Rationale and Objectives
The study goal was to retrospectively evaluate the effectiveness of computed tomography (CT)-guided spinal biopsies.
Material and Methods
Two hundred two CT-guided vertebral biopsies performed between May 1999 and June 2004 in 187 patients were retrospectively analyzed. Patient characteristics (age, sex, antibiotic therapy), technical parameters (depth and number of biopsies, needle approach), lesion features (spinal level, osteolysis, fluid collections, soft tissue tumor), and complications were documented. Furthermore, histopathological and microbiological diagnoses were considered.
Results
There were two focal hematomas in our study group (complication rate: 1%). Histopathological diagnosis was established in 74% of examinations with spondylitis (41% of cases) being most common. In spinal tumors (27% of cases), malignant lesions were found in 52 of 54 examinations (96%). Osteolysis was diagnosed in 98% of patients with spondylitis and in 87% of patients with tumors ( P < .01). Spinal tumors were most commonly seen in the sacrum (53%, P < .001), whereas spondylitis typically occurred in the lumbar spine (55%, P = .001). Neither patient age nor sex, needle approach, needle depth, or vertebral abnormalities showed a significant impact on diagnostic accuracy. Microbiological tests were performed in 98 patients (49%); 62 of 98 patients (65%) received antibiotic therapy. In 12 of 62 patients (19%) with antibiotic therapy and in 9 of 36 patients (25%) without antibiotic treatment, microbiological tests were positive ( P = .153). Staphylococcus aureus was found in 9 of 21 examinations (43%).
Conclusions
CT-guided vertebral biopsy is a safe and effective procedure to establish final diagnosis in spinal lesions of unclear origin. Patient characteristics, lesions features, and technical considerations did not influence sample quality. In spondylitis, which was commonly caused by Staphylococcus aureus , microbiological yield was low regardless of antibiotic therapy.
Precise histological diagnosis has become a necessary prelude to successful management of diseases of the spine. Although many symptomatic patients with spinal lesions present with osteolysis, spinal masses, or sclerosis on image studies, radiographic findings can be misleading. For years open biopsy has been the reference standard to obtain adequate tissue specimen in spinal lesions. After early attempts of performing biopsies blindly ( ), intensified fluoroscopic guidance became the major imaging device to obtain spinal biopsies. Although early results were promising ( ), this method was not without disadvantages. Conventional radiography does not accurately distinguish between the physical characteristics of a lesion and its surrounding structures ( ). Moreover, poor spatial resolution and superposition of structures further limited its use. Ultrasound has also been used to navigate spinal biopsies ( ), but its inability to assess osseous structures substantially limits its value.
First reports of computed tomography (CT)-guided biopsies of the spine were presented in the late 1970s ( ), after CT had been extensively applied to characterize spinal lesions based on imaging features. Recent advances in imaging technology, including the clinical introduction of multidetector CT, have further improved navigation techniques for spinal biopsies. Although CT guidance is now widely accepted as the standard procedure for image-guided spinal biopsies ( ), little is known about the dependence of its diagnostic accuracy on patient characteristics and on technical considerations of the biopsy procedure. We describe our techniques of CT-guided spinal biopsies and provide an analysis of all examined patients considering final histopathological and microbiological diagnoses.
Materials and methods
Patient Selection
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Biopsy Procedure
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Statistical Analyses
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Results
Patient Group
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Biopsy Procedure
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Histopathological Results
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Table 1
Histopathological Diagnoses in Spinal Tumor Lesions Established by CT-Guided Percutaneous Biopsy
Histopathological Diagnosis Incidence ( N = 58) Plasmocytoma_n_ = 9 (16%) Metastasis of undifferentiated malignant tumor_n_ = 7 (12%) Metastasis of small cell lung cancer_n_ = 5 (9%) Metastasis of adenocarcinoma_n_ = 5 Metastasis of prostate cancer_n_ = 4 (8%) Metastasis of colon carcinoma_n_ = 3 (5%) Metastasis of renal cell carcinoma_n_ = 2 (4%) Metastasis of urothelial carcinoma_n_ = 2 Primary hemangioma/lymphangioma_n_ = 2 Non-Hodgkin’s lymphoma_n_ = 2 Chondrosarcoma_n_ = 2 Metastasis of spinocellular carcinoma_n_ = 1 (2%) Metastasis of carcinoid carcinoma_n_ = 1 Metastasis of squamous cell carcinoma_n_ = 1 Metastasis of thyroid carcinoma_n_ = 1 Metastasis of breast cancer_n_ = 1 Angiosarcoma_n_ = 1 Leukemia with osseous infiltration_n_ = 1 Metastasis of malignant melanoma_n_ = 1 Lymphangiosis carcinomatosa_n_ = 1 Osteoblastic osteosarcoma_n_ = 1
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Microbiological Results
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Morphology and Level of Vertebral Lesions
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Table 2
Comparison of Level of Spinal Findings and Major Histopathological Diagnoses
Cervical Spine Thoracic Spine Lumbar Spine Sacral Spine Final Histopathological Diagnosis ( n = 4) ( n = 69) ( n = 83) ( n = 40) Tumor 2 of 4 (50%) 16 of 69 (23%) 21 of 40 (53%)n = 54 of 196 (28%)P = .305P = .201 15 of 83 (18%)☆ P = .008P <.001 Spondylitis 1 of 4 (25%) 30 of 69 (43%) 5 of 40 (13%)n = 82 of 196 (42%)P = .443P = .423 46 of 83 (55%) P = .001P < .001 No histopathological diagnosis established 1 of 4 (25%) 20 of 68 (29%) 17 of 83 (20%) 14 of 40 (35%)n = 52 of 196 (27%)P = .711P = .319P = .064P = .129
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Inconclusive Histopathological/Microbiological Results
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Table 3
Comparison of Patients With and Without Final Histopathological Diagnosis With Respect to Patient Characteristics, Technical Considerations of the Biopsy Procedure, and Vertebral Abnormalities
Patients With Final Histopathological Diagnosis ( n = 143) Patients Without Final Histopathological Diagnosis (normal findings or insufficient specimen quality) ( n = 52)P value Patient characteristics .034 Age (63 ± 14 y) 63 ± 12 y 59 ± 16 y .374 ⁎ Sex (117 of 195 male, 60%) 90 of 143 male (63%) 27 of 52 male (52%) .111 Biopsy procedure No. of biopsies performed (1.2 ±.47) 1.2 ± 0.44 1.2 ± 0.55 .103 Patient position during biopsy (67% POS) 100 of 143 POS (70%) 21 of 52 POS (40%) .119 Biopsy approach (47% TPA) 67 of 143 TPA (47%) 25 of 52 TPA (48%) .504 Final biopsy depth (7.5 ± 1.8 cm) 7.6 ± 1.7 cm 7.0 ± 1.5 cm .561 Vertebral abnormalities Vertebral osteolysis ( n = 180, 92%) 135 of 143 (94%) 45 of 52 (87%) .069 Spinal stenosis ( n = 53, 27%) 41 of 143 (29%) 12 of 52 (23%) .279 Paravertebral soft tissue mass ( n = 107, 55%) 79 of 143 (55%) 28 of 52 (57%) .495 Paravertebral fluid collection ( n = 36, 18%) 27 of 143 (19%) 9 of 52 (17%) .492
POS, position on the side; TPA, transpedicular approach.
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Discussion
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