Osteoid osteoma: a case for conservative management.

Osteoid osteoma: a case for conservative management SIR, Osteoid osteoma is a benign bone tumour with a predilection for long bones, occurring predominantly in children and young adults. The conventional paradigm holds that, once suspected on clinical and radiological grounds, surgical excision is necessary, both for its cure and to exclude other, more sinister pathologies. We report the case of a 17-yr-old male with a classical clinical picture of osteoid osteoma, managed conservatively , and review evidence that contemporary radiological studies frequently allow confident identification without biopsy. This case adds to a poorly appreciated but enlarging body of evidence demonstrating the benign long-term outcome of this condition, which can be successfully managed with expectant therapy, employing non-steroidal anti-inflammatory drugs (NSAIDs) to suppress symptoms pending spontaneous healing, typically over 3–8 yr [1–6]. A 17-yr-old male presented with 3 months of symptoms referable to the right hip. Nocturnal pain was the predominant symptom and was promptly relieved with diclofenac therapy. On examination, the right hip showed moderate global restriction in range of motion. The erythrocyte sedimentation rate, rheumatoid factor status and full blood examination were normal. An X-ray revealed a 1-cm lucency in the right femoral neck. The clinical impression was that of osteoid osteoma. A bone scan revealed increased uptake in the right femoral neck, with no uptake elsewhere. A computed tomo-graphy (CT) scan showed a 7-mm lytic lesion anteriorly in the right femoral neck (Fig. 1A, B). This represented a radiolucent nidus with surrounding sclerosis, which is the typical appearance of an osteoid osteoma. The management options of excision or conservative management with long-term anti-inflammatory therapy and monitoring were discussed. The patient elected to take the latter option. At 12 months, non-steroidal analgesics continued to provide adequate pain relief. A CT scan revealed minimal change compared with the initial scan. At 2 yr, the patient ceased anti-inflammatory treatment and remained pain-free. At 7 yr, when the patient was symptom-free, a scan revealed radiological resolution of the lesion (Fig. 2). Classically, osteoid osteoma has a male preponderance , with approximately 50% of all lesions found in the femur and tibia, usually no more than 2 cm in size [7, 8]. It is rarely seen in older people, with the great majority (86%) reported under the age of 30 yr. This epidemiological pattern prompts speculation that spontaneous resolution occurs over time [7]. Surgical intervention, both diagnostic and therapeutic , has been conventionally …