What is the management approach for osteoid osteoma?

From the Guidelines

The management of osteoid osteoma should prioritize CT-guided radiofrequency ablation (RFA) as the definitive treatment for patients with persistent symptoms despite NSAID therapy, given its high success rates exceeding 90% and minimal complications 1. The diagnosis of osteoid osteoma is typically confirmed using CT scans, which are considered the optimal imaging modality due to their high sensitivity for detection and precise delineation of the nidus 1.

• CT scans are preferred over MRI when osteoid osteoma is strongly suspected, as they are more accurate in detecting the osteoid osteoma nidus 1.
• CT perfusion is a useful dynamic examination that can further characterize suspected osteoid osteoma by showing early enhancement with a delay between nidus and arterial peak below 30 seconds, although this is not pathognomonic 1. For patients with newly diagnosed osteoid osteoma, conservative treatment with nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen can be initiated to control pain, with the possibility of spontaneous resolution over time 1.
• NSAIDs can be continued for 6-12 months, as some osteoid osteomas can resolve spontaneously during this period.
• The choice of treatment should consider the patient's age, lesion location, symptom severity, and potential risks of each approach. The characteristic night pain of osteoid osteoma, which responds dramatically to NSAIDs, is due to high levels of prostaglandins produced by the tumor's nidus, explaining the effectiveness of anti-inflammatory medications in symptom management 1.

From the Research

Management Approach for Osteoid Osteoma

The management approach for osteoid osteoma can be divided into two main categories: non-operative treatment and surgical treatment.

• Non-operative treatment: This approach is considered for patients with mild symptoms, as the natural history of osteoid osteoma is that of spontaneous healing 2, 3, 4. Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used to control pain, and symptoms often resolve after a mean time of 2.5 years 2.
• Surgical treatment: This approach is considered for patients with severe pain, those not responding to NSAIDs, or those who cannot tolerate prolonged NSAID therapy due to side effects 3, 4. Surgical options include:
  • Open surgery
  • Percutaneous ablation (e.g., radiofrequency ablation, cryoablation, microwave ablation) 5, 6
  • CT-guided percutaneous excision
  • En bloc resection 3

Factors Influencing Treatment Choice

The choice of treatment depends on various factors, including:

• Location of the osteoid osteoma: Open surgery and cryoablation may be preferred for lesions close to the nerve or at atypical sites, while radiofrequency ablation and microwave ablation may be preferred for lesions in most other sites 5.
• Patient tolerance: Patients who cannot tolerate NSAIDs or have severe pain may require surgical intervention 2, 4.
• Technical success rate: Percutaneous ablation has a higher technical success rate compared to open surgery 5.

Efficacy and Safety of Treatment Options

Studies have shown that both percutaneous ablation and open surgery are safe and reliable for osteoid osteoma, with low complication and recurrence rates 5, 6. However, the choice of treatment ultimately depends on individual patient factors and the specific characteristics of the osteoid osteoma.