND METHODS
After approval from the Institutional Review Board, five patients’ clinical symptoms, radiological studies (MR/CT), surgical details (posterior decompressions/resections), outcomes/pain scores, and recurrence rates were studied from 2011 to 2017. We also did a literature review regarding the relevant articles in PubMed and Medline databases [Table 1].[1-16]

RESULTS
The five patients who all presented with back pain attributed to OO averaged 36.6 years of age and included three males and two females. Lesions were located in the posterior elements of the lumbar (two patients), thoracic (two patients), and cervical spine (one patient) [Table 2]. The histopathological examination confirmed OO in all cases. All patients had good clinical outcomes with VAS scores improving to <2 postoperatively [Table 3].


Case 1
A 26-year-old male presented with low back pain with CT scan showing a L4 pedicle lesion with lysis of pars [Figure 1]. He underwent intralesional curettage, bone grafting, and bilateral pedicle screw fixation.

Case 2
A 63-year-old female presented with back pain with CT scan showing a hyperdense sclerotic lesion at the right D9 pedicle/ lamina. Transpedicular biopsy with posterior D8-D10 fusion was done [Figure 2].

Case 3
A 43-year-old male presented with a CT scan demonstrating hyperdense left sided C3 lateral mass for which he underwent a curettage without instrumentation [Figure 3].

Case 4
A 15-year-old female presented with a left-sided L5 laminar lesion for which she underwent decompression in the form of L5 laminectomy with transforaminal lumbar interbody fusion [Figure 4].

Case 5
A 26-year-old male with pain in thoracic region underwent left T10 hemilaminectomy with bone grafting and D8 to D10 fusion [Figure 5].

DISCUSSION
OO is a benign skeletal neoplasm consisting of a highly vascularized nidus of connective tissue surrounded by sclerotic bone. The size of the nidus (15 mm) distinguishes it from osteoblastoma. OO comprises 10% of all benign bone tumors and only 1% of all spinal tumors. It mainly involves the lumbar spine with predilection for posterior elements seen in 75% of cases.[1,2] Pars interarticularis is the most common site of involvement. OOs are usually seen in patients under the age of 30 with a male preponderance (sex ratio – 2–4:1).[3] The most common clinical symptom is night pain (up to 80–100%) believed to be due to prostaglandin/prostacyclin production) and painful scoliosis (63–70%). Nonsteroidal anti-inflammatory drugs effectively relieve pain by pain reducing inflammation.[3] Radionuclide bone scanning remains the most sensitive tool for localization. It reveals focal increased uptake surrounded by a decreased uptake due to the sclerotic bone known as the “Double density” sign.
Surgical intralesional excision has been the commonly accepted treatment for a long time.[3,5] The goal of OO surgery is to remove the nidus entirely without causing pathologic fracture, especially of the facets and pedicles or disrupting the adjacent uninvolved tissues. The posterior approach was carried out in all the surgical patients. Three patients underwent laminectomy and one patient underwent lateral mass partial resection of tumor [Table 3]. Four patients underwent fusion with instrumentation. Literature shows that the rate of recurrence of OO is higher after intralesional resection compared with en bloc resection.[3,5] We did not have any recurrence in our series. No patient deteriorated neurologically after surgical excision. Although percutaneous CT-guided radiofrequency ablation is also accepted as the standard treatment for OO due to fewer complications and shorter length of hospital stay, the risk of thermal damage to adjacent neurovascular structures remains.[4,6-9]
CONCLUSION
OO is a rare benign tumor, commonly involving the posterior elements of the lumbar, thoracic, and cervical spine in descending order of frequency. Gross total surgical excision with/without radiofrequency ablation is the optimal treatment, resulting in good functional outcomes and rare recurrences.
Declaration of patient consent
Institutional Review Board permission obtained for the study.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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