Two patients complaining of a lengthy history of pain on the scapula. The pain was continuous during the day with no night exacerbation. The plain X-rays were normal in each case.
The first patient, a right-handed manual worker, complained of a 2-year pain over the left shoulder area, not associated with trauma. His general practitioner suggested non-steroidal anti-inflammatory medication along with physiotherapy, but there was no improvement. Five months later, the patient was referred to an orthopaedic surgeon because of reduced motility of the shoulder joint and increasing pain. The first clinical diagnosis was impingement syndrome. The plain radiograph was normal. CT showed a lytic lesion in the scapular neck (Fig. 1a). MR imaging showed a lesion of intermediate signal intensity on T2-weighted images, along with intra-articular fluid (Fig. 1b). The scintigram showed an increased uptake in the blood pool phase (Fig. 1c). The patient underwent surgical excision and has since remained asymptomatic for 2 years.
The second patient complained of a 4-year pain in the right shoulder area, not associated with a traumatic event. The pain was continuous during the day and there was no night exacerbation. The plain radiograph was normal. The orthopaedic surgeon suggested a CT scan. The 5mm thick axial scan showed diffuse osteosclerosis (Fig. 2a) and a 1.5mm bone algorithm examination showed a lytic lesion with a central nidus associated with periosteal reaction (Fig. 2b). The patient underwent surgical excision and has since remained asymptomatic for 13 months.
Osteoid osteomas are benign bone tumours presenting radiologically as lytic lesions with or without sclerotic nidus. The lesion is associated with a typical sclerotic periosteal reaction. The clinical features of aching pain worsening at night and relieved with aspirin are typical. However, there are cases that may present atypically as a less painful synovitis. In cases where non-typical clinical features are associated with rare locations, the diagnosis may be delayed for years (1). The cases presented here did not present with typical clinical symptoms, but the histology of the excised lesions showed osteoid osteoma.
The scapula is a rare location for osteoid osteomas with fewer than 20 cases being reported in the literature (2-4). Plain radiographs are not very helpful in identifying the lesion because of overlapping structures. Hot scintigraphy and CT with bone algorithm at the area of interest are the suggested methods for diagnosing osteoid osteomas. MR imaging can suggest the diagnosis but it is not the method of choice. Treatment of choice used to be complete surgical excision but since a substantial piece of bone is usually resected, complications such as hematoma, infection, and fracture may result. CT-guided percutaneous thermocoagulation is a minimally invasive, safe, and effective procedure for treatment of osteoid osteoma, including spinal lesions, with a success rate of over 76%(5).
Osteoid osteoma of the scapula
Based on the provided CT, MRI, and bone scan data, a small localized bony lesion is noted in the scapular region:
Taking into account the clinical symptoms (scapular pain persisting during the day without typical nocturnal exacerbation, previously normal X-rays) and the imaging findings, the following potential diagnoses are considered:
Based on the pathological findings after surgical resection indicating osteoid osteoma, combined with the patient’s clinical presentation and imaging characteristics, the final diagnosis is: Osteoid Osteoma (Scapula).
Although the patient did not exhibit classic nighttime exacerbation or dramatic relief with aspirin, atypical presentations are not uncommon. Effective auxiliary diagnostic approaches include CT localization and bone scan.
Following surgery or minimally invasive treatment, patients may benefit from the following exercise prescription principles (FITT-VP):
Throughout the rehabilitation process, pain intensity and shoulder mobility should be closely monitored. If symptoms worsen, seek prompt medical evaluation. Patients with fragile bone conditions or other comorbidities should engage in these exercises under the guidance of a specialist or physical therapist.
This report is based solely on the provided imaging and available information for initial analysis and does not replace in-person clinical evaluation. If you have any questions or if your condition changes, please seek professional medical advice promptly for appropriate assessment and treatment.
Osteoid osteoma of the scapula
