Table Of ContentEngeletal.SpringerPlus2013,2:34
http://www.springerplus.com/content/2/1/34
a SpringerOpen Journal
RESEARCH Open Access
CT-guided percutaneous drilling is a safe and
reliable method of treating osteoid osteomas
Edgard Eduard Engel1*, Nelson Fabrício Gava1, Marcello Henrique Nogueira-Barbosa2 and Filipe Almeida Botter1
Abstract
Computed tomography(CT)-guided percutaneous drilling is an alternative for osteoid osteoma treatment. This
study aims to evaluate the remodeling of the drill orifice. The success rate and complicationswere also recorded
and compared with other treatment methods.
Fifteen patients with an average age offourteen years (ranging from 4 to 25) submitted to CT-guided percutaneous
drilling between 2003 and 2009 were retrospectively analyzed according to clinical and radiological criteria.
Fourteen cases showed complete alleviation of pain one week after surgery. No relapse was detected even in the
subject who continued complaining of pain. Allpatients were treated witha day-hospital regimen and were
discharged with partial weight bearing. Total weight bearing was allowed after one month, and sports were
allowed after consolidation, which occurred inall but one case after the third month. One patient,who did not
follow our medical advice,returned to sports activities after two weeksand experienced a fracture as a result.
Atrophy of thevastus lateralis muscle developed after theprocedure inanother patient.
Our case series suggests that this method is reliable and safe. The level of complexity is comparable withother
minimally invasive percutaneous procedures. The cost is low because there is noneed to buy probes or other
equipment. The negative points includeweakening of thebone and the logistical problem ofassembling the
orthopedic surgeon, radiologist, and anesthesiologistin thetomography room.
Keywords: Osteoid osteoma, Interventional radiography, Bone remodeling,Treatment outcome, Bone neoplasms
Introduction mechanical precariousness of the remaining bone after
An osteoid osteoma is a small, painful, benign tumor resection (Steinberg et al. 1990). Total resection must be
that primarily affects people younger than 30 years old. achieved to avoid relapse and assure pain relief (Norman
An osteoid osteoma is less than 2 cm in diameter, which 1978). Because not all osteoid osteomas can be
distinguishes it from an osteoblastoma (Campanacci visualized with the image intensifier, one proposed solu-
et al. 1999, Schulman & Dorfman 1970, Akhlaghpoor tion was to pinpoint its location prior to resection using
et al. 2007,Vanderschueren et al. 2002). The pain is not a computed tomography (CT) scan and mark it with a
associated with physical activity, usually intensifies at Kirschner wire, which could then be easily found at the
night, and is typically alleviated by aspirin or other time of surgery (David et al. 1997, Steinberg et al. 1990).
NSAIDs (Vanderschueren et al. 2002, Fenichel et al. Another possibility was to use a radioactive tracer with
2006, David et al. 1997). The bones that are most bone tropism (Pratali et al. 2009 ). In addition to identi-
affected are the femur and the tibia, accounting for 50% fying the affected area, the use of a probe during surgery
of the cases, although theoretically any bone could be allows the complete resection of the tumor to be
affected (Gangi etal. 2007). confirmed(Pratali etal. 2009).
The difficulties in treating osteoid osteomas lie in the With respect to the reduction of morbidity caused by
intra-surgical pinpointing of the tumor and the mechanicalinstability,thefocuswastoreducetheamount
of normal bone removal without failing to remove the
*Correspondence:[email protected] tumor tissue. Extensive resectioning predisposes the pa-
1DepartmentofOrthopedicsandTraumatology,SchoolofMedicineof
tient to fractures, thereby demanding long periods of rest
RibeirãoPreto,UniversityofSãoPaulo,Av.Bandeirantes,3900,Hospitaldas
Clínicas11(cid:2)andar,MonteAlegre,RibeirãoPreto,SP14049-900,Brazil (Rosenthaletal.1998).Varioustechniquesweredeveloped
Fulllistofauthorinformationisavailableattheendofthearticle
©2013Engeletal.;licenseeSpringer.ThisisanOpenAccessarticledistributedunderthetermsoftheCreativeCommons
AttributionLicense(http://creativecommons.org/licenses/by/2.0),whichpermitsunrestricteduse,distribution,andreproduction
inanymedium,providedtheoriginalworkisproperlycited.
Engeletal.SpringerPlus2013,2:34 Page2of4
http://www.springerplus.com/content/2/1/34
toaddressthisissue,suchasthegradualeliminationofthe The bones affected were the femur in seven cases, the
nidus by curettage or planing, by drilling with a bit, or by tibiainsix,andtheiliacandthedistalhumerusinoneeach.
localized resectioning with a trephine (David et al. 1997, The diagnoses were based on clinical history aided by
Ward et al. 1993, Assoun et al. 1993, Voto et al. 1990). CT and were sometimes confirmed by magnetic reson-
Destruction of the nidus without resectioning by ance imaging. Cases where the diagnosis was dubious
radiofrequencyablation,electro-coagulation,laserablation, were nottreatedbythepercutaneousdrillingmethod.
ortheinjectionofethanolwerealsodescribedwithvarying After the procedure, the improvement in the clinical
incidences of relapse (Nayman et al. 2011, Mahnken et al. symptoms was analyzed, focusing mainly on the im-
2006, Busser et al. 2011, Capanna et al. 1991, Adam et al. provement regarding pain. The patients were evaluated
1995,Peyseretal.2009,Lindneretal.2001). at one week, two weeks, one month, three months, six
There is no consensus about the best method to treat months, one year, two years, and five years post-
osteoid osteomas. The technique of CT-guided percutan- operatively. Starting in the first month, X-rays were
eous drilling is appealing because it minimizes the taken of the affected area to observe the bone remodel-
complications of more extensive surgeries, facilitates the ing, which was classified into four phases. The first
pinpointingofthenidus,provokesminimum traumainthe phase showed the empty hole where the bone was
bone and neighboring tissues, diminishes hospitalization drilled, the second showed a shadow in that area, the
time and causes less post-operative pain (Rosenthal et al. third showed the bony callus, and the last phase showed
1998,Peyseretal.2009). the completeremodelingofthebone.
Materials and methods Results
The medical data of 15 consecutive patients treated by One week after surgery, twelve patients (80%) reported a
CT-guidedpercutaneousdrilling for osteoidosteomabe- complete absence of pain. After one month, 13 patients
tween 2003 and 2009 were reviewed after approval of had no more pain. Of the two remaining patients, one
the ethics committee. Twelve patients were male, and reported a lessening of pain three months after the pro-
three were female. The average age at diagnosis was cedure,andonlyonecaseshowednoimprovementinthe
14.2years(4to25years). pain symptoms four years after the procedure despite
The procedure was performed in the CT room with X-rays and scans that demonstrated complete remodeling
the patient anaesthetized by spinal block and sedation. of the bone, no relapse, and the absence of any other
After pinpointing the nidus by tomography, the skin was lesions. All patients were treated with a day-hospital regi-
marked in the area of the lesion, and the patient was men and were discharged with partial weight bearing.
slidden out from the CT arc. Based on the image and Total weight bearing was allowed after one month, and
skin markings, the bone was punctured by an 11 G bone sportswereallowedafterconsolidation,whichoccurredin
cannula. The patient was slidden back into the CT, and all but one case after the third month. Histological con-
the positioning was confirmed. If the positioning was firmationwaspossibleinsevencases(41%).
correct, a small fragment was removed with the cannula The X-rays showed rapid filling of the hole with new
for a biopsy, and a Kirschner wire was introduced into bone. After one month, five patients were already shown
the same opening and anchored in the cortical bone. to be in phase two with incipient calluses by X-ray, and
Next, the bone was drilled with a 7.0 mm tubular bit, atthreemonths,fivehad bonycalluses blockingthehole
followed by a 10.0 mm rounded bit if necessary. The pa- (Figure 2).
tientwasonceagainsliddenintothemachinetoconfirm There were two complications that had no impact on
the complete resection of the tumor. Repositioning the the outcome of the treatment. In one case, there was a
guide wire and moving it a few millimeters towards the lesion of the motor branch of the quadriceps with mild
residual lesion was occasionally necessary for supple- atrophy of the vastus lateralis muscle. The other case
mentary resectioning. Ideally, the deepest part of the presentedwithanincompletefractureinthedrilledregion
cortex was preserved, but frequently the cortex has been of the tibia 13 days after the procedure. This fracture oc-
completely severed. In some situations, to avoid curred during a sports activity because the patient was
neurovascular structures, access was gained through the completely free of pain and did not follow the medical
opposite cortex, requiring the perforation of both corti- recommendationtoavoidfullweightbearingatthattime.
ces. In nine cases (60%), access to the tumor was direct, The use of a functional brace was enough for the patient
and it was operated on with only a single cortical orifice. torecovercompletely.
In six cases, access was obtained from the opposite side,
creatingtwoorificesInoneofthempartofthethickness Discussion
of the cortical wall on the affected side could be The rationale of osteoid osteoma treatment consists of
preserved(Figure 1). complete resection of the nidus with minimum bone
Engeletal.SpringerPlus2013,2:34 Page3of4
http://www.springerplus.com/content/2/1/34
Figure1A.CTshowingthewellpositionedK-wire(whitearrow).Accesstothenidus(blackarrow)viatheoppositecortexwasusefulinthis
casetoavoidtheneurovascularbundle.B.CTafterresection.Notethatthecortexwasnottotallydrilled.Theblackdashedarrowindicatesthe
remainingcortex.Smallbonedebriswasleftinthepathandisconsideredharmless(dashedwhitearrow).
weakening. The existing methods of reaching these Mahnkenetal.2006,Busseretal.2011,Capannaetal.1991,
objectives lie between two extremes when cost and mor- Adam et al. 1995, Peyser et al. 2009, Lindner et al. 2001).
bidityareanalyzed.Ononehand,thereareopenenblock Thesetechniquesshowrelapseratescomparablewiththose
and curettage techniques. These methods have a low cost of open resectioning and do not require post-operative
advantage and offer a confirmation of complete resection immobilization because the patient can bear weight on the
of the nidus during the procedure, combined with a low operated limb as soon as the first day after the procedure.
relapse rate and an anatomopathological diagnosis be- The disadvantages include the high cost of acquiring the
cause the entire lesion is sent for biopsy (Campanacci probes and specific materials required by these techniques
et al. 1999). The disadvantages are the higher morbidity, and being unable to confirm the complete resection of the
the need for more prolonged post-operative rest periods nidus during the procedure (Vanderschueren et al. 2002,
and sometimes a greater risk of fractures (Campanacci Lindner et al. 2001). An additional disadvantage is the low
et al. 1999, David et al. 1997, Rosenthal et al. 1998). An rate of anatomopathological confirmation due to the
additional disadvantage is the difficulty in pinpointing the scant quantity of material sent for biopsy, even though
nidus during open resectioning, even with the use of an this rate can range from 36% to 90% (Fenichel et al.
imageintensifier(Steinbergetal.1990). 2006, Gangi et al. 2007, Peyser et al. 2009, Lindner et al.
On the other hand, there are percutaneous techniques 2001,Mylonaetal.2010).
such as radio frequency ablation, laser photo-ablation, and The percutaneous CT-guided drilling technique
ethanol injection. The advantages of these methods include presented in this study confirms this method as an
the ease of pinpointing the nidus with tomography and a appealing alternative compared with the other treatment
reducedmorbidityrateduetominimalresectionofthebone options. It demonstrated a high rate of success (14 of 15
(Akhlaghpooretal.2007,Vanderschuerenetal.2002,Gangi patients, 94%), similar to that of the other percutaneous
et al. 2007, Rosenthal et al. 1998, Nayman et al. 2011, methods (Vanderschueren et al. 2002, Gangi et al. 2007,
Figure2Graphshowingthepercentageofpatientsineachphaseofboneremodelingaccordingtothefollow-uptime.(Phase1,hole;
phase2,shadow;phase3,callus;phase4,remodeled).
Engeletal.SpringerPlus2013,2:34 Page4of4
http://www.springerplus.com/content/2/1/34
Peyser et al. 2009). Because the entire surgery, from AkhlaghpoorS,TomasianA,ArjmandShabestariA,EbrahimiM,Alinaghizadeh
pinpointingthenidustotheendofthedrilling,isperformed MR(2007)Percutaneousosteoidosteomatreatmentwithcombinationof
radiofrequencyandalcoholablation.ClinRadiol62:268–273
with the aid of tomography, the resectioning remains con-
AssounJ,RailhacJJ,BonnevialleP,PoeyC,deSallesGJ,BauninCetal(1993)
trolledduringtheprocedurewithnoneedofasecondinter- Osteoidosteoma:percutaneousresectionwithCTguidance.Radiology
vention due to an incomplete resection, which can occur in 188:541–547
BusserWM,HoogeveenYL,VethRPetal(2011)Percutaneousradiofrequency
the other percutaneous methods (Vanderschueren et al.
ablationofosteoidosteomaswithuseofreal-timeneedleguidanceforaccurate
2002, Gangi et al. 2007, Peyser et al. 2009) in which the needleplacement:apilotstudy.CardiovascInterventRadiol34:180–183
destroyed nidus cannot be visually monitored. The relapse CampanacciM,RuggieriP,GasbarriniA,FerraroA,CampanacciL(1999)Osteoid
osteoma.Directvisualidentificationandintralesionalexcisionofthenidus
rates are comparable with those of all the other methods. withminimalremovalofbone.JBoneJointSurgBr81:814–820
The anatomopathological confirmation rate is also com- CapannaR,BorianiS,MabitC,DonatiD,SaviniR(1991)[Osteoidosteomaofthe
parable with that of the other percutaneous procedures spine.TheexperienceoftheRizzoliInstitute].RevChirOrthopReparatrice
ApparMot77:545–550
(Gangietal.2007,Peyseretal.2009,Lindneretal.2001).
DavidA,RiosAR,TarragôR,OliveiraGK,GarzellaMM,OliveiraRK(1997)Excisão
Drilling,which is a percutaneous technique, also does not deosteomaosteóideportrefinaorientadapelatomografia
necessitate prolonged rest time or additional implants to computadorizada.RevBrasOrtop32:396–400
FenichelI,GarniackA,MoragB,PaltiR,SalaiM(2006)PercutaneousCT-guided
guaranteestability.Ithasalowcostbecausethereisnoneed
curettageofosteoidosteomawithhistologicalconfirmation:aretrospective
forspecialprobesorotherequipmentandthehospitalization studyandreviewoftheliterature.IntOrthop30:139–142
timeisshort.Thelevelofcomplexityiscomparablewiththat GangiA,AlizadehH,WongL,BuyX,DietemannJL,RoyC(2007)Osteoid
osteoma:percutaneouslaserablationandfollow-upin114patients.
of other percutaneous procedures involving minimally inva- Radiology242:293–301
sivetechniquesandguidedbonebiopsies. LindnerNJ,OzakiT,RoedlR,GoshegerG,WinkelmannW,WörtlerK(2001)
We consider apotential negativepointto bethelogistical Percutaneousradiofrequencyablationinosteoidosteoma.JBoneJointSurg
Br83:391–396
problem of assembling the orthopedist, radiologist, and
MahnkenAH,TackeJA,WildbergerJE,GüntherRW(2006)Radiofrequency
anesthesiologist at the same time in the tomography room. ablationofosteoidosteoma:initialresultswithabipolarablationdevice.J
Theotherpercutaneoustreatmentmethodsalsoneedtouse VascIntervRadiol17:1465–1470
MylonaS,PatsouraS,GalaniP,KarapostolakisG,PomoniA,ThanosL(2010)
CTguidingtobemoreprecise,andthereforethisinconveni-
Osteoidosteomasincommonandintechnicallychallenginglocations
enceisnotuniquetothedescribedtechnique. treatedwithcomputedtomography-guidedpercutaneousradiofrequency
Our results confirm the high success rate and low ablation.SkeletalRadiol39(5):443–449
NaymanA,KoçO,KüçükapanA,ÖzbekS,ÜlküK(2011)Radiofrequencyablation
complication rate of the described method and suggest
ofphalangealosteoidosteoma:technicalchallengesencounteredinsmall
that early weight bearing is safe. Surgeon’s selection of a bone.EklemHastalikCerrahisi22:107–109
procedure depends on subjective preference, because no NormanA(1978)Persistenceorrecurrenceofpain:asignofsurgicalfailureis
osteoid-osteoma.ClinOrthopRelatRes130:263–266
comparativestudies are currentlyavailable.
PeyserA,ApplbaumY,SimanovskyN,SafranO,LamdanR(2009)CT-guided
radiofrequencyablationofpediatricosteoidosteomautilizingawater-cooled
Competinginterest tip.AnnSurgOncol16:2856–2861
Theauthorsandtheinstitutiondidnotreceiveanyfundingorfinancial
PrataliR,ZuianiG,InadaM,HanasiloC,ReganinL,EtchebehereEetal(2009)
support.Therewerenopayments,benefits,agreements,orcommitments
Openresectionofosteoidosteomaguidedbyagamma-probe.IntOrthop
relatedtothisresearchfromanyorganization,andtherewasnocommercial 33:219–223
aim.Theauthorsdeclarenoconflictofinterest.
RosenthalDI,HornicekFJ,WolfeMW,JenningsLC,GebhardtMC,MankinHJ
(1998)Percutaneousradiofrequencycoagulationofosteoidosteoma
Authors’contributions comparedwithoperativetreatment.JBoneJointSurgAm80:815–821
EEEcontributedtothestudyconceptanddesign,patient’soperationand
SchulmanL,DorfmanHD(1970)Nervefibersinosteoidosteoma.JBoneJoint
follow-up,dataanalysisandinterpretation,writingandeditingofthefinal SurgAm52:1351–1356
manuscript.NGcontributedtothestudyconceptanddesign,patient’s
SteinbergGG,CoumasJM,BreenT(1990)Preoperativelocalizationofosteoid
operationandfollow-up,dataanalysisandinterpretation,writingofthe osteoma:anewtechniquethatusesCT.AJRAmJRoentgenol155:883–885
manuscript.MHNBcontributedtothedataanalysisandinterpretationand
VanderschuerenGM,TaminiauAH,ObermannWR,BloemJL(2002)Osteoid
madecriticalrevisionsofthemanuscript.FABcontributedtoradiological osteoma:clinicalresultswiththermocoagulation.Radiology224:82–86
andclinicaldatacollectionandassembly,dataanalysisandwrotethefirst
VotoSJ,CookAJ,WeinerDS,EwingJW,ArringtonLE(1990)Treatmentofosteoid
draftoftheManuscript.Allauthorsreadandapprovedthefinalmanuscript.
osteomabycomputedtomographyguidedexcisioninthepediatricpatient.
JPediatrOrthop10:510–513
Authordetails
WardWG,EckardtJJ,ShayestehfarS,MirraJ,GroganT,OppenheimW(1993)
1DepartmentofOrthopedicsandTraumatology,SchoolofMedicineof
Osteoidosteomadiagnosisandmanagementwithlowmorbidity.Clin
RibeirãoPreto,UniversityofSãoPaulo,Av.Bandeirantes,3900,Hospitaldas OrthopRelatRes291:229–235
Clínicas11(cid:2)andar,MonteAlegre,RibeirãoPreto,SP14049-900,Brazil.
2DepartmentofRadiology,SchoolofMedicineofRibeirãoPreto,University
ofSãoPaulo,Av.Bandeirantes,3900,HospitaldasClínicas11(cid:2)andar,Monte doi:10.1186/2193-1801-2-34
Citethisarticleas:Engeletal.:CT-guidedpercutaneousdrillingisasafe
Alegre,RibeirãoPreto,SP14049-900,Brazil.
andreliablemethodoftreatingosteoidosteomas.SpringerPlus20132:34.
Received:1October2012Accepted:24January2013
Published:31January2013
References
AdamG,KeulersP,VorwerkD,HellerKD,FüzesiL,GüntherRW(1995)[The
percutaneousCT-guidedtreatmentofosteoidosteomas:acombinedprocedure
withabiopsydrillandsubsequentethanolinjection].Rofo162:232–235
