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Vascular and Interventional Radiology |
1 From the Departments of Radiology (D.I.R.), Anesthesia (J.J.A.M.), and Orthopedic Surgery (F.J.H.), Harvard Medical School, Massachusetts General Hospital, 199 Cambridge St, Boston, MA 02114. Received November 29, 2001; revision requested February 18, 2002; revision received March 21; accepted May 7. Address correspondence to D.I.R. (e-mail: dirosenthal@partners.org).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMATERIALS AND METHODS RESULTSDISCUSSIONREFERENCES |
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MATERIALS AND METHODS: Changes in cardiac and respiratory rates were evaluated after establishment of stable general anesthesia in 14 patients who underwent needle biopsy and radio-frequency treatment. Cardiac and respiratory rates were recorded at penetration of skin, muscle, periosteum, cortex, and tumor. Treatment was performed before the biopsy report was available.
RESULTS: Biopsy results revealed osteoid osteoma in 10 patients, chondroblastoma in one, and a herniation pit in one. Results in the two remaining patients were nondiagnostic and were excluded. Puncture of skin, muscle, and periosteum caused no detectable change. However, in the 10 patients with biopsy-proved osteoid osteoma, puncture of the tumor caused the mean cardiac rate to increase an average of 26 beats per minute (40%) to 91 (range, 62–114; P < .001) and the mean respiratory rate to increase an average of 12 breaths per minute (50%) to a mean of 37 (range, 25–52; P < .001). These changes occurred within seconds of tumor puncture and were often the first indication to the surgeon that the tumor had been entered. In the two patients with other diagnoses at biopsy, no such change was apparent.
CONCLUSION: Mean cardiac and respiratory rates increase significantly at needle puncture of osteoid osteoma.
© RSNA, 2002
Index terms: Bones, biopsy, 40.1261, 40.3122 • Osteoma, 40.3122
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODS RESULTSDISCUSSIONREFERENCES |
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It is well-established that bone contains the neural elements required for transmission of nociceptive signals (6) and that these neural elements are present within trabecular and cortical bone and cancellous spaces (7,8). Despite these observations, there is a common misconception that all painful sensations arising from bone are a result of stimulation of the periosteum.
In the course of more than 200 percutaneous treatments of osteoid osteoma, we found that intensely painful stimuli arise from placement of a needle into the tumor itself. Our early attempts to perform this treatment by using local anesthetic were unsuccessful because of pain. Passage of a needle through skin, muscle, periosteum, and cortical bone does not have this effect. In our experience, this feature of osteoid osteoma is rarely seen in other entities and is almost never observed with malignant tumors. It may cause abrupt physiologic reactions in the patient, even during general anesthesia, that can be a cause of concern if not anticipated.
The purpose of this study was to evaluate changes in cardiac and respiratory rates in a consecutive series of patients who underwent percutaneous treatment for lesions presumed to be osteoid osteoma in whom general anesthesia was established.
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MATERIALS AND METHODS |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODS RESULTSDISCUSSIONREFERENCES |
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Our study was approved by our institutional review board. After informed consent had been obtained, general anesthesia was induced with propofol (200 mg administered intravenously) (Gensia Sicor Pharmaceuticals, Irving, Calif). Then a laryngeal mask airway was positioned, and the patient was permitted to breathe Sevoflurane (1.5% inhaled) (Abbott Laboratories, North Chicago, Ill) and a nitrous oxide–oxygen mixture spontaneously. Neither narcotic nor nonsteroidal analgesics were administered prior to positioning of the biopsy needle within the lesion. The anesthetic concentration was maintained constant during the procedure. The area was not infiltrated with local anesthetic prior to the procedure.
A small hand-operated drill (Bonopty Bard; Radi Medical Systems, Uppsala, Sweden) was used to penetrate the cortex of the bone. The drill was advanced through periosteal and cortical bone with frequent computed tomographic (CT) monitoring until it was close to the tumor. It was then exchanged for a hollow bone biopsy needle (Osty-Cut; Bard/Angiomed, Karlsruhe, Germany) for tumor penetration. After biopsy, a radio-frequency electrode was introduced, and the tumor was heated to 90°C for 6 minutes by using our previously described methods (9).
Data Collection
Cardiac and respiratory rates were recorded throughout the procedure. The procedures were performed with CT monitoring, and each adjustment of the needle position was documented with an image. Since both the CT images and the cardiac-respiratory rate monitor were time-stamped, it was possible to relate the physiologic changes to the needle location. Particular attention was paid to these parameters when the skin and muscle were punctured, the periosteum was crossed, and the tumor was entered with the needle.
A biopsy sample was obtained in each case. However, the results were not available for several days; therefore, the procedure was performed without knowledge of the final histologic diagnosis.
Statistical Analysis
Differences in the mean cardiac and respiratory rates from baseline to peak values were analyzed by using commercially available statistical tools (Excel 97; Microsoft, Redmond, Wash). A two-sample t test for paired values with two tails was used. In addition, the Student t test for independent variables was used to compare the mean changes in cardiac and respiratory rates for the 10 patients with osteoid osteoma with those for the two patients with other diagnoses. A P value less than .05 was considered to indicate a statistically significant difference.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODS RESULTSDISCUSSIONREFERENCES |
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In the 10 patients with osteoid osteoma, puncture of the tumor caused the mean cardiac rate to increase an average of 26 beats per minute (40%) to 91 (range, 62–114; P < .001) and the mean respiratory rate to increase an average of 12 breaths per minute (50%) to a mean of 37 (range, 25–52; P < .001). These changes occurred within seconds of tumor puncture and were often the first indication to the surgeon that the tumor had been entered.
In the two patients with other diagnoses, neither cardiac rate nor respiratory rate increased significantly.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODS RESULTSDISCUSSIONREFERENCES |
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A larger number of cases in the comparison group would be desirable. However, with the exception of osteoid osteoma, we perform most percutaneous procedures with local anesthetics. We believe that it would be difficult to interpret cardiac and respiratory changes in a patient who is awake; therefore, we are limited to the occasional instance in which osteoid osteoma is suspected but shown to be some other entity.
In a histologic study (10) of 18 osteoid osteoma specimens, nerve fibers were found in 16. Interestingly, one of the two cases without nerve fibers was from a rare example of a patient without symptoms. The authors believe that the nerves are sensitive to changes in vascular pressure, as are glomus tumors, and are the source of the pain that arises from the tumors.
Authors of a more recent study (11) used immunohistochemical methods that demonstrated the presence of nerves within both the tumor and the reactive tissues surrounding it. This feature appeared to be of diagnostic value, as it was not found in various other bone tumors including osteoblastoma, fibrous dysplasia, aneurysmal bone cyst, osteosarcoma, giant cell tumor, and chondroblastoma.
Pain sensations due to osteoid osteoma are probably mediated by prostaglandin release. High levels of prostacyclin and prostaglandin E2 have been found in cultured samples of tumor, and even in the urine of patients with tumors (12). Prostaglandin inhibitors such as nonsteroidal antiinflammatory medications usually block pain. Local features suggestive of inflammation (ie, bone marrow and periosteal edema, joint effusion) may simulate an inflammatory joint disorder (13). Some authorities (14) have suggested that the vasoactive properties of the prostaglandins result in pressure on unmyelinated nerves within the tumor to cause pain.
High concentrations of prostaglandins may be seen in other entities such as chondroblastoma, but in the absence of intratumoral nerves they do not cause the same pain pattern (15). We believe that our experience supports this interpretation. The rapidity of the response we have observed strongly suggests that nerves within the lesion mediate the process.
Pain originating from an osteoid osteoma may change over time. Initially described by many patients as dull and aching, it can become sharper and more intense over time (3). Some patients report intervals during which their pain is less severe. Over the course of years, the pain may diminish or even vanish despite the fact that the lesions still appear to be present at radiography (16,17). Not every patient experiences a marked response to penetration of the tumor. Perhaps those patients who do not experience exaggerated changes in cardiac and respiratory rates are in a different phase of the evolution of disease. An understanding of the frequency of this response would require evaluation in a larger group of patients; however, it is frequent enough that we now rely on it as an indication of successful needle placement.
On the basis of our experience, local infiltration of the soft tissues and periosteum with local anesthetics is not adequate analgesia for this procedure. Although spinal anesthetics are a good alternative for lesions of the lower extremities, they may require a longer recovery period and may not be appropriate for children, patients with certain back diseases, or those receiving anticoagulation therapy and nonsteroidal agents. When general anesthesia is used, the surgeon and anesthetist should be aware that painful stimuli that occur at the moment of tumor puncture can be much more intense than those that accompany other aspects of the procedure, and they must be alert to the possibility of patient movement.
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FOOTNOTES |
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REFERENCES |
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