Osteoid Osteoma of the Scapular Neck: A Cause of Long-lasting Unexplained Pain

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Learning Point of the Article:

Osteoid Osteoma should always be in the differential diagnosis of any patient presenting with long lasting shoulder pain.


Case Report | Volume 11 | Issue 2 | JOCR February 2021 | Page 45-48 | Mohamad K Moussa, Ali Allouch, Mohammad O Boushnak, Fadi Tannouri, Samer Hijazi, Youssef Daher . DOI: 10.13107/jocr.2021.v11.i02.2020


Authors: Mohamad K Moussa, Ali Allouch, Mohammad O Boushnak, Fadi Tannouri, Samer Hijazi, Youssef Daher

[1]Department of Orthopaedic, Faculty of Medical Sciences, Lebanese University, Beirut, Lebanon,
[2]Department of Orthopaedic, Zahraa Hospital, University Medical Center, Beirut, Lebanon,
[3]Department of Oncology, Faculty of Medical Sciences, Lebanese University, Beirut, Lebanon,
[4]Department of Interventional Radiology, Notre Dame de Secours Hospital, Byblos, Lebanon,
[5]Department of Orthopedic Surgery, Zahraa Hospital, University Medical Center, Beirut, Lebanon.

Address of Correspondence:
Dr. Mohamad Moussa,
Department of Orthopaedic Surgery, Zahraa Hospital, University Medical Center, Beirut, Lebanon.
E-mail: mhamadmoussa71976798@gmail.com


Abstract

Introduction: Osteoid osteoma (OO) is a common tumor of the diaphysis of long bone, where the reported incidence is up 10% of all benign bone tumors. Its presence in flat bone is seldom mentioned in literature and can be misleading when the bone involved is in proximity to a zone of wide variety of possible pathology. We report a case of a young patient with OO in a very rare location of the body –the scapular neck – that was misdiagnosed for a long period of time before receiving adequate therapy.
Case Report: A 20-year-old female patient presented to the clinic with chronic left shoulder pain. During the past 2 years, she received medical and physical therapy, to deal with different diagnosis such as cervical spine pathology, muscular spasm, and rotator cuff disease. However, she did not improve. At time of presentation to our clinic, radiographs of the shoulder were done and turned to be inconclusively normal. After negative magnetic resonance imaging of the cervical spine, a computed tomography scan of the shoulder was done and showed a round well-defined lesion localized in the scapular neck with a focal lucent nidus within surrounding sclerotic reactive bone measuring 8.5 mm in largest diameter, compatible with OO. Bone scan showed increased uptake. The patient was given aspirin in an intention to test and treat. The patient had dramatic pain relieve at first, which confirmed the diagnosis of OO. But then, pain became unremitting, so a decision was made for radiofrequency ablation of the lesion which gave excellent results.
Conclusion: OO is a common benign neoplasm with high variable clinical picture and anatomic localization. Despite being more common in long bone, flat bone OO localization should be always kept in mind. Careful history and physical examination should be done for each patient presenting with unexplained pain; night pain should always raise suspicion of this condition. Radiographs are not always conclusive, and the patient with high suspicion of this condition should undergo more investigation to make the diagnosis.
Keywords: Osteoid osteoma, shoulder pain, scapular neck.


Introduction
Osteoid osteoma (OO) is a benign bone forming tumor characterized by painful lesion and specific imaging features [1]. It is the third most common benign tumor of bone, constituting 12% of them [2], and affecting patients during their second decade of life [3]. OO can be present at variable location, with the most common site being lower extremities [1]. Its presence in flat bone – in the scapula specifically – represents a very rare localization that is seldom mentioned in literature [4, 5]. Night pain is a highly sensitive symptom that can be present in up to 95% of cases where its presence should increase index of suspicion of OO even if the localization was atypical [1]. Diagnosis can be challenging and involves a careful history, proper imaging, and high index of suspicion. We presents herein, an extremely rare case of scapular neck OO, that was misdiagnosed for a long period of time before receiving adequate diagnosis and treatment.

Case Report
A 20-year-old female patient presented to the clinic with chronic left shoulder pain. History goes back to 2 years before presentation, when the patient presented at night, to an emergency department, where he was diagnosed as having “simple” muscular spasm, so he was treated with muscle relaxant and painkillers. However, after 1 month of therapy, the patient did not improve, so he was sent for orthopedic specialist for investigation. Unfortunately, the patient was continuously given symptomatic treatment over a long period of time base on a diagnosis of cervical spine pathology, muscular spasm, and rotator cuff disease. He received medical and physical therapy over 2 years without improvement. At time of presentation to our clinic, radiographs of the shoulder were done and turned to be inconclusively normal (Fig. 1).Hence, a magnetic resonance imaging (MRI) of the cervical spine was done to rule out congenital cervical stenosis or disc herniation, but it turned out to be normal. When asked about the onset of pain, he complained of increased pain intensity at night. That is why; a computed tomography (CT) scan of the shoulder was done and showed a round well-defined lesion localized in the scapular neck with a focal lucent nidus within surrounding sclerotic reactive bone measuring 8.5 mm in largest diameter, compatible with OO (Fig. 2). Bone scan was also done and showed focal uptake localized at the scapular spine (Fig. 3). The patient was given aspirin in an intention to test and treat. The patient had dramatic pain relieve at first, which confirmed the diagnosis of OO. But then, pain became unremitting. The patient was diagnosed as having scapular neck OO refractory to medical treatment that is why, a decision was made for radiofrequency ablation of the lesion which gave excellent results.
After 3 years, the patient is still free of symptoms without any morbidity or recurrence.

Discussion
OO is a benign osteoblastic bone tumor, characterized by a wide variety of clinical presentation depending on the affected site [1]. Improvement of histological studies yielded to the description and characterization of this lesion on 1935; in fact, it was easily misdiagnosed as inflammation or infection before its description by Jaffe who confirmed the absence of any inflammation or infection in the histological analysis, and the presence of highly cellular area containing vascular tissue and immature bone and osteoid [6]. The mean age of diagnosis of OO is the second decade of life with male predominance (two to three times more frequently diagnosed in males) [3]. The most frequent affected site is lower extremities, mainly the proximal femur, and to a less extend the tibia, the spine, and the remainder of the femur [7]. OO can rarely involve flat bones, of which scapular involvement is an extremely rare location [1]. In a study of 95 cases, Cohin et al. have only found two cases of OO involving the scapula [1]. Afterward, several cases reports were presented in the literature (Table 1) [1, 4, 5, 8, 9, 10, 11, 12, 13, 14]. OO is characterized by a small radiolucent nidus, usually <1–1.5 cm in diameter. The nidus is usually characterized by the secretion of high levels of prostaglandins and in a less frequency secretion of osteocalcin [1]. Patients with OO can either be asymptomatic or can present with progressive increasing pain that mainly worsens at night and not be related to activity and can be relieved by nonsteroidal anti-inflammatory medications (i.e., prostaglandin inhibitors). [1, 15]. The diagnosis of OO relies on history, physical examination, and the radiographic appearance of the lesion. On radiographs, OO appears as small round intracortical lucency with sclerotic margin, which may contain in some cases small central sequestrum [16]. However, in 25–40% of cases, the diagnosis cannot be made by radiographs because of the location of the tumor (spine, scapula, or iliac bone) or due to cortical thickening that can obscures the nidus mainly in the shaft of a long bone such as the tibia or femur. Furthermore, it can be blunted and obscured on MRI due to juxtacortical soft-tissue edema and can appear similar to stress reaction or infection or malignancy. In such cases, CT is the best modality for identification and diagnosis of OO [17]. The treatment of OO relies on the presence or absence of symptoms. Observation with serial examinations and imaging every 4–6 months is an option for asymptomatic lesions or even mildly painful lesions that are well tolerated or can be controlled with nonsteroidal anti-inflammatory agents. Symptomatic lesions causing intolerable pain, limp, scoliosis, or decrease range of motion of the affected site should be treated. Surgical resection, radiofrequency ablation, cryotherapy, or MRI-guided high-intensity focused ultrasound are all options for symptomatic OO [18, 19, 20]. Concerning the prognosis of OO, if untreated, it can spontaneously resolve over several years. Surgical removal of the nidus generally results in resolution of symptoms but it can recur if not completely removed [21, 22].

Conclusion
OO is common benign bone tumor that deserves special attention careful history and physical examination should be done for each patient presenting with unexplained pain; night pain should always raise suspicion of this condition. Radiographs are not always conclusive, and the patient with high suspicion of this condition should undergo more investigation to make the diagnosis.

Clinical Message
Shoulder pain can be due to wide variety of differential diagnosis. Clinician should be aware of the possible presence of OO at this location to allow early diagnosis, decreasing the time span before adequate treatment is given.

References
1. Cohen MD, Harrington TM, Ginsburg WW. Osteoid osteoma: 95 cases and a review of the literature. Semin Arthritis Rheum 1983;12:265-81.
2. Hakim DN, Pelly T, Kulendran M, Caris JA. Benign tumours of the bone: A review. J Bone Oncol 2015;4:37-41.
3. May CJ, Bixby SD, Anderson ME, Kim YJ, Yen YM, Millis MB, et al. Osteoid osteoma about the hip in children and adolescents. J Bone Joint Surg Am 2019;101:486-93.
4. Mosheiff R, Liebergall M, Ziv I, Amir G, Segal D. Osteoid osteoma of the scapula. A case report and review of the literature. Clin Orthop Relat Res 1991;262:129-31.
5. Malavolta EA, Assunção JH, Rebolledo DC, Gracitelli ME, Correia LF, Neto AA, et al. Osteoid osteoma of the glenoid: Arthroscopic treatment. Orthop Traumatol Surg Res 2015;101:977-80.
6. Jaffe H. Osteoid-osteoma: A benign osteoblastic tumor composed of osteoid and atypical bone. Arch Surg 1935;31:709-28.
7. De Ga K, Bateni C, Darrow M, Mcgahan J, Randall RL, Chen D. Polyostotic osteoid osteoma: A case report. Radiol Case Rep 2020;15:411-5.
8. Dussaussois L et al. Traitement percutanee d’un osteome osteoid de l’omoplate par laser sous controle scanner. 1998. Acta Orthopedica Belgica
9. Ishikawa Y, Okada K, Miyakoshi N, et al. Osteoid osteoma of the scapula associated with synovitis of the shoulder. J Shoulder Elbow Surg. 2005;14(3):329-332.
10. Rouhani A, Mohajerzadeh S, Ansari M. Osteoid osteoma in the neck of the Scapula; A misleading case. Arch Bone Jt Surg 2014;2:234-7.
11. Ghosh PS, Mitra S, Moodley M. Pearls and oy-sters: Osteoid osteoma of the scapula masquerading as neuralgic amyotrophy. Neurology 2012;79:e7-9.
12. Pourfeizi HH, Sales JG, Elmi A, Tabrizi A. Osteoid osteoma of a scapula: A case report in a 34 years old woman. Med J Islam Repub Iran 2012;26:143-6.
13. Alaya Z, Osman W. Monoarthritis of the knee revealing tabetic arthropathy. Pan Afr Med J 2017;26:100.
14. Rubab N, Gillani F, Imran M, Akhtar M. 2017. Osteoid osteoma in acromion of scapula: A case report. Eur J Med Case Rep 2017;1:102-5.
15. Greenspan A. Benign bone-forming lesions: Osteoma, osteoid osteoma, and osteoblastoma. Clinical, imaging, pathologic, and differential considerations. Skeletal Radiol 1993;22:485-500.
16. Iyer RS, Chapman T, Chew FS. Pediatric bone imaging: Diagnostic imaging of osteoid osteoma. AJR Am J Roentgenol 2012;198:1039-52.
17. Assoun J, Richardi G, Railhac JJ, Baunin C, Fajadet P, Giron J, et al. Osteoid osteoma: MR imaging versus CT. Radiology 1994;191:217-23.
18. Gasbarrini A, Cappuccio M, Bandiera S, Amendola L, Van Urk P, Boriani S. Osteoid osteoma of the mobile spine: Surgical outcomes in 81 patients. Spine (Phila Pa 1976) 2011;36:2089-93.
19. Earhart J, Wellman D, Donaldson J, Chesterton J, King E, Janicki JA. Radiofrequency ablation in the treatment of osteoid osteoma: Results and complications. Pediatr Radiol 2013;43:814-9.
20. Fiori R, Forcina M, Di donna C, D’Onofrio A, Spiritigliozzi L, Cavallo AU, et al. Cryotherapy of acetabular osteoid osteoma under fluoroscopic guidance using the XperGuide system. Radiol Case Rep 2019;14:989-92.
21. Kneisl JS, Simon MA. Medical management compared with operative treatment for osteoid-osteoma. J Bone Joint Surg Am 1992;74:179-85.
22. Aboulafia AJ, Kennon RE, Jelinek JS. Begnign bone tumors of childhood. J Am Acad Orthop Surg 1999;7:377-88.


Dr. Mohamad K Moussa Dr. Ali Allouch Dr. Mohammad O Boushnak
Dr. Fadi Tannouri Dr. Samer Hijazi Dr. Youssef Daher

How to Cite This Article: Moussa MK, Allouch A, Boushnak MO, Tannouri F, Hijazi S, Daher Y. Osteoid osteoma of the scapular neck: A cause of long-lasting unexplained pain. Journal of Orthopaedic Case Reports 2021 February;11(2): 45-48.

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