CT引导下经皮穿刺射频消融术治疗脊柱骨样骨瘤3例报告

目的评价CT引导下经皮穿刺射频消融术治疗脊柱骨样骨瘤的临床效果。方法 3例脊柱骨样骨瘤,分别位于颈椎、腰椎和骶椎,肿瘤边缘紧邻脊髓或神经。局部麻醉后,CT引导下经皮穿刺将射频电极置入骨样骨瘤中心,应用90℃的射频高温持续4 min对瘤巢进行损毁。结果术中及术后无明显并发症发生。术后分别随访2、6、7个月（平均5个月）,疼痛缓解满意,3例VAS评分分别下降了6、8、8分,随访期内疼痛无复发,无神经功能损害。结论 CT引导下经皮穿刺射频消融术治疗脊柱骨样骨瘤微创、安全,患者耐受性好,近期效果确切。     

Case Report: Curetting Osteoid Osteoma of the Spine Using Combined Video-assisted Thoracoscopic Surgery and Navigation

Background

A spinal osteoid osteoma is a rare benign tumor. The usual treatment involves complete curettage including the nidus. In the thoracic spine, conventional open surgical treatment usually carries relatively high surgical risks because of the close anatomic relationship to the spinal cord, nerve roots, and thoracic vessels, and pulmonary complications and postoperative pain.

Case Report

We report the case of a 16-year-old girl with a symptomatic osteoid osteoma at the T9 level whose lesion was currettaged using video-assisted thoracoscopic surgery (VATS) guided by a navigation system (VATS-NAV). There were no complications and the patient had immediate relief of the characteristic pain after surgery and was asymptomatic at 5 months’ followup.

Literature Review

Progressive advances in the technology of spinal surgery have evolved to offer greater safety and less morbidity for patients. The advent of minimally invasive surgery has expanded the indications for VATS for anterior spinal disorders. Spinal navigation systems have become useful tools allowing localization and excision of the nidus of osteoid osteomas with minimal bone resection and without radiation exposure.

Clinical Relevance

The VATS-NAV combination in our patient allowed accurate localization and guidance for complete excision of a spinal osteoid osteoma through a minimally invasive approach without compromising spinal stability.     

Osteoma arising from the lumbar articular process

A 57-year-old man presented with an extremely rare osteoma originating from the left L-5 inferior articular process and causing lumbo-crural sciatica. Postmyelography computed tomography and magnetic resonance imaging showed an osteoma compressing the spinal nerve root at the lateral recess. Decompression facetectomy and excision of the lesion followed by transforaminal lumbar interbody fusion between L-5 and S-1 provided complete relief from the symptoms. Histological examination confirmed the diagnosis of benign osteoma. The previous seven cases of spinal osteoma involved the vertebral body, pedicle and posterior elements. Spinal osteomas should be considered in the differential diagnosis of benign lesion originating from the articular process.     

Case Report: Osteoid Osteoma of the C2 Pedicle: Surgical Technique Using a Navigation System

An osteoid osteoma of the cervical spinal pedicle is rare and carries a high surgical risk because of the close anatomic relationship to the spinal cord, nerve root, and vertebral artery. We report the case of a 12-year-old girl with an osteoid osteoma of the C2 pedicle. Computed tomograms showed an oval nidus and marked sclerosis around this lesion at the right C2 pedicle. There also was expansion of the medial and inferior cortical bone of the C2 pedicle. After failure of nonoperative treatment, we planned surgery. Owing to concerns regarding thermal damage to the spinal cord, nerve root, and/or vertebral artery using computed tomography (CT)-guided radiofrequency ablation, we curetted the nidus using a navigation system. Twenty-eight months after surgery, her pain was relieved with no limitation of cervical movement and there has been no evidence of recurrence. Navigation allowed safe curettage of the nidus through a small hole while maintaining spinal stability.     

计算机导航辅助骨样骨瘤的外科治疗

目的 探讨计算机导航技术在骨样骨瘤外科治疗中的意义.方法 回顾性分析2008年1月至2009年12月应用计算机导航辅助切除骨样骨瘤手术26例患者的临床资料,其中男性23例,女性3例,平均年龄18岁(7～35岁).26例患者肿瘤位于股骨干9例、股骨粗隆部4例、股骨颈2例、胫骨干5例、胫骨近端干骺端1例、髋臼2例、耻骨1例、脊柱附件1例、桡骨干1例.术前均经局部X线及CT扫描明确诊断.其中4例采用CT数据导航,22例采用Iso-C 3D C型臂术中实时导航.术中导航指引定位,精确切除瘤巢.结果 全部病例均完成导航手术,其中行开窗刮除12例、整块切除14例;植骨21例、未植骨5例.26例患者均经术中肉眼判定、术中导航指引器确认、术后X线和(或)CT扫描确认瘤巢去除充分.全部病例均经组织病理学确诊为骨样骨瘤,术后疼痛即刻缓解.全部病例均获随访,平均随访20.6个月(12～35个月),未见肿瘤复发和疼痛复发.结论 将计算机导航技术应用于骨样骨瘤的外科治疗,不仅使术中瘤巢定位更精确,而且对于复杂部位瘤巢的切除可以达到骨结构微创治疗的目的.对于骨干部位的骨样骨瘤,Iso-C 3D C型臂术中实时导航较CT数据导航更有帮助.

Abstract：

Objective To report the experience for the precision osteoid osteoma resection using computer navigation system. Methods Between January 2008 and December 2009, 26 surgical resections were performed for 26 patients who had osteoid osteoma with computer navigation system. There were 23 males and 3 females with an average age of 18 years (7 to 35). Tumors were located at femoral shaft 9,femoral trochanter 4, femoral neck 2, tibial shaft 5, metaphysic of proximal tibia 1, acetabulum 2, pubis 1,vertebral appendix 1 and radial shaft 1. Pre-operative X-ray and CT of each patient was performed to confirm the diagnosis. It was carried out intraoperatively the process of CT-based navigation in 4 cases and intraoperative Iso-C three-dimensional navigation in 22 cases. The Navigation System software was Spine Navigation 1.2 in all cases. The Pointer was helpful to localize the lesion and precisely resected the lesion without removal of any excess bone. Results All the navigation operations were finished successfully with curettage for 12 and En Bloc resection for 14. Bone grafting was made in 21 cases and none in 3 cases. The completely clearance of nidus by intraoperative visual inspection and Pointer confirmation, postoperative X-ray and (or) CT scan was performed in all cases. All cases had histopathology diagnosis of osteoid osteoma and immediate pain relief after surgery. All cases were followed up for 20. 6 months averagely (12 to 35 months). No local recurrence and pain relapse occurred. Conclusions The navigation system is very helpful for the precision tumor resection of nidus. Especially for the patients with osteoid osteoma located at diaphysis, Intraoperative Iso-C three-dimensional navigation is more useful.     

Vertebral osteoid osteoma--peroperative detection of its nidus using a surgical gamma probe

The case of a vertebral osteoid osteoma localized in the arch and pedicle of the fourth lumbar vertebra in a young girl is described. The condition was manifested by the development of scoliosis, which was also the initial diagnosis. Because of painful muscle contractions and persistent pain at night, osteoid osteoma was suspected and then confirmed by scintigraphy. In order to minimize resection of the posterior stabilizing structures and to ensure removal of the complete nidus, surgery was carried out with the use of a surgical gamma probe. The method is based on administration of a radionuclide (99m Techneciumlabeled methylenediphosphonate) 2 to 3 h before the operation and intraoperative detection of the intensity of radiation directly in the operative wound. The values of impulses recorded over the nidus were more than ten-times higher than the background values, i.e., the impulses over the surrounding, unaffected bone. The nidus was exactly localized and removed as a whole. Posterolateral fusion without instrumentation was carried out. The patient was almost immediately free from night pain. After fixation with TLSO for 3 months, the patient started physical therapy. One year later she was without any complaints, fusion was healed and she had no relapse. The aim of this study was to draw attention to this less known and therefore less frequently employed method that may enable the surgeon to detect conditions otherwise difficult to localize. This method can also be used for other body sites if the lesion treated accumulates radionuclides.     

Osteoid osteoma in the lumbar and sacral regions: two cases of difficult diagnosis

We present two cases of osteoid osteoma affecting a lumbar vertebral body and the sacrum, being both in a very infrequent localization and difficult diagnosis. We found the scintigraphy to be of invaluable assistance in revealing the presence of this small nodular lesion of the spine, and the computed axial tomography (CAT) scan study was likewise useful for its precision in localizing the tumor as a basis for deciding upon a viable surgical approach. Without such techniques, correct diagnosis may be made too late. In our experience, surgical resection of the osteoid osteoma brings about immediate relief of the symptoms.     

Atypical location of an osteoid osteoma with atypical anterior knee pain

INTRODUCTION

An osteoid osteoma is a painful tumor that most commonly affects the extra-articular parts of the long bones. An intra-articular location of an osteoid osteoma is rare. Various differential diagnoses may arise in connection with such an unusual location because it causes atypical clinical signs.

PRESENTATION OF CASE

A 24-year-old male developed pain in the central region of the right knee. Magnetic resonance imaging (MRI) showed no clear pathology in the knee joint. A technetium bone scan and computed tomography (CT) were then ordered and confirmed the presence of an osteoid osteoma in the knee joint. The patient was treated through an anteromedial approach to the knee, and the lesion was removed by excisional biopsy under fluoroscopy.

DISCUSSION

The diagnosis of intra-articular osteoid osteoma is challenging because the clinical presentation can be misleading. MRI is often requested as the first imaging method when dealing with knee symptoms, and radiologists are often unaware of the clinical presentation. Edema seen on MRI can be misleading with respect to the location of the nidus. CT is considered to be the best imaging method because it usually allows for clear visualization of the nidus. Different treatments have been proposed, ranging from open excision to arthroscopic resection.

CONCLUSION

Osteoid osteoma should be considered in young adult patients with chronic knee pain and no history of trauma.     

腰椎椎体后缘骨内软骨结节所致腰椎管狭窄症16例CT分析

目的　总结腰椎椎体后缘骨内软骨结节 (LPMN)所致腰椎管狭窄症临床、CT诊断及鉴别诊断 ,探讨有关的发病因素。方法　对经手术证实的 16例PLMN所致腰椎管狭窄症的临床表现、CT表现、手术方式进行回顾性分析总结。结果　典型的CT改变为 (1)椎体后上缘类圆形骨质缺损 ,边缘较致密硬化 ;(2 )缺损后方有一骨块突入椎管 ,(游离或部分与椎体相连 ) ;(3)硬膜囊及神经根受压 ,可伴有椎间盘突出。结论　CT检查能明确诊断腰椎椎体后缘骨内软骨结节 (LPMN)所致腰椎管狭窄症 ,并为制订治疗方案提供可靠依据。     

Classical surgical resection of osteoid osteoma of the cervical spine

Osteoid osteoma is a benign primary skeletal neoplasm occurring mainly in the cortex of long bones, but also in the spine. It occurs most often in young adult males and causes pain in the affected area. It presents as a nidus surrounded by reactive osteosclerosis or less often as a cancellous lesion with only a slight osteosclerosis. Osteoid osteoma may occur in basically any bone of the body, but the strategy of treatment has to be considered carefully, especially when it occurs in the spine. We report about a 38 year old female diagnosed with an osteoid osteoma located in the posterior element of the 5th cervical vertebra. She presented with persisting neck pain over one and a half years. An MRI and CT scan was performed. Due to the vicinity seen in the MRI imaging to neural structures and the slim rest of cortex in this area we decided to use the classical surgical excision through a minimal invasive approach to resect the lesion. Histological examination revealed the typical structures for osteoid osteoma. The patient was immediately free of symptoms and still is nine months after treatment. Surgical excision of an osteoid osteoma is still a good alternative to percutaneous radiofrequency ablation when treating osteoid osteoma located in close vicinity to neural structures.     

影像导航引导椎体成形术治疗多发性椎体转移瘤的临床分析

目的探讨影像导航引导椎体成形术在多发性椎体转移瘤中的临床应用。方法获取23例多发性椎体转移瘤患者，手术椎节的正侧位及斜位片，采用影像导航的方法虚拟成椎体的正侧位及椎弓根轴位片，引导经皮椎弓根穿刺行椎体成形术。结果本组23例患者均为单侧穿刺，导航引导椎体成形术均获成功，术中进行导航虚拟影像与实际穿刺针影像进行匹配，两者影像基本吻合。PMMA的注射量为2～5ml，术后CT复查显示PMMA填充病灶良好。术后完全缓解8例，部分缓解15例。结论影像导航通过术中获取病椎的正侧位及左右的斜位片，模拟手术椎体的正侧位及椎弓根轴位的虚拟影像，可以更加精确地引导椎体成形术治疗多发性椎体转移瘤，减少了手术时间和术中放射线的照射，使手术更安全、更准确、更微创。     

胸腰椎椎体骨样骨瘤的临床表现和切除重建策略

目的探讨胸腰椎椎体骨样骨瘤患者的临床表现特点和后路经椎弓根肿瘤切除植骨内固定手术的疗效。方法 2001年1月-2010年6月,收治8例胸腰椎椎体骨样骨瘤患者。男5例,女3例;年龄6～27岁,中位年龄15.5岁。出现症状至就诊时间为2～19个月,平均11.8个月。病灶节段:L2、L5各2例,L3、L4、T8和T10各1例。主要临床表现为腰背部疼痛,1例存在下肢放射痛,4例合并脊柱侧凸。病灶直径0.9～2.0 cm,平均1.6 cm。患者均行后路经椎弓根椎体内病灶刮除、打压植骨、一期内固定手术。结果手术时间70～170 min,平均110 min。术中出血量300～1 400 mL,平均720 mL。术后病理检查均证实为骨样骨瘤。患者切口均Ⅰ期愈合,腰背疼痛和下肢放射痛均完全消退,无并发症发生。术后随访时间12～58个月,平均39个月。随访期间无肿瘤复发及脊柱畸形发生。结论 CT能显示椎体骨样骨瘤低密度瘤巢和周围的骨硬化带,是胸腰椎椎体骨样骨瘤重要影像学检查方法;采用后路经椎弓根椎体内病灶刮除、打压植骨、一期内固定手术可获得较好疗效。     

Osteoid osteoma treated with computed tomography-guided percutaneous radiofrequency ablation: a case series

The nidi of osteoid osteoma are small and difficult to identify precisely; this can necessitate substantial resection of the surrounding normal bone. We applied percutaneous, image-guided radiofrequency ablation to treat 5 patients with osteoid osteoma. The precise location of each nidus was determined using a 3-mm-thick spiral computed tomographic scan. The most appropriate needle pathway was selected to avoid major neural and vascular structures. A 14-gauge core needle was introduced into the nidus and then exchanged for a 17-gauge straight rigid electrode with a 1-cm exposed tip to heat the lesion to 90 degrees centigrade for 5 minutes. Four of the 5 patients were discharged on the day after surgery without any external supports, and were pain-free after a few days. The remaining patient had a pes equinus contracture induced by the penetration of the calf muscles through a posterior approach but was fully recovered 6 days later. The mean follow-up period was 20.6 months. No recurrences or late complications were observed in this series. This case series shows that the computed tomography-guided percutaneous radiofrequency ablation is a simple, minimally invasive, and highly effective technique for the treatment of osteoid osteoma.     

Osteoid osteoma of the vertebral body: a clinical case

The authors describe a case of lumbar vertebral osteoid osteoma localized in the body of L5 characterized by a very subtle clinical onset (limping as a result of poor positioning of the hip), and by a clinical course where pain was totally absent.     

Quantification of continuous in vivo flexion–extension kinematics and intervertebral strains

Purpose

Healthy subjects performed lumbar flexion and were assessed by video fluoroscopy to measure the in vivo kinematics of the lower lumbar motion segments.

Methods

Fifteen healthy subjects (8 male, 7 female, 28 ± 10 years) performed lumbar flexion and extension back to neutral while their vertebrae were imaged. The sagittal plane vertebral margins of L3–S1 were identified. Lumbar angle, segmental margin strains, axial displacements, anterior–posterior (A–P) translations, and segmental rotations over the course of flexion were measured.

Results

L4–L5 had the largest posterior margin Green strain (65 %). Each segment displayed more axial displacement than A–P translation. Peak vertebral angulation occurred at approximately 75 % of peak flexion during the extension phase.

Conclusion

L4–L5 exhibited the largest anterior and posterior margin strains (29 and 65 %, respectively). Strains in the disc during in vivo lumbar flexion are due to both angular rotation and linear translation.     

Biomechanical study of the spinal cord in thoracic ossification of the posterior longitudinal ligament

Background

Ossification of the posterior longitudinal ligament (OPLL) in the thoracic spine produces myelopathy. This is often progressive and is not affected by conservative treatment. Therefore, decompressive surgery is usually chosen.

Objective

To conduct a stress analysis of the thoracic OPLL.

Methods

The three-dimensional finite element spinal cord model was established. We used local ossification angle (LOA) for the degree of compression of spinal cord. LOA was the medial angle at the intersection between a line from the superior posterior margin at the cranial vertebral body of maximum OPLL to the top of OPLL with beak type, and a line from the lower posterior margin at the caudal vertebral body of the maximum OPLL to the top of OPLL with beak type. LOA 20°, LOA 25°, and LOA 30° compression was applied to the spinal cord in a preoperative model, the posterior decompressive model, and a model for the development of kyphosis.

Results

In a preoperative model, at more than LOA 20° compression, high stress distributions in the spinal cord were observed. In a posterior decompressive model, the stresses were lower than in the preoperative model. In the model for development of kyphosis, high-stress distributions were observed in the spinal cord at more than LOA 20° compression.

Conclusions

Posterior decompression was an effective operative method. However, when the preoperative LOA is more than 20°, it is very likely that symptoms will worsen. If operation is performed at greater than LOA 20°, then correction of kyphosis by fixation of instruments or by forward decompression should be considered.     

A Painless Subungual Osteoid Osteoma

BACKGROUND: Osteoid osteoma is a benign bone tumor. Its etiology is not fully understood and the role of trauma is still elusive. OBJECTIVE: Osteoid osteoma mostly presents with a poorly localized pain that is worst at night and characteristically relieved by salicylates. It usually occurs on the weight-bearing bones of the lower extremities, but toe location is quite rare. Here, we present a case of painless osteoid osteoma located subungually on the dorsum of the great toe. RESULT: A 29-year-old woman presented with a painless subungual mass on the dorsum of her great toe. Subungual exotosis, osteochondroma, and osteoma were considered in the differential diagnosis and the lesion was totally excised. Histopathologic examination showed characteristic findings of osteoid osteoma. CONCLUSION: A painless osteoid osteoma is rarely seen and it can be easily misdiagnosed if it occurs in an atypical location such as the subungual area.     

Computer-assisted localization of osteoid osteoma: an initial experience

This article evaluates our initial experience with computer-assisted localization of osteoid osteoma. Nine patients with osteoid osteoma underwent minimally invasive computer-assisted surgery. Patients were followed prospectively for symptomatic relief and complications for an average of 31 months. Successful localization of osteoid osteoma occurred in 7 of 9 patients. Mean operative time was 88 minutes, and mean time to discharge was 1 day (range: same day to 2 days). No fractures, infections, or neurovascular complications occurred. Minimally invasive computer-assisted surgical excision of osteoid osteoma is a safe and feasible option for the surgical localization of osteoid osteoma. It is especially attractive for lesions located in poorly accessible anatomic sites.     

Percutaneous core excision and radiofrequency thermo-coagulation for the ablation of osteoid osteoma of the spine

Percutaneous radiofrequency ablation is the treatment of choice for osteoid osteoma of the appendicular skeleton. However, difficulties in localizing the lesion in the spine and its proximity to neural elements have yet to make it the prevalent treatment for spine. This study assesses the safety and effectiveness of two percutaneous techniques for ablating osteoid osteoma of the spine. Seven patients were treated between 1998 and 2005. Four patients underwent percutaneous radiofrequency coagulation. The lesions were located at the articular processes of L3 and L4, the lamina of L3 and in the head of the 11th rib. Three patients with lesions in close proximity to neural structures (pedicle of T9, the posterolateral inferior aspect of L3 vertebral body and the inferior articular process of C5) were subjected to percutaneous core excision. Mean follow-up was 4.2 ± 1.6 years. Three out of four patients who underwent radiofrequency ablation had an immediate and sustained response. One patient with a lesion in the head of the rib failed to respond. The three patients in the group of pecutaneous core excisional biopsy demonstrated immediate relief of pain. However, one patient experienced relapse of symptoms 6 months after transpedicular core excision. CT scan suggested partial targeting of the lesion that corroborated with histologic examination revealing only reactive tissue. Subsequent percutaneous core excision was successful. Therefore, the overall success rate was 85.7%. Mean VAS improved dramatically from 9 ± 1 to 2 ± 1 after surgery (P < 0.05). No neurological or other complications were encountered. This study indicates that radiofrequency ablation of spinal osteoid osteomas is safe and reasonably effective when an intact cortical shell separates the nidus from the neural elements. Percutaneous core excision can obviate the risk of thermal damage for lesions located in close proximity to the neural elements. Effectiveness of treatment can also be evaluated by CT scan and histological examination. Difficulties in targeting the nidus can lead to treatment failure. The minimal morbidity and the effectiveness of these minimally invasive procedures make them a valid alternative in the treatment of spinal osteoid osteoma.     

Radiofrequenzablation bei Osteoidosteomen der Wirbels?ule

Osteoid osteoma was first described by Jaffe in 1935 as a benign bone neoplasm mainly located in the diaphyseal areas of long bones: 10% are located in the spine, mainly in the lumbar and thoracic posterior elements. Therapy is required due to nocturnal pain independent of the physical load and responds especially well to anti-inflammatory drugs due to the excessive production of prostaglandins in the nidus. Diagnosis is confirmed by multi-slice computed tomography (CT), magnetic resonance imaging (MRI) and skeletal scintigraphy scans. In cases with typical symptoms and imaging, open biopsies are rarely needed. Although CT-guided radiofrequency ablation is accepted as the gold standard treatment option for osteoid osteoma in the extremities, this technique is limited in spinal applications due to the risk of thermal damage to adjacent neurovascular structures. Technical advances in the administration of radiofrequency ablation have, however, resulted in new and expanded indications in the spine so that the necessity for open surgical excision of spinal osteoid osteoma is becoming less.