|Year : 2021 | Volume
| Issue : 3 | Page : 92-96
Efficacy of computed tomography-guided biopsy in vertebral lesions: A prospective study
Virender Kumar1, Rajpal Beniwal1, Zile Singh Kundu2, Ankush Kundu1, Muhammad Naqvi1, Kunal Arora1, Ravi Sihag1
1 Department of Orthopaedics, PGIMS, Rohtak, Haryana, India
2 Positron Hospital, Rohtak, Haryana, India
|Date of Submission||12-Jul-2021|
|Date of Decision||23-Jul-2021|
|Date of Acceptance||23-Jul-2021|
|Date of Web Publication||20-Dec-2021|
Dr. Virender Kumar
Pt. BDS, PGIMS, Rohtak - 124 001, Haryana
Source of Support: None, Conflict of Interest: None
Background: A wide variety of lesions involve spine, spectrum including vascular lesions, metabolic diseases, infections, and tumors. Magnetic resonance imaging with its multiplanar capabilities, high soft tissue, and contrast resolution plays a pivotal role in the characterization, diagnosis, and differentiation of these lesions. However, a definitive diagnosis based solely on radiological and laboratory investigations is not always possible, particularly in differentiating primary and metastatic tumors, specific and nonspecific infections, and metabolic diseases. Accurate diagnosis of spine lesions is important for its successful management. Therefore, a biopsy is generally necessary for accurate diagnosis. Materials and Methods: The present study was conducted in the Department of Orthopaedics in collaboration with the Department of Radiodiagnosis and Pathology, Pt. B. D. Sharma PGIMS, Rohtak. Eighty-seven patients of clinically and radiologically undiagnosed vertebral lesions will be underwent computed tomography scan-guided core-needle biopsy between July 2016 to May 2018. Results: Patients were of the age group from 38 to 90 years with the mean age of 56.69 ± 12.93 years with significant male preponderance. Posterolateral approach was most commonly used at dorsal and lumbar sites, whereas lateral approach was only used at sacral site. The most common approach used was posterolateral approach (51 patients), followed by transpedicular approach (33 patients), while lateral approach (3 patient) was least preferred. Transpedicular approach was found to be most accurate in our study irrespective of the spinal site ([dorsal – 83.33%], [lumbar – 100%]). Out of 87 biopsies, 66 were diagnostic and 21 were nondiagnostic (dorsal spine was the most common site to be involved). Out of 66 diagnostic cases, 18 were tuberculosis, 18 were metastasis, 9 were malignant (adenocarcinoma), and 6 were benign lesion (hemangioma), while chronic osteomyelitis, lymphoplasmocytic disorder, plasma cell dyscrasia, and nonspecific granuloma were three each. Twelve patients had the complication of local hematoma, whereas none of the patients had any kind of partial paresis and infection. Conclusion: For spinal lesions, CT guided core needle biopsy is an effective, economical, safe and minimally invasive procedure.
Keywords: Computed tomography-guided biopsy, posterolateral approach, Vertebral lesions
|How to cite this article:|
Kumar V, Beniwal R, Kundu ZS, Kundu A, Naqvi M, Arora K, Sihag R. Efficacy of computed tomography-guided biopsy in vertebral lesions: A prospective study. J Orthop Dis Traumatol 2021;4:92-6
|How to cite this URL:|
Kumar V, Beniwal R, Kundu ZS, Kundu A, Naqvi M, Arora K, Sihag R. Efficacy of computed tomography-guided biopsy in vertebral lesions: A prospective study. J Orthop Dis Traumatol [serial online] 2021 [cited 2022 Jan 24];4:92-6. Available from: https://www.jodt.org/text.asp?2021/4/3/92/332938
| Introduction|| |
A biopsy is commonly performed by interventional radiologist, a surgeon, or an interventional cardiologist to harvest tissues or sample cells for the examination to ascertain the extent of a disease or the presence of pathology. The sample thus extracted is generally examined under a microscope by a pathologist and can also be analyzed chemically. Excellent care and the highest degree of precision are essential for a definitive and precise outcome. An accurate biopsy is mandatory to make a diagnosis for spinal lesions. Even with recent advances in modern imaging technology, histological examination is the gold standard for making an exact diagnosis. Earlier, for pathological evaluation, an incisional biopsy was considered the gold standard. Mankin et al. reported a complication rate of 15.9% for incisional biopsy including hematoma, infection, and tumor contamination, affecting approximately 8% of the patients. Taking a biopsy from deeper tissues, such as spinal lesions, an open incisional biopsy is challenging to perform as it is associated with a significant risk of complications. Percutaneous core needle biopsy (NB) is suitable for spinal lesions. It has lower complication rates and a relatively low cost, less morbidity, minimal hospital stay with high accuracy. Computed tomography (CT)-guided core NB is minimally invasive and is advantageous for diagnosing spinal lesions; however, it is not widely used.
There are multiple approach-based techniques for CT-guided biopsy of vertebral lesions. These techniques depend on various factors such as site of the lesion within the vertebrae; focal or diffuse lesion; level of the lesion, i.e. cervical, thoracic, or lumbar spine location; vertebra plana; and associated soft tissue mass. The fundamental principles to be followed can be best denoted in the form of 3 Ps: “planning” of successful biopsy, “positioning” of the patient to achieve optimum biopsy plane, and “protection” of the vital vascular and neural structures in the trajectory of a biopsy needle.
| Materials and Methods|| |
This is a prospective study conducted in postgraduate teaching and tertiary care hospital. The purpose of our study was to evaluate the accuracy of CT-guided core NB in the diagnosis of spinal lesions. Eighty-seven patients of clinically and radiologically assessed vertebral lesion underwent CT scan guided core NB. Inclusion criteria – all vertebral lesions where the definitive diagnosis is not possible clinically and/or radiologically. Exclusion criteria – bleeding diathesis, pregnancy, and skin infection (local site infection).
Detailed history and clinical examination were recorded, and then patients were subjected to scrupulous radiological examination. Aspirin, coumadin, and other nonsteroidal anti-inflammatory medications were stopped a week before the procedure. If infectious etiology was suspected, antibiotics were arrested 48 h before the procedure. Patients positioning were dependent on the site of the lesion.
The biopsy site was confirmed under the CT image guidance, deciding the approach to the lesion. Throughout the procedure, the patient's vital signs were continuously monitored. The needle entry site on the skin was marked. The parts were prepared and draped in a sterile fashion. Local anesthesia was infiltrated in the area about 4–5 cm away from the midline in the subcutaneous tissue till the vertebral body taking care not to penetrate the dura mater or major vessels. A stab incision was given at the intended site of needle puncture. Needle with trocar was inserted up to the involved vertebrae through either transpedicular or paravertebral route, and trocar was pulled out. The needle was further inserted and rotated in a clockwise direction so that the pathological tissue came inside the hollow needle. A 20 cc syringe on the other end of the needle was connected to create and maintain negative suction pressure while taking the needle out so that material would stay inside the needle. The material from inside the needle was removed with the stellate. The procedure was repeated. Three to five cores of pathological tissue were taken for histopathological examination.
The complications such as perioperative bleeding and hematoma formation were managed with a compression bandage, while postoperative infection and neurological deficit were not noted.
| Observation and Results|| |
In our study, patients were of the age group from 38 to 90 years with the mean age of 56.69 ± 12.93 years. There was a significant male preponderance, with a total of 63 (72.4%) male and 24 (27.6%) female patients. Different approaches were used at different spinal sites for CT-guided biopsy in the present study, namely, transpedicular, posterolateral, and lateral approach. The posterolateral approach was most commonly used at dorsal and lumbar levels, while the lateral approach was only used for the sacral vertebrae. The most common approach used was the posterolateral approach (51 patients), followed by the transpedicular approach (33 patients), whereas the lateral approach (3 patients) was least preferred. The transpedicular approach was found to be most accurate in our study, irrespective of the spinal level ([Dorsal - 83.33%], [Lumbar - 100%]). Out of 87 biopsies, 66 were diagnostic, and 21 were nondiagnostic (the dorsal spine was the most common site to be involved). Out of 66 diagnostic cases, 18 were tuberculosis, 18 were metastasis, 9 were malignant (adenocarcinoma), six were benign lesions (Hemangioma), whereas chronic osteomyelitis, lymphoplasmacytic disorder, plasma cell dyscrasia, and nonspecific granuloma were three each. Out of 87 patients, 12 patients had local hematoma, while none of the patients had any partial paresis and infection.
| Discussion|| |
Accurate diagnosis of spine lesions is essential for its successful management. With the advances in imaging, there is a considerable increase in sensitivity of detecting spinal lesions and specificity of differentiating tumors from other pathology that involve the spine. However, a definitive diagnosis is not always possible solely by radiological or laboratory investigations; therefore, a biopsy is often necessary for accurate diagnosis. Before the development of image-guided biopsy techniques, an open biopsy procedure was used for definitive diagnosis. The open biopsy procedure is done under direct visualization, and a larger tissue sample can be obtained. Moreover, it can be done as a part of surgical decompression/stabilization of the spine. Besides these advantages, open biopsy is associated with many complications such as those related to general anesthesia, local spread of a tumor, significant large cost, more extended hospital stay, and resultant morbidity. To overcome these complications and problems associated with open biopsy for spine lesions diagnosis, another safe and less cumbersome technique is required. The study aims to determine the accuracy of CT-guided spinal biopsy.
The spinal biopsy is an excellent diagnostic asset in managing patients presenting with symptoms, signs, and imaging features of a primary spinal tumor, spinal metastasis, spondylodiscitis, or a paraspinal mass.,, Various approaches have been described, and based on the location of the lesion, an approach is selected. In this study, out of 45 dorsal spine biopsies performed, 18 underwent through transpedicular and 27 through posterolateral approach with an accuracy of 83% and 66% for transpedicular and posterolateral approach, respectively, with an overall accuracy of 73%. Hao et al [Figure 1]. reported on 158 consecutive thoracic spine biopsies, with an overall diagnostic accuracy of 90.5%, 98.2% for metastatic disease, and 80.9% for primary bone tumors, but only 47% for hematological malignancies. However, they did not conclude any statistically significant difference in biopsy success rate between the transpedicular or posterolateral approaches. Rimondi et al. obtained a diagnosis in 114 of 124 (92%) thoracic CT guided Needle Biopsy (CT-NB), whereas Lis et al. obtained a diagnosis in 88% of 123 thoracic CT-NB.
In the lumbar region, the transpedicular approach is a well-described technique with a high diagnostic yield.,, It is ideally used for lesions that are either diffusely infiltrating the vertebral body or involving the lateral third of the vertebra, mainly if there is extension into one or both pedicles. Approximately 50% of the volume of the lumbar vertebra is accessible through a transpedicular route, as concluded by a cadaveric study. Therefore, if the pedicle is not involved, then 2–3 cm of normal bone may have to be traversed before a lesion is entered. In this scenario, alternative techniques which allow direct access can be utilized. For a diffuse vertebral body lesion or a focal lesion in the posterolateral/lateral vertebral body, the posterolateral extra-pedicular technique or the transforaminodiscal approach as described in the thoracic spine can be employed. In our study, we have performed 15 transpedicular (accuracy of 100%) and 24 posterolateral (accuracy of 62.5%) lumbar biopsies [Table 1] and [Table 2]. Rimondi et al. obtained a diagnosis in 166 of 178 (93%) lumbar CT-NB, whereas Lis et al. obtained a diagnosis in 85% of 164 lumbar CT-NB.
Various approaches to CT-NB of the sacrum have been advocated, depending on the location of the lesion. For proximal sacral lesions chiefly involving the sacral ala, a midline posterior approach angling laterally into the sacral ala should be considered for the likelihood of a primary sacral tumor that may require resection, or a direct posterior approach into the sacral ala when metastatic disease, lymphoma, or infection is contemplated the most likely diagnosis. For lesions arising centrally within the upper sacrum, a posterolateral approach with medial angulation into the sacral body is ideal, taking care to avoid the sacral foramina. For centrally originating tumors such as chordoma arising in the distal sacral/sacrococcygeal region, a posterior midline approach is used. However, in many cases, due to the presence of posterior extra-osseous tumor extension, the lesion can be adequately targeted under Ultrasound guidance. Lis et al. reported a diagnostic rate of 96% in 96 sacral lesions, although the approach was not clarified, while the study by Rimondi et al. included 118 sacral lesions biopsied through a posterior midline approach with 97% of cases being diagnostic. In the present study, we had three lateral sacral biopsy procedures with 100% accuracy.
It is recommended that CT-NB is undertaken in a center where the spinal surgical backup is readily available in spite of low complication rates. Heyer et al. reported two focal hematomas (complication rate 1%). In the study of 430 CT-NB by Rimondi et al., biopsy-related complications were reported in nine cases (2.1%), five transient lower limb pareses, three psoas hematomas, and one retroperitoneal hematoma due to inadvertent puncture of a lumbar vein. None of the complications affected either patient management or overall patient outcome. In a series of 410 CT-NB, Lis et al. described two major complications (0.5%), a posterior paraspinal hematoma requiring transfusion and neurological deficit following mid-thoracic CT-NB requiring acute surgical intervention with no long-term complications. There was only one minor complication reported by Lis et al. In the study of 168 thoracic CT-NB by Hao et al., 2 major (1.2%) and nine minor (5.6%) biopsy-related complications were recorded. In a patient undergoing spinal biopsy using the posterolateral approach, a pathological fracture occurred with resulting canal compromise 3 days after the procedure requiring acute neurosurgical intervention with no permanent neurological deficit. In the second patient, a fistula developed in a patient with tuberculosis but was surgically excised and did not recur. Eight psoas muscle hematomas were reported, and one patient was unable to tolerate the biopsy due to pain. A higher rate of complications was reported by Olscamp et al. Of 94 CT-NB of the spine and sacrum, 6 (6.4%) complications were noted, including one aortic puncture, two psoas hematomas, one biopsy of an incorrect level, and two aborted procedures due to patient discomfort. From these studies, it would appear that postoperative muscle hematoma is the most typical complication following CT-NB. We found that, out of 87 patients, 12 had local hematoma only.
In our study, the age of the patients ranged from 38 to 90 years with a mean of 56.69 ± 12.3 years which is comparable with the mean age observed in studies done by Lis et al. 61 years (7–90 years), Maciel et al. 53 ± 16.4 years, and Kaltsikis et al. 62 years (30–80 years). Gender-wise distribution in the present study shows males to be more in number than females, i.e., 63 (72.4%) male and 24 (27.6%) female, which in accordance with the studies done earlier by Kaltsikis et al., in which they reported 44 (55.7%) males and 35 (44.3%) females. The present study was done with a 13G (thick) osteo site cooks needle, which led to higher diagnostic accuracy rates. Similar results have been observed by the studies done earlier by Kattapuram and Rosenthal, Fyfe et al., and Ward et al., which found much increase in diagnostic accuracy using thicker gauge needle.
| Conclusion|| |
CT-guided core NB is an effective, economical, safe, and minimally invasive procedure for the precise identification of spinal pathologies. It can be performed with high diagnostic accuracy with very few complications. If the CT-guided biopsy has not been successful, it should be repeated, and accuracy can be increased in experienced hands with a team approach. Therefore, CT-guided biopsy is a welcome alternative to surgical exploration and biopsy; it should be recommended for spinal lesions, deeply situated bone lesions.
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Conflicts of interest
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[Table 1], [Table 2]