educacion continua osteoma osteoide

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O RTHOPEDICS | Healio.com /Orthopedics

Review Article

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educational objectives

Osteoid OsteomaPetros J. Boscainos, MD, FRCSEd; Gerard R. Cousins, MBChB, BSc(MedSci), MRCS;Rajiv Kulshreshtha, MBBS, MRCS; T. Barry Oliver, MBChB, MRCP, FRCR;Panayiotis J. Papagelopoulos, MD, DSc

ABSTRACT

Osteoid osteoma is the third most com-mon benign bone tumor. The authorsdescribe the clinical presentation, diag-nostic investigations, differential diagno-sis, histopathology, and treatment optionsfor this condition, including a compre-hensive review of the literature. Osteoid

osteomas have wide variations in presen-tation and tend to present in the seconddecade of life, with pain that is worse atnight and is relieved by salicylates. Plainradiographs and computed tomographyscans are the mainstay of imaging; how-ever, bone scintigraphy, single-photonemission computed tomography, magnet-

As a result of reading this article, physicians should be able to:

1. Discuss the clinical presentation of and different imaging modality options

for suspected osteoid osteomas.2. Develop an insight into the histopathology and histochemistry of osteoidosteomas.

3. Use diagnostic processes in the differential diagnosis of suspected osteoidosteomas.

4. Apply current treatment depending on the location and accessibility ofthe lesion.

The authors are from the Department of Trauma and Orthopaedic Surgery (PJB, GRC, RK), Perth Royal Inrmary, NHS Tayside, Perth, Scotland; Department of Radiology (TBO), Ninewells Hospital,

NHS Tayside, Dundee, United Kingdom; and the Department of Orthopaedics (PJP), Athens University Medical School, Athens, Greece.The authors would like to thank Dr Elaine MacDuff, Western Inrmary, Glasgow, United Kingdom,

for providing the image of the hematoxylin-eosin stain.The material presented in any Keck School of Medicine of USC continuing education activity does not

necessarily reect the views and opinions of O RTHOPEDICS or Keck School of Medicine of USC. NeitherO RTHOPEDICS nor Keck School of Medicine of USC nor the authors endorse or recommend any techniques,commercial products, or manufacturers. The authors may discuss the use of materials and/or products thathave not yet been approved by the US Food and Drug Administration. All readers and continuing education

participants should verify all information before treating patients or using any product.Correspondence should be addressed to: Petros J. Boscainos, MD, FRCSEd, Department of Trauma

and Orthopaedic Surgery, Perth Royal Inrmary, NHS Tayside, Taymount Terrace, Perth, United King-dom, PH1 1NX ([email protected]).

doi: 10.3928/01477447-20130920-10

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O STEOID O STEOMA | BOSCAINOS ET AL

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ic resonance imaging, and sonographyare also used. Osteoid osteomas consistof a nidus with surrounding scleroticbone. The differential diagnosis covers a

wide range of conditions due to the vari-able presentation of osteoid osteoma. Thenatural history is for regression to occurwithin 6 to 15 years with no treatment;however, this can be reduced to 2 to 3years with the use of aspirin and non-steroidal anti-inammatory drugs. Com-puted tomographyguided percutaneoustechniques, including trephine excision,cryoablation, radiofrequency ablation,and laser thermocoagulation, are de-scribed.

Osteoid osteoma is a small, dis-tinctive, nonprogressive, be-nign osteoblastic lesion that is

usually accompanied by severe pain.Jaffe 1 was the rst to report the iden-tication of this osteoblastic lesion in1935. As the third most common biopsy-analyzed benign bone tumor after osteo-chondroma and nonossifying broma,osteoid osteoma is a relatively commonlesion. It represents 11% to 14% of be-nign bone tumors. Two percent to 3% ofexcised primary bone tumors are osteoidosteomas. 2,3

CLINICAL P RESENTATION

Osteoid osteoma can manifest at anyage, but the majority of patients are agedbetween 5 and 20 years, with 50% of pa-tients aged between 10 and 20 years. 4,5 Osteoid osteomas are 1.6 to 4 times moreprevalent in males. 4 In the majority of cas-

es, osteoid osteoma occurs in long bones,affecting the metaphysis or diaphysis.The most common loci are the femur andthe tibia, with the most characteristic sitebeing the femoral neck and the intertro-chanteric region. 4 Rarely, it also involvesthe epiphyseal and intracapsular aspect oflong bones (known as intra-articular os-teoid osteomas). Less commonly affectedare the spine and the small bones of thehand and feet. It can involve the talus,

predominantly the talar neck. Flat bonesin the body and the skull are rarely af-fected. Osteoid osteoma is usually local-ized within the bone cortex. Subcortical,

intracortical, and intraperiosteal osteoidosteomas have been described. Osteoidosteomas of the spine account for ap-proximately 6% of cases and almost al-ways involve the posterior arch area closeto the pedicles. 6,7 The lumbar spine is themost commonly affected region. Multipleosteoid osteoma nidi in the same or dif-ferent bones are rare. 8,9

Pain is the most common clinicalpresentation. Its usual characteristicsare dull, unremitting, initially mild andintermittent pain that increases in inten-sity and persistence over time. It tendsto become increasingly severe at nightand is usually relieved by salicylates andnonsteroidal anti-inammatory drugs(NSAIDs). The indolent nature of earlyosteoid osteoma may result in delayedpresentation. Swelling, erythema, andtenderness may be present in bones insubcutaneous locations. 5 Referred painand muscular atrophy may result in themisdiagnosis of a neurological disor-der. 10 This observation is common inpatients who have a painful osteoid os-teoma in posterior elements of the spine,where a postural scoliosis is found due toparavertebral muscle spasm but is revers-ible after treatment. 4

Osteoid osteomas in the region ofthe proximal femur or pelvis may pres-ent with symptoms of knee pain, and thediagnosis may require a bone scan. Intra-or juxta-articular lesions are commonly

associated with synovitis.11

Joint painwith exion contracture, abated range ofmotion, and antalgic gait can be a clini-cal pattern of an intra-articular osteoidosteoma. 5 In children, the most commonpresenting symptom is nocturnal pain. Ina young child with an osteoid osteoma,a limp may be the only symptom. If thelesion is close to an open physis, it cancause lengthening, angular deformity, orboth of the extremity. 4

IMAGINGPlain Radiographs

Plain radiographs are the initial imagingstudy of choice. The osteoid osteoma ap-

pears as a small, radiolucent nidus (usuallyless than 1 cm) surrounded by a variablearea of sclerotic bone or cortical thicken-ing (Figure 1). The nidus can be difcultto detect when it is obscured by scleroticcortical bone or in cases of intra-articularlesions, where bone deposition from the in-tracapsular periosteum is usually less. 12,13 In addition, intramedullary-located oste-oid osteomas may not exhibit surroundingbone sclerosis. 14 Indirect manifestations ofsynovial inammation and joint effusionmay be evident, or symptoms that mimicosteoarthritis may be present. 13,15 Whentreatment is delayed, secondary osteopeniaand changes in bone morphology may beobserved. 11 If the nidus is larger than 1.5cm, the lesion is usually designated as anosteoblastoma. 16,17 Osteoblastomas areseen radiologically as lesions with a lucent,slow-growing, expansile area with irregu-lar sclerosis and no denite nidus. 18

Computed TomographyThe most common appearance of osteoid

osteoma on computed tomography (CT) isas a small, well-delineated, low-attenuationnidus surrounded by a dense sclerotic reac-tion (Figure 2). Foci of calcication maybe visible. A recently described CT ndingis the presence of ne, linear, low-densityvascular channels that can surround oste-oid osteomas. When present, such vasculargrooves have high sensitivity and specicityin the diagnosis of osteoid osteoma. 19

A CT scan is useful in diagnosingintra- or juxta-articular osteoid osteomas,and it has been proposed that CT must beused in all patients with suspected osteoidosteomas because it has better diagnos-tic accuracy compared with plain radio-graphs or magnetic resonance imaging inthese cases. 20,21 Preoperative localizationof osteoid osteomas can be facilitated us-ing CT guidance. 22,23 Percutaneous abla-tion of lesions under CT guidance is well

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established and is discussed later (Figure3). 24-28 Computed tomographyguided ab-lation of osteoid osteomas has also beendescribed in technically challenging loca-tions, such as the spine. 29,30

Bone ScintigraphyDue to the correlation between osteo-

blastic activity and the intensity of radio-pharmaceutical uptake, bone scintigraphy

usually shows intense uptake in the arterialphase within the richly vascular nidus andin the delayed phase within surrounding re-active bone (Figure 4). 31 Usually, an intensearea of radiotracer uptake is found in theregion of the nidus and less in the reactivebone. This pattern, which is known as thedouble-density sign, is diagnostic of osteoidosteoma. 32 The area of uptake may be wide.Historically, a pinhole collimator has been

used to demonstrate the nidus because thereactive bone uptake may obscure it. 14

In children, increased uptake by activegrowth plates can obscure an adjacent os-teoid osteoma. In this situation, compari-son with the contralateral unaffected siteis helpful to identify the tumor. 13 In situa-tions where radiofrequency ablation is notavailable, intraoperative radionucleotideimaging may be used to conrm completeresection of the tumor. 14,33

Single-photon Emission ComputedTomography

Although in most cases a conventionalbone scan followed by thin-section CTscan is sufcient, single-photon emissioncomputed tomography (SPECT) can behelpful in diagnosing osteoid osteomasin cases in which bone scintigraphy up-take is subtle. 34 A SPECT scan can detect

smaller lesions by improved spatial reso-lution of overlying normal tissue uptakeand has been advocated as helpful in de-picting osteoid osteomas of the spine. 14,35 Transaxial anatomic imaging of SPECTcan further enhance its diagnostic abilityin positioning suspicious lesions. 36

Magnetic Resonance ImagingThe appearance of osteoid osteoma is

variable with magnetic resonance imaging

Figure 1: An 11-year-old girl presented with chronic midtibial pain and localized warmth on examination.Lateral radiograph showing diffuse anterior cortical thickening (arrow) centered on a subtle lucency,which was diagnosed as an osteoid osteoma (A). Axial proton-density fat-saturated magnetic resonanceimage showing diffuse high-signal medullary edema and periostitis surrounding a markedly thickenedlow-signal cortex, within which a 3-mm osteoid osteoma lies (B). Axial computed tomography scanobtained during radiofrequency ablation showing the densely thickened cortex and an ablation needle

completely occupying the nidus (C).1A

1B 1C

Figure 2: A 23-year-old man presented after 18 months of knee pain due to medullary osteoid osteoma.Axial computed tomography scan from a treatment planning study showing the lucent osteoid osteoma,subtle central calcication, and surrounding medullary sclerosis. Note the vascular channel entering themedial aspect of the lesion (A). Coronal proton-density fat-saturated magnetic resonance image showinga zone of marrow edema centered on a high-signal nidus adjacent to the physeal scar (B).

2A 2B

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(MRI). A primarily cellular nidus will dem-onstrate low to intermediate signal inten-sity on T1-weighted images that increaseson T2-weighted images (Figure 1B). Aheavily calcied nidus appears as low tointermediate signal intensity on both T1-and T2-weighted images. 37A more strikingnding is the presence of surrounding bonemarrow edema or periostitis, best demon-strated on uid-sensitive sequences (Figure2B). Areas of densely sclerotic medullaryor cortical bone may retain low signal in-tensity on all sequences. In some cases,the bone marrow and soft tissue edema isorid and can mimic an aggressive process,such as infection or malignancy. Reactivesoft tissue mass with myxomatous change,cell-depleted juxtanidal bone marrow, and

proteinaceous material may be confusedwith those of a malignant tumor or osteo-myelitis. 38,39

It has been suggested that MRI mustnot be interpreted without reference toplain radiographs and CT scans becausethe appearance of osteoid osteomas onMRI can mimic that of an aggressive le-sion. 25 Correlation with clinical infor-mation is the most important aspect ofdiagnosing osteoid osteomas. Following

intravenous gadopentate dimeglumine,both the central nidus and surroundingedema show enhancement. This techniqueis not always necessary, but occasion-ally it may assist the differential diagnosisalong with other modalities.

SonographyHistorically, the use of preoperative

Doppler duplex color localization of os-teoid osteomas has been reported as ameans of assessment of the vascularityof the nidus or the nidus feeding artery. 40 Color Doppler sonography may show in-creased blood supply and demonstrate theentering vessel at the site of the lesion. 41 Sonography is limited by its inability topenetrate bone and has been replaced by

other imaging modalities.

HistopathologyOsteoid osteomas consist of a nidus

that is surrounded by sclerotic bone, thedensity of which usually varies with timefrom the onset of the lesion. 42 Macroscop-ically, the nidus is a distinct round or ovalreddish area with little contact with itssurrounding sclerotic bone. Depending onthe degree of calcication, the nidus con-

sistency may vary from soft and granularto hard and sclerotic. Older lesions dem-onstrate formation of dened trabeculae.

Intraoperatively, the tumor can be visu-alized protruding from the bone surface, orit may be hidden under a thick cortical lay-er of hyperostotic reactive bone. Intracorti-cal and subperiosteal lesions are often as-sociated with hyperemia and edema of thesurrounding soft tissues. 4 In tubular bonesspecically, osteoid osteomas that presentsubperiosteally tend to become intracorti-cal due to continuous bone remodeling andsubperiosteal new bone apposition. 43

Histologically, the nidus appears asa small, well-dened area consisting ofinterlacing, irregular bone trabeculae ofvarying mineralization (Figure 5). Size,

thickness, and mineralization diversity oftrabeculae are evident among different le-sions, as well as in different areas of thesame lesion. The nidus may demonstrate azonal arrangement of trabecular architec-ture, with the central part being more scle-rotic and the periphery less mineralizedand with more cells. Osteoid trabeculaeare surrounded mainly by osteoblasts. 44

Osteoclast-like, multinucleated giantcells have also been reported to be pres-

Figure 3: An 11-year-old boy presented with an osteoid osteoma in the right medial femoral neck that wastreated with radiofrequency ablation. Computed tomography (CT) scanogram image showing the lucentosteoid osteoma surrounded by medullary sclerosis and overlying cortical thickening. An ablation needlehas been placed in the lesion under CT guidance (A). Axial CT scan showing the needle traversing theosteoid osteoma. A lateral approach was used to avoid the grossly thickened cortical bone (B).

3A 3B

Figure 4: A 16-year-old boy presented with a

1-year history of knee pain but normal clinical ex-amination. Radionuclide bone scan image showinga wide zone of increased uptake in the proximal tib-ia due to increased osteoblastic activity provokedby an osteoid osteoma.

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ent. 45 A reactive bone-formation zone withthickened trabeculae and a loose bro-vascular stroma surrounds the nidus. Thesurrounding zones of soft tissue, skeletalmuscle, and bone show increased vascular-ity, with vessels becoming smaller closerto the nidus. 46 In chronic lesions, the bro-vascular stroma may be dense with chronicinammatory cell inltration.

Pain commonly induced by osteoid os-teomas is attributed to unmyelinated nervebers found within the nidus. 47 Immunohis-tochemical analysis has detected peripheralnerve bers in the reactive zone and the ni-dus, with the greatest number being at theinterface between the reactive zone and theedge of the nidus. 44 Increased local concen-tration of prostaglandins (PGE 2, PGI 2, PGF 2-alpha) and increased urinary excretion of6-keto-PGF 1 (the major urinary metaboliteof PGI 2) have been discussed in the literaturein cases of osteoid osteoma. 48,49 Pain medi-ated by prostaglandins has been attributed tothe vasodilatory and vascular proliferation

effect causing increased local pressure andthus stimulating the peripheral nerve bersof the reactive zone, or through activation ofthe bradykinin system. 50 Increased prosta-glandin values are reversible after osteomaremoval. 49 Although the remodeling and os-teolytic effect of prostaglandins is still underconsideration, prostaglandins of the E seriesstimulate osteoclastic bone resorption in vi-tro and may contribute to the formation ofosteoid osteoma. 51

Nidus osteoblasts also display strongdiffuse staining for COX-2, a key enzymein the production of prostaglandins andin particular of prostaglandin E2. 52 This

enzyme appears to be a major factor inosteoid osteoma pain, and inhibition ofCOX-2 production enables control ofsymptoms. 53

DIFFERENTIAL D IAGNOSIS

The differentiation of osteoid osteomasfrom other benign bone-forming lesions isbased on the difference in size, location,pathology, and clinical symptoms, pathol-ogy, and clinical symptoms. 5 In particular,osteoblastomas are larger in size (usuallymore than 1.5 to 2 cm) and tend to expandinstead of regress. 45 Osteoblastomas arealso painful but generally without charac-teristic night exacerbation seen with oste-oid osteomas, and pain does not responddramatically to salicylates or NSAIDs.Osteoblastomas have a predilection forvertebrae and can be accompanied morefrequently with neurological symptoms orparavertebral muscle spasm. 6,7 Instancesof osteoid osteoma transition to osteo-blastoma have been reported, althoughthey are rare. 54,55 Radiographically, osteo-blastomas appear larger with less reactivesclerosis. 5 Plain radiographs alone maynot be distinctive enough to establish thediagnosis, and CT scans can give more in-formation on the expansive nature of thelesion.

When small in size, a Brodies abscessmay appear similar to an osteoid osteomaon plain radiographs. 9 Imaging usingMRI, CT, and scintigraphy can help dif-

ferentiate between osteoid osteomas andosteomyelitis, as well as other types oftumors, including nonossifying bromas,chondroblastomas, enchondromas, eosin-ophilic granulomas, and malignant bonetumors. 32,39,56

In children, infantile cortical hyperos-tosis, osteomyelitis, Perthes disease, leg-length discrepancy, healing stress frac-tures, tuberculosis, and neuromuscularconditions should be considered. 57 Imag-

ing using CT, bone, and SPECT scans areuseful in delineating the nature of the le-sion. Patients with unexplained low-backpain and sciatic pain in the second decade

of life should be carefully examined torule out osteoid osteoma. 58

TREATMENT

Moberg 59 suggested that the naturalhistory of osteoid osteoma is that of spon-taneous healing. In various studies, it hasbeen noted that if the osteoid osteoma isnot excised, complete resolution of symp-toms occurs within 6 to 15 years. 42,59 Ad-ministering aspirin or other NSAIDs canreduce this time period to 2 to 3 years. 50,53 Kneisl and Simon 60 reported permanentrelief of symptoms and regression of thenidus after prolonged NSAIDs treatmentfor 30 to 40 months. Strict selection cri-teria should be applied if nonoperativetreatment is considered, given the poten-tial side effects of prolonged NSAIDs ad-ministration. Nonoperative managementshould be considered in patients whereosteoid osteoma is not easily accessibleby surgery.

Various techniques have been de-scribed for the preoperative localizationof osteoid osteomas, such as angiographyand placing wires and needles dipped inmethylene blue over the nidus while un-der CT guidance. 23 Radioisotope imagingwith scintimetric guidance for intraop-erative localization and excision has beenreported. 61-63 Historically, in cases of in-tracortical lesions, preoperative oral tetra-cycline administration and examination ofnidus uorescence under ultraviolet light

has been used to demonstrate the lesionand to verify excision, but such techniquesare not currently considered practical. 64,65

Osteoid osteoma was traditionallytreated with excision of the nidus. 6,16 Al-though the nidus needs to be removedcompletely to achieve symptomatic relief,complete removal of the sclerotic boneis not necessary. A well-planned surgicalapproach is essential. Radiographs or CTscans conrm identication of the nidus

Figure 5: Hematoxylin-eosin stain (original magni-cation 200) showing trabeculae of woven bonelined by osteoblasts surrounded by a loose vascu-lar connective tissue stroma.

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before and after en bloc removal, and thenthe nidus undergoes histological examina-tion for conrmation. En bloc resectionhas the disadvantages of a large surgical

exposure and excision of a large part ofsclerotic bone. Bone grafting or internalxation may be necessary, depending onthe size of the bone defect left by the re-section. 5 Unroong and curettage has arole in structurally critical locations, suchas the neck of femur because the centralsclerotic structure is not disrupted. 4 Mul-tiple articles report arthroscopic removalof intra-articular osteoid osteomas. 66-69

Several methods have been describedwhereby osteoid osteomas may be treatedpercutaneously using CT guidance. Theseinclude trephine excision, cryoablation,radiofrequency ablation, and laser thermo-coagulation. 24-28 The use of 3-dimensionalC-arm radiographs during percutaneousexcision in the long bones of childrenhas also been reported. 70 However, mostpatients in the literature undergoing per-cutaneous ablation or resection requiredgeneral anesthesia for pain control. Theneed for a general anesthetic increasesthe invasive nature and the cost of theseprocedures and reduces the advantagesof percutaneous treatment over surgicalresection. Furthermore, these techniquesrequire equipment not commonly avail-able in all hospitals.

Fine drills, bone trephine, or Tru-Cutneedles (Medline Industries, Inc, Mun-delein, Illinois) have been described foruse in precise and bone-sparing resec-tion. With smaller instruments, the needfor a general anesthetic is also reduced,

and the procedure can be performedin the outpatient setting, reducing theoverall cost. Roger et al 26 reported 16patients who were treated using per-cutaneous CT-guided excision and hadsatisfactory results in 14 patients. The 2failures were attributed to the proximityof the lesion to the articular margin andexcessive periosteal reaction preventingaccess. The authors concluded that in-traoperative CT guidance and immediate

postoperative scintigraphy were effectivein localizing and conrming removal ofthe nidus in an outpatient setting. 26 In aseries of 38 patients, Sans et al 71 reported

a cure rate of 84% at 3.7 years postopera-tively and 2 instances of femoral fractureat 2 months. Muscolo et al 72 reported su-perior outcomes of CT-guided minimallyinvasive surgery rather than open sur-gery. Overall, percutaneous CT-guidedprocedures have profoundly modied thetreatment of osteoid osteoma. Rosenthalet al 73 reported a statistically signicantreduction in hospital stay over the past20 years by using more conservative andintralesional procedures.

Gangi et al 74 reported laser interstitialphotocoagulation as a successful mini-mally invasive procedure. In their caseseries of 114 patients, 112 patients had avisual analog score of 0 at 1 week postop-eratively. Six patients had recurrence andwere successfully treated at the secondattempt. 74 A recent retrospective study re-ported 26 patients treated by percutaneoustrephine resection and 100 by percutane-ous interstitial laser ablation. 75 Percutane-ous trephine resection had a success rateof 95% at 24 months. Two patients sus-tained skin burns and 1 reported meralgia.Interstitial laser ablation had a successrate of 94% at 24 months, with compli-cations including infection, tendonitis,hematoma, and common peroneal nerveinjury. The outcome was worse regardlessof treatment method in patients youngerthan 18 years and in instances where thenidus was 12 mm or larger. 75

Percutaneous thermocoagulation of

the nidus has been used by de Berg et al,76

who reported 17 patients treated success-fully with this method. Percutaneous ra-diofrequency ablation has been proposedas an alternative to the operative treatmentof osteoid osteomas. 77 The newer technol-ogy radiofrequency probes allow thermo-coagulation of a region as large as 5 cmusing a single probe (Figure 1C). Gener-ally, osteoid osteoma nidus size is up to 1cm; consequently, the conventional mono-

polar radio frequency probe is adequate. Aseries of 21 patients with osteoid osteomain atypical locations (eg, hip, radioulnar

joint, phalanx) showed radiofrequency

ablation to be successful, albeit with onlyshort-term follow-up data available. 78 A5-year review of radiofrequency ablationconrmed cure in 38 of 39 patients, with 1case of a broken drill and 1 of infection asthe only reported complications. 79 Simi-larly, a 5-year case series of 21 patientsconrmed a primary cure rate of 89.6%that increased to 93% if a second treat-ment was required. 80

With osteoid osteoma affecting thespine, the efcacy and safety of this pro-cedure has been assessed, especially con-sidering the effect of increased temperaturein the spinal canal. Dupuy et al 81 reportedthat this technique has no cytotoxic ef-fects into the spinal canal, especially withinternally cooled radiofrequency probes.Recently, Peyser et al 82 and Neumann etal83 also concluded that CT-guided percu-taneous radiofrequency ablation of osteoidosteomas is a safe, effective, and minimallyinvasive procedure with a high success rateand no recurrence. Rimondi et al 84 reporteda series of 557 patients and recommendedmodications to electrode parameters, du-ration of ablation with regard to the size,and morphology of the lesion.

Recently, bipolar radiofrequency tech-nology has gained interest in the manage-ment of osteoid osteoma. Some drawbacksof monopolar radiofrequency ablationinclude skin burns at the site of neutralelectrode and aberrant currents causing ir-regular areas of necrosis or inducing heat

at metallic implants.85

Another innovativeapproach with promising results, particu-larly for inaccessible lesions, has beendescribed by Mylona et al, 29 who success-fully performed radiofrequency ablationusing a probe needle with expandableelectrodes. A retrospective review of 81patients treated either by conventionalsurgery or minimally invasive techniquesfor osteoid osteoma of the spine found nodifference in outcome. 86

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