Percutaneous Needle Technique Musculoskeletal Biopsy
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Percutaneous image-guided musculoskeletal biopsy provides an accurate, rapid, and cost-effective method for helping clinicians diagnose benign and malignant musculoskeletal lesions. [1] In patients who present with nonspecific physical findings, imaging studies, and laboratory values, percutaneous biopsy can lead to a rapid and accurate diagnosis and allow implementation of the most appropriate therapy. Most biopsies can be performed using local anesthesia, with the addition of conscious sedation if necessary.
Various imaging modalities can be used to target the lesion, including computed tomography (CT), fluoroscopy, [2] ultrasonography (US), and magnetic resonance imaging (MRI). The procedure is safe, with major complications uncommonly reported. When proper techniques are used, nondiagnostic or insufficient specimens are obtained in only approximately 8-10% of biopsies. Accuracy is expected to be 70-100% and is improved with expert cytopathologic interpretation. [3, 4, 5, 6, 7, 8]
A 2009 review of 309 biopsies noted that image-guided core needle biopsy was particularly effective in diagnosing homogenous soft-tissue tumors. [9] Rimondi et al also noted the reliability of percutaneous CT-guided biopsy after analyzing 2027 cases over a period of 18 years. [10]
Certain limitations or contraindications apply to musculoskeletal biopsy, as follows.
Coagulation disorders should be corrected prior to biopsy; fresh-frozen plasma (FFP) can be administered immediately beforehand to temporarily correct the prothrombin time (PT), the activated partial thromboplastin time (aPTT), and the international normalized ratio (INR).
Some sites are not accessible to this procedure, including the following [11] :
Biopsy of hemorrhagic lesions frequently is less accurate, even with core needle biopsy (CNB). Prebiopsy imaging can help guide needles to areas with less vascularization. A fine needle should be used if a path is in close proximity to vessels or if a hemorrhagic lesion is suspected.
An uncooperative patient precludes biopsy; however, general anesthesia, particularly in children, should be considered. [12]
Biopsy of the correct lesion is imperative for accurate and timely patient care. In one study, biopsy was performed at an incorrect vertebral level in one of 94 patients. [13] The patient did not have a reported complication; however, this case underscores the need for thorough review of preprocedural imaging studies. The authors in that case also recommended obtaining a visual CT scan or MRI of the lesion that is consistent with the suggested lesion prior to biopsy.
Choice of imaging guidance
The choice of imaging guidance depends to some degree on operator preference; options include US, CT, fluoroscopy, and MRI. [14] In general, biplane fluoroscopy can be used for superficial bony lesions, whereas CT is preferred for deeper lesions and lesions in anatomically complex areas. US obviates the need for ionizing radiation and can be used if an accompanying soft-tissue mass or cortical destruction is present.
On rare occasions, MRI may be used to visualize lesions occult to CT and to visualize the procedure in real time. However, MRI is of limited use in sclerotic lesions, in a relatively small number of interventional MRI systems, and with less cumulative operator experience. In a 2007 study of 45 biopsies, MRI was better for diagnosing bone lesions than soft-tissue lesions. [15]
Choice of biopsy route
The choice of biopsy route is crucial to success. The transpedicular approach prevents the leaking of cerebrospinal fluid (CSF) or the spread of infection or tumor, as long as the medial pedicular wall remains intact. Paraspinal approaches may be technically difficult secondary to a lack of purchase obtained with an angled approach to the vertebral body.
Some lesions may not be good candidates for percutaneous biopsy. Specifically, hypervascular metastases, such as renal cell carcinoma with posterior vertebral body or spinal canal extension, pose an increased risk of cord compression if biopsy is performed. Biopsy of a compression fracture should be performed under CT guidance; if the compression is too great, a percutaneous biopsy may not be appropriate.
Traina F, Errani C, Toscano A, Pungetti C, Fabbri D, Mazzotti A, et al. Current concepts in the biopsy of musculoskeletal tumors. J Bone Joint Surg Am. 2015 Jan 7. 97 (1):e7. [Medline].
Qi D, Hu T, Zhang G. Evaluation of the use of fluoroscopy guided needle biopsies for diagnosing cases of suspected pathological fractures. Asia Pac J Clin Oncol. 2016 Sep. 12 (3):235-41. [Medline].
Mitsuyoshi G, Naito N, Kawai A, et al. Accurate diagnosis of musculoskeletal lesions by core needle biopsy. J Surg Oncol. 2006 Jul 1. 94(1):21-7. [Medline].
Ogilvie CM, Torbert JT, Finstein JL, et al. Clinical utility of percutaneous biopsies of musculoskeletal tumors. Clin Orthop Relat Res. 2006 Sep. 450:95-100. [Medline].
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Omura MC, Motamedi K, UyBico S, Nelson SD, Seeger LL. Revisiting CT-guided percutaneous core needle biopsy of musculoskeletal lesions: contributors to biopsy success. AJR Am J Roentgenol. 2011 Aug. 197(2):457-61. [Medline].
Sung KS, Seo SW, Shon MS. The diagnostic value of needle biopsy for musculoskeletal lesions. Int Orthop. 2009 Dec. 33 (6):1701-6. [Medline].
Rimondi E, Rossi G, Bartalena T, Ciminari R, Alberghini M, Ruggieri P, et al. Percutaneous CT-guided biopsy of the musculoskeletal system: results of 2027 cases. Eur J Radiol. 2011 Jan. 77(1):34-42. [Medline].
Bancroft LW, Peterson JJ, Kransdorf MJ, Berquist TH, O’Connor MI. Compartmental anatomy relevant to biopsy planning. Semin Musculoskelet Radiol. 2007 Mar. 11(1):16-27. [Medline].
Shin HJ, Amaral JG, Armstrong D, Chait PG, Temple MJ, John P, et al. Image-guided percutaneous biopsy of musculoskeletal lesions in children. Pediatr Radiol. 2007 Apr. 37(4):362-9. [Medline].
Olscamp A, Rollins J, Tao SS, et al. Complications of CT-guided biopsy of the spine and sacrum. Orthopedics. 1997 Dec. 20(12):1149-52. [Medline].
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Carrino JA, Khurana B, Ready JE, Silverman SG, Winalski CS. Magnetic resonance imaging-guided percutaneous biopsy of musculoskeletal lesions. J Bone Joint Surg Am. 2007 Oct. 89(10):2179-87. [Medline].
Schweitzer ME, Gannon FH, Deely DM, et al. Percutaneous skeletal aspiration and core biopsy: complementary techniques. AJR Am J Roentgenol. 1996 Feb. 166(2):415-8. [Medline].
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Ceraulo A, Ouziel A, Lavergne E, Perrier L, Decouvelaere AV, Chotel F, et al. Percutaneous guided biopsy for diagnosing suspected primary malignant bone tumors in pediatric patients: a safe, accurate, and cost-saving procedure. Pediatr Radiol. 2017 Feb. 47 (2):235-244. [Medline].
Sperandeo M, Trovato FM, Melillo N, Dimitri L, Musumeci G, Guglielmi G. The role of ultrasound-guided fine needle aspiration biopsy in musculoskeletal diseases. Eur J Radiol. 2017 May. 90:234-244. [Medline].
Dupuy DE, Rosenberg AE, Punyaratabandhu T, et al. Accuracy of CT-guided needle biopsy of musculoskeletal neoplasms. AJR Am J Roentgenol. 1998 Sep. 171(3):759-62. [Medline].
Krause ND, Haddad ZK, Winalski CS, Ready JE, Nawfel RD, Carrino JA. Musculoskeletal biopsies using computed tomography fluoroscopy. J Comput Assist Tomogr. 2008 May-Jun. 32(3):458-62. [Medline].
Motamedi K, Levine BD, Seeger LL, McNitt-Gray MF. Success rates for computed tomography-guided musculoskeletal biopsies performed using a low-dose technique. Skeletal Radiol. 2014 Nov. 43 (11):1599-603. [Medline].
Carrino JA, Khurana B, Ready JE, Silverman SG, Winalski CS. Magnetic resonance imaging-guided percutaneous biopsy of musculoskeletal lesions. J Bone Joint Surg Am. 2007 Oct. 89(10):2179-87. [Medline].
López JI, Del Cura JL, Zabala R, et al. Usefulness and limitations of ultrasound-guided core biopsy in the diagnosis of musculoskeletal tumours. APMIS. 2005 May. 113(5):353-60. [Medline].
Leffler SG, Chew FS. CT-guided percutaneous biopsy of sclerotic bone lesions: diagnostic yield and accuracy. AJR Am J Roentgenol. 1999 May. 172(5):1389-92. [Medline].
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Jelinek JS, Kransdorf MJ, Gray R, et al. Percutaneous transpedicular biopsy of vertebral body lesions. Spine. 1996 Sep 1. 21(17):2035-40. [Medline].
Richard L Hallett, MD Chief, Cardiovascular Imaging, Northwest Radiology Network; Clinical Assistant Professor, Cardiovascular Imaging Division, Department of Radiology, Stanford University Hospital and Clinics
Richard L Hallett, MD is a member of the following medical societies: American College of Radiology, American Heart Association, Indiana Radiological Society, North American Society for Cardiac Imaging, Radiological Society of North America, Society of Cardiovascular Computed Tomography, Society of Interventional Radiology
Disclosure: Nothing to disclose.
Bernard D Coombs, MB, ChB, PhD Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand
Disclosure: Nothing to disclose.
William R Reinus, MD, MBA, FACR Professor of Radiology, Temple University School of Medicine; Chief of Musculoskeletal and Trauma Radiology, Vice Chair, Department of Radiology, Temple University Hospital
William R Reinus, MD, MBA, FACR is a member of the following medical societies: Alpha Omega Alpha, Sigma Xi, American College of Radiology, American Roentgen Ray Society, Radiological Society of North America
Disclosure: Nothing to disclose.
Felix S Chew, MD, MBA, MEd Professor, Department of Radiology, Vice Chairman for Academic Innovation, Section Head of Musculoskeletal Radiology, University of Washington School of Medicine
Felix S Chew, MD, MBA, MEd is a member of the following medical societies: American Roentgen Ray Society, Association of University Radiologists, Radiological Society of North America
Disclosure: Nothing to disclose.
Jacqueline C Hodge, MD Assistant Professor, Department of Radiology, McGill University, Royal Victoria Hospital
Jacqueline C Hodge, MD is a member of the following medical societies: American College of Radiology
Disclosure: Nothing to disclose.
Percutaneous Needle Technique Musculoskeletal Biopsy
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