- Department of Surgery and Biological and Biomedical Sciences, Aga Khan University, Karachi, Pakistan
- Graduate, Dow Medical College, Karachi, Pakistan
- Department of Surgery, Aga Khan University, Karachi, Pakistan
- Resident Medical Officer, Abbasi Shaheed Hospital, Karachi, Pakistan
Riaz Hussain Lakdawala
Department of Surgery, Aga Khan University, Karachi, Pakistan
DOI:10.4103/2152-7806.127761Copyright: © 2014 Ahmad T. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Ahmad T, Ahmed Hussain MF, Hameed AA, Manzar N, Lakdawala RH. Conservative surgery for osteoid osteoma of the lumbar vertebrae. Surg Neurol Int 25-Feb-2014;5:24
How to cite this URL: Ahmad T, Ahmed Hussain MF, Hameed AA, Manzar N, Lakdawala RH. Conservative surgery for osteoid osteoma of the lumbar vertebrae. Surg Neurol Int 25-Feb-2014;5:24. Available from: http://sni.wpengine.com/surgicalint_articles/conservative-surgery-for-osteoid-osteoma-of-the-lumbar-vertebrae/
Background:We present two patients with osteoid osteomas of the lumbar spine to highlight the delay in diagnosis and the utility of precise radiological localization enabling tumor resection without jeopardizing spinal stability.
Case Description:Two young patients with refractory back pain presented after having undergone a year of conservative treatment for presumed mechanical back pain. The presence of “red-flag” symptoms (e.g. rest and night pain, and transient pain relief with aspirin) led to the performance of an isotope bone scan, and subsequent computed tomography (CT), which were both consistent with the diagnosis of an osteoid osteoma. After accurate CT-based preoperative planning for tumor excision, a customized conservative surgical technique was utilized that included marginal en-bloc surgical resection of the tumors. As the intervertebral facet joints were also carefully preserved along with stability, no accompanying instrumented fusion was warranted. Both patients returned to full function with complete resolution of their long-standing back pain of more than 2 years.
Conclusions:The diagnosis of osteoid osteoma of the spine requires a high index of clinical suspicion. Diagnostic evaluations should include thin-slice CT scan to assist in planning the most restricted/conservative en-bloc surgical resection while preserving vertebral stability with facet preservation, and thus avoiding instrumented fusions. Without the availability of percutaneous radiofrequency ablation, such restricted/conservative approaches to osteoid osteomas are viable options in countries with developing economies.
Keywords: Lumbar vertebrae, osteoid osteoma, spine, tumor resection
Low back pain is the fifth most common reason for all physician visits in United States.[
A 20-year-old male presented with localized low back pain of 2 years duration, attributed to lifting a heavy object. Pain was persistent, worse at night, unrelated to activity, but characteristically relieved promptly with NSAIDS. He was misdiagnosed for over a year, and prescribed physiotherapy, analgesic/antiinflammatory therapy, and trycyclic antidepressants without improvement. On presentation he exhibited mild scoliosis, negative straight-leg-raise test and no focal neurological deficit. Plain X-rays of lumbosacral spine were normal, but the radioisotope bone scan (Tc-99m) showed increased uptake in left posterior half of the L2 vertebra. The CT scan confirmed that the L2 lesion was sclerotic with a lucent focus in the left postero-inferior quadrant [
(Case 1 and 2): Case 1 (a-d); preoperative images (a): axial CT image showing dense sclerotic ring (arrow) around a lucent nidus in the left posterior quadrant of the vertebral body of L2. (b): Preoperative planning: line drawings of proposed bone resection and reconstruction with bone graft. Postoperative axial CT images showing intact posterior cortex and bone graft (arrow) in situ (c) and fully incorporated at 12 months (d). Case 2 (e-h); Radioisotope bone scan posterior view (e) showing dense uptake in right side of L2 vertebra (arrow); AP X-ray (f) abnormal bony shadow over the right lamina of L2 vertebra (arrow); axial CT image (g) showing dense sclerosis around a nidus in the left lamina of L2. Postoperative AP X-ray (h) bone defect (arrow) in the left lamina of L2 vertebra at the site where tumor was resected using high-speed burr without violating the facet joint
At 2-weeks postoperative follow-up the patient reported complete relief of his long-standing pain. At 12 postoperative weeks, the X-rays documented full incorporation of the bone graft [
A 16-year-old male presented with persistent localized lower lumbar pain of 2 years duration. Pain was progressive, occurred at rest and at night, was relentless, was increased by walking, and immediately although transiently relieved with NSAIDS. He had been labeled neurotic and given antidepressants. On examination, he exhibited a mild postural scoliosis in the lumbar spine concave to the right, but had no focal neurological deficit and negative straight-leg-raise test. Radioisotope bone scan showed increased uptake over the right side of L2 vertebra on posterior view [
The challenges with spinal osteoid osteomas are twofold; (1) establishing the diagnosis, and then (2) management without compromising function. Of interest, both our patients had the classical findings of chronic back pain dramatically relieved with NSAIDS, and both remained undiagnosed for 2 years during which time they were thought to be suffering from depression. These findings were consistent with the literature, which cites an average delay of 10 months between the onset of symptoms and definitive diagnosis,[
Clinical “Red flags” that signal the presence of possible serious spinal pathology (including tumors such as osteoid osteoma), include constant progressive pain which does not get relieved with bed rest [
Surgical management of osteoid osteomas:
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.[
Thin-slice CT scan enables surgical planning of focal tumor resection, without resection of facet and intervertebral joints. This avoids compromise of vertebral stability and obviates the need for instrumented intervertebral fusion, which would otherwise have resulted in decrease of spinal motion. Both our patients had full spinal motion at final follow-up.
A high index of clinical suspicion is the key to diagnosing spinal osteoid osteomas. In developing countries, where the newer technology and expertise for minimally invasive treatment may not be available, precise radiological localization using thin-slice CT scan can enable complete tumor excision without destabilization, and without symptom or tumor recurrence.
Informed consent has been obtained from patients for publication of clinical images and radiological investigations.
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