The patient is a 13-year-old male who feels mid-thoracic pain. An active junior high student who enjoys playing basketball, 7 months ago he woke up with back pain. Since then, the pain has continued, growing progressively worse. The pain is present at all times, becoming worse with activities. He believes physical therapy has worsened his pain, but can obtain some relief with ibuprofen. This patient previously was diagnosed with ADHD and has no known drug allergies. His older brother has a herniated nucleus pulposus.
The physical exam reveled no bladder or bladder dysfunction, no weakness, and no fever, chills, or night sweats. He was alert and oriented, demonstrated a normal gait pattern, and appeared well nourished and well developed for his age.
The patient is 6’ tall, weighing 209 pounds. His skin is intact with no café au lait spots. Further, the patient is Romberg negative with no focal motor of sensory deficit, and his reflexes are symmetric and intact. His SLR test was negative and there was no clonus detected.
The patient obtains partial symptom relief with ibuprofen, but has not yet tried alternative pharmaceutical therapies nor other treatments.
The images indicate reactive scoliosis as evidenced in the radiograph in Figure 1. Figures 2 and 3, a bone scan and T2-weighted MRI, indicate a mass in or near the upper thoracic vertebrae.
Discussion of Treatment Options and Recommendation
This 13-year-old has a history of sudden onset thoracic back pain that is growing progressively worse. His pain is persistent, although ibuprofen improves pain somewhat. Other than thoracic back pain, the patient is healthy, neurologically normal, and shows no evidence of chest wall deformity. Thoracic spine X-rays show a slight scoliosis centered at the T7-8 level without rotational malalignment.
This teenage patient should undergo a Technetium bone scan as a screening test for his thoracic spine pain to demonstrate a hot spot on the concavity of the small scoliotic curve. Follow-up MRI and CT scan findings demonstrate the lesion in the lamina of the mid-thoracic level is consistent with an osteoid osteoma.
The workup of a teenager with a painful and small thoracic scoliosis includes a screening test such as a bone scan. If increased uptake is noted (hot spot), a follow-up CT and/or MRI are needed.
The patient’s symptoms are somewhat classic for an osteoid osteoma. The CT scan demonstrating the lesion (nidus) seen on the concave lamina is also diagnostic. Treatment varies depending on the severity of the symptoms.
If the patient’s symptoms are not too severe, NSAIDs and rest is acceptable. In time, the nidus of the osteoid osteoma will burn out and symptoms will improve. It is not known how long this may take and, for patients in pain, surgical intervention is indicated.
Because of the lesion location, precise surgical isolation is imperative to excise the lesion completely and minimize bony resectioning that could destabilize the spinal region. My preference is localization using a preoperative CT scan with a small marker placed into the region to tract down to during surgery. Similarly, radioisotope localization has been reported with intraoperative confirmation.
At a minimum, the entire nidus must be excised with any resultant instability determined following the resection. If a unilateral facetectomy is performed during excision, I would perform a single-level fusion at that level. However, excision should be performed precisely to avoid the need for fusion.
The patient’s symptoms should resolve following excision with a very low recurrent rate (only seen with retained nidus).
Anticipated pathological involvement of mass, causing reactive scoliosis.
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Pathology was osteoid osteoma. Patient underwent resection of the lesion.