This article was downloaded by:[CDL Journals Account] On: 9 December 2007 Access Details: [subscription number 785022368] Publisher: Informa Healthcare Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK Acta Radiologica Publication details, including instructions for authors and subscription information: http://www.informaworld.com/smpp/title~content=t713394674 Percutaneous Needle Biopsy of the Spine J. Tehranzadeh a ; C. Tao a ; C. A. Browning a a Department of Radiological Sciences, Irvine Medical Center, University of California, Orange, California, USA; Private Practice, Anaheim, California Online Publication Date: 01 January 2007 To cite this Article: Tehranzadeh, J., Tao, C. and Browning, C. A. (2007) 'Percutaneous Needle Biopsy of the Spine', Acta Radiologica, 48:8, 860 - 868 To link to this article: DOI: 10.1080/02841850701459783 URL: http://dx.doi.org/10.1080/02841850701459783 PLEASE SCROLL DOWN FOR ARTICLE Full terms and conditions of use: http://www.informaworld.com/terms-and-conditions-of-access.pdf This article maybe used for research, teaching and private study purposes. Any substantial or systematic reproduction, re-distribution, re-selling, loan or sub-licensing, systematic supply or distribution in any form to anyone is expressly forbidden. The publisher does not give any warranty express or implied or make any representation that the contents will be complete or accurate or up to date. The accuracy of any instructions, formulae and drug doses should be independently verified with primary sources. The publisher shall not be liable for any loss, actions, claims, proceedings, demand or costs or damages whatsoever or howsoever caused arising directly or indirectly in connection with or arising out of the use of this material.
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This article was downloaded by:[CDL Journals Account]On: 9 December 2007Access Details: [subscription number 785022368]Publisher: Informa HealthcareInforma Ltd Registered in England and Wales Registered Number: 1072954Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
Acta RadiologicaPublication details, including instructions for authors and subscription information:http://www.informaworld.com/smpp/title~content=t713394674
Percutaneous Needle Biopsy of the SpineJ. Tehranzadeh a; C. Tao a; C. A. Browning aa Department of Radiological Sciences, Irvine Medical Center, University ofCalifornia, Orange, California, USA; Private Practice, Anaheim, California
Online Publication Date: 01 January 2007To cite this Article: Tehranzadeh, J., Tao, C. and Browning, C. A. (2007)'Percutaneous Needle Biopsy of the Spine', Acta Radiologica, 48:8, 860 - 868To link to this article: DOI: 10.1080/02841850701459783URL: http://dx.doi.org/10.1080/02841850701459783
PLEASE SCROLL DOWN FOR ARTICLE
Full terms and conditions of use: http://www.informaworld.com/terms-and-conditions-of-access.pdf
This article maybe used for research, teaching and private study purposes. Any substantial or systematic reproduction,re-distribution, re-selling, loan or sub-licensing, systematic supply or distribution in any form to anyone is expresslyforbidden.
The publisher does not give any warranty express or implied or make any representation that the contents will becomplete or accurate or up to date. The accuracy of any instructions, formulae and drug doses should beindependently verified with primary sources. The publisher shall not be liable for any loss, actions, claims, proceedings,demand or costs or damages whatsoever or howsoever caused arising directly or indirectly in connection with orarising out of the use of this material.
Department of Radiological Sciences, Irvine Medical Center, University of California, Orange, California, USA;Private Practice, Anaheim, California
Tehranzadeh J, Tao C, Browning CA. Percutaneous needle biopsy of the spine. ActaRadiol 2007;48:860–868.
The purpose of this review article is to provide a brief overview of the recent literature onthe two main types of percutaneous biopsy methods done in the spinal column: fineneedle aspiration biopsy (FNAB) and core needle biopsy (CNB). FNAB is the process ofobtaining a sample of cells and bits of tissue for examination by applying suction througha fine needle attached to a syringe. Core needle biopsy involves extracting a cylindricalsample of tissue using a large, hollow needle. The decision for needle biopsy is a jointeffort between the clinician, pathologist, radiologist, surgeon, and patient. Specifictechniques and approaches with varying needle systems are described for each spinalregion. Percutaneous image-guided spine biopsy is a safe and effective procedure. It is theprocedure of choice in definitive diagnosis of pathologic lesions of the spine.
Jamshid Tehranzadeh, Department of Radiology R-140, UCI Medical Center, 101 The CityDr., Orange CA 92868, USA (tel. +1 714 456 6921, fax. +1 714 456 7430, pager. +1 714506 6472, e-mail. [email protected])
Accepted for publication April 27, 2007
Percutaneous spine biopsy was first described byBALL in 1934 (4). Image-guided biopsy was reportedin 1949 with conventional radiographs, followed byfluoroscopy in 1969, computed tomography (CT) in1981, magnetic resonance imaging (MRI) in 1986,and CT fluoroscopy in 1996 (2, 6, 39). Initially, openbiopsies were done, but percutaneous needle biopsyoffers a faster, cost-effective approach with fewercomplications (14, 26, 27, 43). In general, tumorsrecognized by both clinical presentation and radio-graphic characteristics can be evaluated further witheither a fine needle aspiration (FNAB) and/or coreneedle biopsy (CNB) (38). The goal of this article isto provide an overview of the recent literature onthe process of percutaneous core and aspirationneedle biopsy of the spine.
Indications for biopsy
Table 1 lists several indications for spinal biopsy.Percutaneous biopsy is an important tool in theevaluation of oncological patients and is useful inestablishing the presence of metastatic disease.Biopsy methods should be used where feasible andwhen the pathologic diagnosis would alter themanagement of the patient (30). Lytic or blasticbone lesions and/or soft tissue masses in patients
with a history of known malignancy are the mostfrequent reason for biopsy (5, 43, 48). The secondmost common presumptive diagnosis, followingmetastasis, is discitis (6, 21, 34). Pathologic vertebralfractures, the presence of a soft tissue mass, oraspirations of symptomatic facet synovial cysts areyet other indications for biopsy evaluation (3, 6, 21,43).
Contraindications
Generalized contraindications for percutaneousbiopsy are listed in Table 2. These include ‘‘do-not-touch lesions’’ that mimic malignant or aggres-sive processes, such as bone islands, degenerativedisc disease, sclerosis, insufficiency fractures, andhemangiomas. Abnormal clotting function orthrombocytopenia should be recognized and cor-rected before the procedure (11, 30). There are fewcontraindications to fine needle aspiration biopsy,such as a small hematoma, but bleeding is uncom-mon due to the fine gauge of the needle. Needle-track seeding used to be a concern, but this wasmore likely with large-bore needles and is not asmuch of a concern with today’s fine needles.Avoiding difficult areas such as the vertebraeadjacent to the aorta, atlas, and dens, and areas of
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osseous fusions preventing disc access or spinal cordcompromise are relative contraindications (6, 11).
Imaging modalities
Ultrasound (US)Ultrasound provides real-time monitoring, is fast,cheap, avoids ionizing radiation, and allows theneedle tip to be monitored throughout the proce-dure. Ultrasound is often used with FNAB of othersites such as the liver, thyroid, pancreas, lung,prostate, and breast, but its applicability to the spineis limited to superficial lesions in the cervical spine(15, 35).
FluoroscopyThe first fluoroscopic procedure done in 1949 sooninvolved single-plane, biplane, or C-arm fluoro-scopy units (16, 39). Fluoroscopic-guided discbiopsy is the most straightforward method in thelumbar, thoracic, or cervical region (2, 7). Real-timeimaging of needle placement, inexpensive cost, shortprocedure times, real-time visualization of needleadvancement, and quick access compared to CT- orMRI-guided procedures are just a few advantages(16). Inability to visualize surrounding soft tissuestructures is a limitation (11, 15).
Computed tomography (CT)CT has been used for over 20 years and is thestandard in many institutions. CT permits trajectoryplanning, avoiding passage through the lungs, yetallows access to central lesions. CT helps distinguishnecrotic from solid lesions and documents theneedle tip unequivocally. CT is very helpful inguiding FNAB. Procedure length and ionizingradiation are the major drawbacks (8, 29). CT is apreferred modality over fluoroscopy alone becauseCT has the ability to visualize both bone and softtissue with the advantage of easing needle localiza-tion into lesions too small to see on fluoroscopy ortoo deep to see on US (16). CT allows for exactneedle depth determination, avoiding injury tocritical structures (5–7, 16, 24).
CT fluoroscopy (CTF)CTF was first described in 1994 (15, 29, 31, 41).CTF permits biopsy of smaller lesions in lessfavorable locations (18). CTF combines the advan-tages of conventional fluoroscopy with near real-time visualization by acquiring six images persecond. CTF is useful for retroperitoneal organsthat are prone to physiologic motion. One of themajor concerns for CTF is its high radiation.Conventional fluoroscopy doses are measured incentigrays per minute of exposure, while CTF dosesare measured in centigrays per second of exposure(29, 41).
Magnetic resonance imaging (MRI)Development of interventional MR systems andMRI-compatible instruments has allowed MRI tobecome a new modality for image guidance andprocedural monitoring during intervention (10).Non-magnetic titanium instruments avoid suscept-ibility artifacts and distortion of the MRI image (7,37). Open-configuration MR systems have allowedstereotaxis targeting and localization techniques fornear real-time interventional procedures (10). Otheradvantages include greater soft tissue contrast,multiplanar imaging capability, and no ionizingradiation to the patient and physician. MRI doesnot use iodinated contrast agents, lowering thepossibility of allergic reactions. MRI can provideinformation concerning level, location, and geome-try of spinal tumors as well as details concerningbony integrity of the spine. The problem with MR isthe cost, reported to be 15% higher than othermodalities (7, 18).
Table 1. Indications for percutaneous spine biopsy
# Confirm metastasis in patients with known primary# Primary bone lesion evaluation# Pathologic vertebral body collapse/fracture assessment# Infection# Chemotherapy effectiveness# Multiple myeloma cytogenetic evaluation# Confirm benign lesion to aid treatment (e.g., osteoporosis, renal
# Suspected vascular lesion# Infected soft tissues surrounding bone to be biopsied# Inaccessible sites, e.g., anterior arch of C1, dens, bone fusion# Uncooperative patient (general anesthesia may be required)# Pregnancy# Systemic infection over skin puncture site# Severe allergy to any medication needed to perform procedure# Patients with significant spinal cord compromise at level to be
studied
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Before biopsy, patients should be evaluated with afocused medical history (15, 16, 27, 47). Aspirin,coumadin, and other non-steroidal anti-inflamma-tory medications should be stopped a week beforethe procedure (30, 47). In cases of spine infection,antibiotics should be stopped 48 hours prior to theprocedure. Allergies with particular attention toanesthetic and imaging contrast agents should benoted (27). Local anesthesia should be given with orwithout conscious sedation after obtaining informedconsent. Patient positioning depends on the locationof the target lesion. Obtain preliminary images fromabove to below the lesion. Biopsy should aim at themost superficial and largest lesion. If a mixed lyticand sclerotic lesion is to undergo biopsy, sample thelytic portions first. Soft tissue masses that occuradjacent to bone lesions should also undergo biopsy.More than one biopsy may be required if multiplelesions have different imaging characteristics (25).
Once the biopsy site has been finalized, obtain theCT image deciding the approach to the lesion,avoiding critical anatomic structures. Needle entrysite on the skin is marked (27). The length and angleof the chosen path from skin to lesion are measured(11). The patient is prepped and draped in a sterilefashion. As the needle tip is advanced, localanesthetic is injected over the periosteum. Thepatient is informed to notify the physician if painis experienced, but to expect to feel pressure.Anesthetizing the periosteum will assist the biopsyby minimizing patient motion due to pain (11, 13).
CT images are taken to ensure correct positioningof the needle. Position corrections are made, and theneedle is further advanced until it touches bone. CTimages are again obtained. The biopsy needle isplaced in varying parts of the lesion to allow propersampling. Performing fine needle aspiration as acomplementary technique to core biopsy is recom-mended, elevating the overall diagnostic accuracy(17, 38). Finally, the needle is advanced deeper toobtain a fragment of bone. If infection is suspected,a fragment of bone should also be sent for cultureand sensitivity (11).
Robotics
Robot development helps during imaging-assistedinterventional procedures, decreasing radiationexposure to the physician and the patient (41).Robots lead to greater accuracy and precisioncompared to humans (28, 41). The disadvantagewith robotics is the cost of development (22).
Needles
Many biopsy needle systems are commerciallyavailable (Table 3). Selection of a needle system isdependent on lesion type (soft tissue or osseous),location (vertebra, disc, paraspinal soft tissues), andmethod of specimen acquisition (27, 30). The idealbiopsy needle requires minimal bleeding risk withmaximum amount of specimen obtained. Needlesare divided into two types: core/cutting, andaspiration. Core needles cut tissue for histology,while aspiration needles provide cytology. Corebiopsy needles are used as part of either a tandemneedle system or a coaxial system. Long spinalneedles (3.599, c. 8.9 cm) are used with a large-bore(11, 12, or 14 gauge) needle for bone biopsy or asmaller needle (18 gauge) for soft tissues (11, 27, 45).Trephine cutting needles have a serrated edge andare most widely associated with bone biopsyprocedures (16). Tru-cut needles are used for softtissue, lytic, or bone marrow lesions (11, 16, 22).Preference is given to large-bore needles becausethese provide an aspirate with bloody admixture ascompared to fine needles.
Differing from large-bore cutting needle biopsy,fine aspiration needles utilize much smaller bore (22to 27 gauge) thin needles equipped with a centralstylet (32). Institutions that have a cytopathologistor pathologist available on site use FNAB morefrequently than those without direct pathologistsupport (46).
Large-bore needles are preferred because theyprovide an aspirate with bloody admixture ascompared to fine needles. This aspirate can provide
Table 3. Some commercially available biopsy needles
Ackermann (Tieman, Long Island, N.Y., USA)ASAP (Meditech)Bonopty (RADI Medical Systems, Uppsala, Sweden)Craig (Tieman)Elson Bone Biopsy Needle Set (Cook Inc., Bloomington, Ind., USA)Franseen (Cook Co.)Geremia Needle Biopsy System (Cook Inc.)Jamshidi (Kormed Co., Minneapolis, Minn., USA)MaxCore (CR Bard, Covington, Ga., USA)Osteo-Site Bone Biopsy Needle (Cook Inc.)Osteo-Rx (Cook Co.)Ostycut (CR Bard)Tru-Cut (Baxter Health Care Corp., Deerfield, Ill., USA)Turkel (Turket Instruments, Inc, Southfield, Minn., USA)
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from the bone. Fluid aspirate is done through alarger-bore needle, especially when working withpus or hematoma (11, 45). Ultimately, first choicedepends on factors such as complication risk,operator experience, and availability of on-sitepathology support (22, 24, 40).
Technique
Both FNAB and CNB are simple, safe, inexpensive,and reliable, with excellent diagnostic accuracy. Thecombination of FNAB and CNB complement eachother (17).
FNAB introduces a fine needle into a mass andaspirates cellular material. The area is puncturedunder real-time image guidance, and the stylet iswithdrawn. Cellular material is expelled for immedi-ate microscopic evaluation by the cytologist orpathologist on site. A preliminary diagnosticimpression is rendered, and a cytological diagnosisoffered. A final report is given within 24 hours.Separate needle passes are made until an area isfound to be malignant or all sites are benign afterthree to four passes. The FNAB method used is oneof the most cost-effective, complication-free, andrapid techniques for preoperative investigation oftumors and tumor-like conditions (44). It has thedistinct advantage of being able to obtain diagnosticmaterial with speed, simplicity, low cost, andminimal patient discomfort (17, 43). If the aspirateis non-diagnostic, which occurs in 10% of cases dueto sampling error, it can be repeated or CNBperformed (2, 39). When lymphoma is suspected,additional tissue for flow cytometry can beobtained. Cytopathology interpretation is essential,increasing the accuracy and efficiency of FNAB (14,30, 44, 46). The radiologist, surgeon, and patholo-gist should be in constant communication using ateam approach (6).
Three main techniques are employed for spinalCNB: the tandem-needle technique, the coaxialtechnique, and the single/direct needle technique.The tandem needle technique uses a 22-gauge(‘‘skinny’’) needle for lesion localization, anestheticapplication, and for visual guidance (27). Thetandem needle technique may be done simulta-neously or sequentially (7).
The coaxial needle technique is preferred forbiopsy of deep spinal and paraspinal lesions (6). Thebiopsy needle is advanced over the anesthetizing andlocalizing 22-gauge needle. The localizing needle isused as a guidewire for the biopsy needle. Since bothcore and aspiration biopsies are complementary
techniques, it is useful that the guiding cannula canbe used for fine needle aspiration prior to corebiopsy (6, 7, 17). Coaxial systems are faster, moreaccurate, and have also decreased risk for spread oftumor and infection (33, 47).
The single/direct needle technique is ideal forsuperficial paraspinal masses, where the lesion canbe safely and accurately sampled with multiplepasses without risking damage to deeper, morecritical structures. This technique is also used forbiopsy of the vertebral body with a posterolateral ortranspedicular approach (6). A single large- orsmall-caliber needle with an inner stylet is used tobiopsy a vertebra or soft tissue mass. A majordisadvantage of this technique is that it requiresmultiple passes (6).
Biopsy approach
Cervical spine approach procedures (Fig. 1)Historically, lesions involving C1, C2, and C3 werereserved for open surgical biopsy; but now, withimage guidance, percutaneous sampling is per-formed (19). A transoral or pharyngeal approachis safest for the upper cervical spine using ananterolateral approach for mid-cervical spine lesions
Fig. 1. Cervical spine biopsy: the patient is in a supine position withneck in extension with a pillow or bolster under the neck. Under C-arm fluoroscopic guidance or CT control, the needle is insertedbetween the carotid sheath and esophagus and trachea into thevertebral body.
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cervical spine (C4–C7) because of the large articularmasses and large posterior elements, which limitaccessibility to the vertebral body (4, 15).
Thoracic spine approach procedures (Figs. 2 and 3)The close proximity of the lung, aorta, and dural sacpresent the major challenges to thoracic spineprocedures (7). Lesion location and size are themajor determinants (14, 16). The most direct routewith the least intervening bone should be selected(14). If the lesion is in the vertebral body, atranspedicular or costovertebral pathway is used(27). For biopsies of the disc, a paraspinal oblique/costovertebral approach is used. A costovertebralapproach is used for thoracic paraspinal masses,assessing laterally located thoracic vertebral lesions(27). The transpedicular approach is optimal foraccessing centrally or posteriorly located vertebralbody and pedicle lesions (7, 28, 33). The pedicleprovides a safe passageway to the vertebral body(28, 42, 45). The costotransverse approach requiresthe needle to go in between the tubercle of the riband its corresponding transverse process, evaluatingthe size of the pedicle and notch between thetransverse process and the adjacent rib (6, 14, 47).A major risk is damage to costotransverse articula-tion (6). The costovertebral approach is useful inaccessing laterally located thoracic vertebral lesions,in sampling the thoracic disc and lesions in the lowerportion of the vertebral body (7, 9, 29). Thisapproach also helps to keep the needle away from
the pleura and exiting nerve roots (14). Theintercostal approach uses posteromedial insertionanteriorly to the head of the rib and costovertebraljoint of the intercostal space. It is helpful forparavertebral soft tissue masses or vertebral bodymasses; however, it has the added risk of lungpuncture and intercostal vascular injury (6, 13). Toavoid lung puncture, it may be useful in certaincases to inject a few CCs of normal saline in theparavertebral soft tissues to push the parietal pleuraand lung forward, to allow for safer needlemaneuvering. A transforaminal discal approach isa safe and effective method for accessing vertebralbody lesions in the thoracolumbar spine. The entirevertebral body, except for the extreme superomedialaspect can be sampled, allowing decreased risk ofpleura puncture due to its entry position withcentral vertebral body access. However, this is acomplex pathway requiring more images and pre-biopsy calculations, lengthening the average totalprocedure time.
Lumbar spine biopsy procedures (Figs. 4 and 5)The lumbar spine was first biopsied by SIFFERT andARKIN using a trephine needle in 1949 (40). Today,paraspinal approaches include transpedicular andposterolateral extrapedicular methods (6). Thetranspedicular approach is used if a lesion is withinthe pedicle or central vertebral bodies and providessafe passageway to the vertebral body. Described asthe ‘‘bull’s eye’’ approach, it has been usedpreviously for treatment of compression fractures
Fig. 2. Thoracic spine biopsy: the patient is in a prone position. The needle is inserted, aiming for the pedicle for the transpedicular approach,and lateral to the pedicle for the transforaminal or paraspinal approach.
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with vertebroplasty (1). Care must be taken not tofracture the pedicle because this could cause cord ornerve root impingement (27). The transpedicularapproach is viewed by some authors as a safer andmore efficacious alternative to other paraspinalapproaches for the lumbar spine (14, 33).
A lateral approach with the patient in lateraldecubitus has been described, allowing a wide fieldfor needle placement, including the vertebral body,disc, and paraspinal soft tissues (9).
Sacrum biopsy proceduresCT-guided Craig needle biopsy of the sacrum is thegold standard in diagnosing pathology of thesacrum (26). Puncture using a dorsal approach isthe most straightforward method; however, bowelperforation is a major risk factor with the sacrum(35). A direct anterior approach is used for presacralspace lesions and the anterior body (15). Low-lyingpelvic lesions can be approached with transrectalultrasound image guidance, but approaching masses
Fig. 3. Thoracic spine biopsy: a 63-year-old female with invasive ductal carcinoma of the breast and T3 spinal lesion. Axial CT scan in theprone position shows the trephine needle (coaxial system) traversing parallel to the Chiba needle using the intercostal transforaminalapproach, aiming for the focal osteolytic lesion of the left side of vertebral body. The trephine needle has passed the posterior cortex of thevertebra and entered the osteolytic lesion. Note the artifact at the tip of the needle, indicating this CT slice is at the level of the tip of needle.
Fig. 4. Lumbar spine biopsy: the patient is in a prone position. The needle is inserted, aiming for the pedicle for the transpedicular approachand lateral to the pedicle for the paraspinal approach.
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that lie higher in the pelvis are logistically moredifficult and may require laparotomy through theabdomen (35).
Complications
Percutaneous biopsy of the spine in experiencedhands has a complication rate of less than 1 to 3%(1, 6). Most complications occur in the thoracicspine because of the proximity of the major bloodvessels, pleura, lung, esophagus, and posteriormediastinum (13, 25). A summary of acute and latecomplications is listed in Table 4. Acute complica-tions occur during or immediately after the proce-dure, which would include anaphylactic allergicreaction to medication or contrast media.Pneumothorax is an acute potential complicationof any spinal biopsy (23, 27). Pneumothorax canoccur with low cervical or thoracic biopsies.
Neural injury, particularly of the spinal cord andnerve roots, is a serious acute complication that canresult in foot drop, transient paresis, transient
paraplegia, and paraplegia (27). Nerve injury canbe caused by nerve root injury during biopsy or dueto anesthesia. Anesthetizing major motor nerves canlead to paresis or paralysis, and thus may simulatedamage from the biopsy procedure, with most caseshaving an uneventful recovery within 3 to 4 hours(16).
Bleeding near the needle puncture site may occur,which can manifest as an immediate complicationwith active hemorrhage or as a late complicationwith venous oozing causing a paravertebral hema-toma (8, 27). When hypervascular tumors involvethe posterior vertebral body cortex and extend intothe central canal, hemorrhage may occur causingcord compression following biopsy. Significantbleeding may still occur despite normal plateletcounts, prothrombin time (PT), and partial throm-boplastin time (PTT) (14, 16). Post-procedural latecomplications that have been reported from percu-taneous bone biopsy include infection, tumorspread, vascular puncture, and death (26, 44).Tumor spread is a risk with any invasive procedure,and there is a strict requirement for aseptictechnique (16, 27). Ensuring the proper proceduraltechnique can prevent these complications fromoccurring.
Biopsy and interpretation error
Percutaneous biopsy is not always successful. Twoof the major technical limitations of vertebralbiopsy are crushing and insufficient sample size(27, 48). In necrotic, sclerotic, or cystic lesions, it isdifficult to retrieve an adequate specimen, despiterepeated attempts (16, 27). In some cases, a
Fig. 5. Transpedicular L5 vertebral biopsy: a 53-year-old man with multiple spine metastases diagnosed after biopsy as B-cell lymphoma.Axial CT in the prone position shows a 20-cm-long, 22-gauge Chiba needle has been inserted obliquely from the pedicle of the L5 vertebra.This needle only serves as a guide for the trephine needle. The needle will be left at the periosteum. Approximately 2 cm3 of lidocaine isinjected to anesthetize the periosteum. A coaxial long Ackerman needle has been inserted obliquely parallel to the Chiba needle toward the L5pedicle. The trephine needle has been advanced to the body of the L5 vertebra for bone biopsy.
Table 4. Complications from percutaneous spine biopsy (12, 47)
Acute complications# Bleeding requiring transfusion due to vascular injury# Neurologic injury# Pneumothorax# Fracture# Drug-related allergic reactions# Puncture of thecal sac# Vasovagal reaction
Late complications# Infection# Tumor seeding along needle tract
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between different modalities causes the wrongsampling of vertebral levels (26, 27). Lesions areobscured by one modality and are easily seen onanother, such as a lesion easily identified on MRimaging that is not seen on CT at the time of biopsy(19).
Another reason for non-diagnosis may occur withbiopsy of infectious spondylitis in patients who arealready on broad-spectrum antibiotics (6, 24, 27,34). Improper specimen handling, discardingintraosseous blood aspirate erroneously, failure toperform microbiologic testing, or failure to followspecific cultures (e.g., Mycobacterium tuberculosis)for an extended period of observation may be othercauses of non-diagnosis (27).
Results
The diagnostic accuracy of percutaneous biopsy ofvertebral body lesions using a variety of approacheswith fluoroscopy or CT guidance is 88–100% (2, 8,12, 14, 19, 26, 31, 45). In a comparison between coreneedle and open biopsy techniques of musculoske-letal tumors, it was found that percutaneous needlebiopsy has an acceptable, but slightly lower rate ofdiagnostic accuracy, especially for soft tissue lesions(37). Negative results should be viewed withcaution.
Fine-needle aspiration biopsy of vertebral lesionshas a similar, but consistently lower success ratewhen compared to core biopsy (30). The reportedpositive predictive value of combined needle aspira-tion and core biopsy is 82% and the negativepredictive value 100% (17).
The success rate of intervertebral disc lesionsundergoing biopsy varies from 4.8 to 50% (30, 42).Non-diagnostic biopsies are more frequent in thecervical and thoracic regions due to small vertebralbody size and the accompanying technical difficul-ties (7). Cystic or densely osteoblastic lesions havelower diagnostic yields (6, 7, 19). Negative resultsshould be viewed with caution, as the false-negativerate is higher for sclerotic lesions (19). A larger-coretrephine bone biopsy is preferred over needleaspiration when considering needle types for sclero-tic lesions since, generally, a larger size specimen willresult in a higher diagnostic accuracy (24, 43). Still,percutaneous CT-guided biopsy of sclerotic bone isa viable alternative to open surgical biopsy (24).There is greater diagnostic accuracy when the lesionis a metastasis or recurrent sarcoma (94%) (7, 8, 20,30, 42, 44). Diagnostic accuracies of primary (87%)and round cell tumors (75%) are consistently lower
than that of metastasis. The success rate in otherdiagnostic results including normal, osteoporosis,and degenerative disease is 100% in spinal biopsiesand 88% in non-spinal biopsies (40). The ability toculture from an infection is poor (46–91%) (13, 24,31, 41). Fungal discitis has an even lower rate ofpositive culture (5).
Conclusion
Image-guided percutaneous biopsy of the spine forosseous and soft tissue lesions is a safe and effectiveprocedure performed by radiologists as part of ateam approach between patient, referring clinician,pathologist, and surgeon. Performing both a coreneedle and fine needle aspiration biopsy arecomplementary techniques, with the optimalapproach resulting in high diagnostic accuracy anda low complication rate.
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