Current Use, Effectiveness, and Safety of Image-Guided Bone Biopsies: Insights from the Registry of the German Society for Interventional Radiology and Minimally Invasive Therapy (DeGIR) Data 2018–2022

Abstract

Purpose

Image-guided bone biopsies have become indispensable in the diagnosis of a wide range of diseases, from incidental suspicious lesions to the evaluation of treatment response and the staging of malignancies. The aim of this evaluation of the prospectively managed voluntary multinational registry of the German Society for Interventional Radiology and Minimally Invasive Therapy (DeGIR) was to analyze the use, technical success, and complications of image-guided diagnostic biopsies of bone lesions.

Materials and Methods

All bone biopsies reported in the DeGIR registry between 2018 and 2022 were included. Technical success was defined as the successful image-guided placement of the sampling device within the bone lesion. Technical success and complication rates were compared across various parameters by Fisher’s exact and chi-square test. p<0.05 was considered statistically significant.

Results

A total of 17397 diagnostic punctures (female: 52% (9046/17397), outpatient procedures: 34% (5924/17397), median age: 64y (IQR 51–75y)) from 214 centers in Germany, Austria, and Switzerland were analyzed. The technical success rate was 98.9% (17201/17397), with histological representativeness in 93.2% of cases (10316/11071). Outpatient procedures had a higher technical success rate (99.3%, 5884/5924) compared to inpatient procedures (98.6%, 11316/11473, p<0.0001), but lower histological representativeness (91.1%, 1284/1410 vs. 93.5%, 9031/9661, p=0.001). The overall complication rate was 0.62% (108/17397), with major complications being predominantly parenchymal bleeding. Solid or subsolid lesions had higher histological representativeness (94.0%, 7846/8346) compared to necrotic-cystic lesions (90.3%, 1558/1725, p<0.0001).

Conclusion

Image-guided bone biopsies are highly effective and safe. The high technical success rates and low complication rates underscore their clinical utility. The DeGIR registry provides valuable insight into the performance and outcomes of these procedures, highlighting their importance in interventional radiology.

Key Points

• Image-guided bone biopsies have a high technical success rate.

• The complication rate is generally low, with major complications being rare.

• The further reduction of complications in patients with normal coagulation parameters indicate that bone biopsies might be safely performed as outpatient procedures.

Citation Format

• Zensen S, Opitz MK, Behr F et al. Current Use, Effectiveness, and Safety of Image-Guided Bone Biopsies: Insight from the Registry of the German Society for Interventional Radiology and Minimally Invasive Therapy (DeGIR) Data 2018–2022. Rofo 2025; DOI 10.1055/a-2600-3915

Zusammenfassung

Ziel

Bildgesteuerte Knochenbiopsien sind in der Diagnostik eines breiten Krankheitsspektrums unverzichtbar geworden, von zufälligen verdächtigen Läsionen bis hin zur Beurteilung des Therapieansprechens und des Stagings von Malignomen. Ziel dieser Auswertung des freiwilligen multinationalen Registers der Deutschen Gesellschaft für Interventionelle Radiologie und minimalinvasive Therapie (DeGIR) war es, den Einsatz, den technischen Erfolg und die Komplikationen bildgesteuerter diagnostischer Biopsien von Knochenläsionen zu analysieren.

Material und Methoden

Eingeschlossen wurden alle Knochenbiopsien, die zwischen 2018 und 2022 an das DeGIR-Register gemeldet wurden. Technischer Erfolg wurde definiert als die erfolgreiche bildgesteuerte Platzierung der Biopsienadel innerhalb der Knochenläsion. Der technische Erfolg und die Komplikationsraten zwischen verschiedenen Parametern wurden mit dem exakten Fisher-Test und dem Chi-Quadrat-Test verglichen, wobei p<0,05 als statistisch signifikant angesehen wurde.

Ergebnisse

Insgesamt wurden 17397 diagnostische Biopsien von Knochenläsionen (weiblich: 52% (9046/17397), ambulante Eingriffe: 34% (5924/17397), mittleres Alter: 64 Jahre (IQR 51–75 Jahre)) aus 214 Zentren in Deutschland, Österreich und der Schweiz ausgewertet. Die technische Erfolgsrate lag bei 98,9% (17201/17397), die histologische Repräsentativität bei 93,2% (10316/11071). Bei ambulanten Eingriffen war die technische Erfolgsrate höher (99,3%, 5884/5924) als bei stationären Eingriffen (98,6%, 11316/11473, p<0,0001), die histologische Repräsentativität jedoch geringer (91,1%, 1284/1410 vs. 93,5 %, 9.031/9.661, p=0,001). Die Gesamtkomplikationsrate lag bei 0,62% (108/17397), wobei es sich bei den schwerwiegenden Komplikationen überwiegend um Parenchymblutungen handelte. Solide oder subsolide Läsionen waren histologisch repräsentativer (94,0%, 7846/8346) als nekrotisch-zystische Läsionen (90,3%, 1558/1725, p<0,0001).

Schlussfolgerung

Bildgesteuerte Knochenbiopsien sind sehr effektiv und sicher. Die hohen technischen Erfolgsraten und geringen Komplikationsraten unterstreichen ihren klinischen Nutzen. Das DeGIR-Register bietet wertvolle Einblicke in die Durchführung und die Ergebnisse dieser Verfahren und unterstreicht ihre Bedeutung in der interventionellen Radiologie.

Kernaussagen

• Bildgesteuerte Knochenbiopsien haben eine hohe technische Erfolgsrate.

• Die Komplikationsrate ist im Allgemeinen niedrig, wobei größere Komplikationen selten sind.

• Die sehr niedrige Komplikationsrate bei Patienten mit normalen Gerinnungsparametern deutet darauf hin, dass Knochenbiopsien bei ausgewählten Patienten sicher ambulant durchgeführt werden können.

Keywords

bone biopsy - bone lesions - register study - interventional radiology

Introduction

A definitive diagnostic workup is crucial for the treatment of bone lesions. Hence, a histologic diagnosis is indispensable for guiding effective treatment strategies for primary tumors, metastatic malignancies, infectious processes, and benign lesions [1] [2] [3]. Furthermore, the evaluation of suspected recurrences, molecular pathology, and genetic analysis can be achieved [4].

Image-guided percutaneous bone biopsies are a well-established, minimally invasive, and cost-effective procedure in routine clinical practice for obtaining samples from bone lesions in any part of the body [5] [6] [7]. These interventions are considered to have a low risk profile but a high diagnostic yield and accuracy [5] [6] [8] [9] [10].

Historically, open biopsies were the standard approach for obtaining bone samples. However, the introduction of image-guided biopsies revolutionized clinical practice by providing a less invasive and more precise method for sampling bone lesions [6] [10] [11]. With advancements in biopsy equipment (e.g., specialized power drills) image-guided techniques have become the preferred method over the past few decades due to their safety and efficacy [2] [6] [9] [12]. Therefore, image-guided bone biopsies are now being favored over the former gold standard of open biopsy in most cases [6] [9] [12] [13] [14]. CT is commonly used for image guidance and needle navigation due to its broad availability and precise tumor visualization [6] [15]. However, ultrasound, fluoroscopy, and MRI also serve as alternatives [6] [16].

Despite the safety and effectiveness of image-guided bone biopsies, new clinical demands have arisen. The demand for histological testing has increased due to advancements in molecular testing, longer therapy durations, and the need for more frequent biopsies for restaging in cases of potential recurrence. To address this rising demand and improve cost-effectiveness, there has been a rising number of interventionalists advocating performing these procedures in an outpatient setting. As historical data, most notably on complication rates, can be difficult to interpret due to the abovementioned changes, this discussion has to be supported by new analyses. Hence, evaluating current practices based on large-scale clinical registry data is essential. The DeGIR (German Society for Interventional Radiology and Minimally Invasive Therapy, Deutsche Gesellschaft für Interventionelle Radiologie und minimalinvasive Therapie) is a member of CIRSE (Cardiovascular and Interventional Radiological Society of Europe). Its registry, involving 303 centers across Germany, Austria, and Switzerland, is managed prospectively for quality assurance and research in interventional radiology and minimally invasive therapy [17] [18] [19].

Therefore, the aim of this retrospective evaluation was to analyze the use, technical success and complications of image-guided diagnostic biopsies of bone lesions in central Europe.

Materials and methods

Data sets of diagnostic bone lesion punctures reported to the prospectively managed DeGIR registry in the years 2018 to 2022 by participating centers were included in this study. Data collection was conducted with online data management software (samedi GmbH, Berlin, Germany). Data submission was possible via the online form until the end of February for each preceding year. The analysis included mandatory parameters such as intervention date, patient demographics (sex, age), setting (inpatient/outpatient), biopsy site, complications within 24 hours, and technical success. Technical success was defined as visually confirming needle placement within the target lesion via the chosen modality for image guidance. Optional parameters included repeat interventions, lesion characteristics (size, density), imaging modality, performed anesthesia, biopsy sample count, and histological adequacy. Complications were graded based on severity using the SIR (Society of Interventional Radiology) classification system, distinguishing between minor (grades A–B) and major (grades C–F) complications ([Table 1]) [20]. Ethical approval for this retrospective registry study was granted by the local ethics committee (22-10893-BO).

Table 1 Classification of complications by severity into minor (A–B) and major (C–F) complications according to the SIR classification system for complications by outcome [20].

Minor complications	A	No need for therapy, no consequences
	B	Symptomatic treatment and overnight observation, if necessary
Major complications	C	Need for therapy, short hospitalization time (< 48h)
	D	Need for therapy, unplanned increase in treatment level, prolonged hospitalization time (> 48h)
	E	Permanent health damage
	F	Death

Statistics and data analysis

Statistical analysis was performed using GraphPad Prism 5.01 (GraphPad Software, San Diego, USA). To determine normal distribution, the D’Agostino-Pearson test was applied. Normally distributed data are reported as mean ± standard deviation (SD), and non-normally distributed data as median and interquartile range (IQR). Technical success and complication rates between different parameters were compared by Fisher’s exact and chi-square test, if not indicated otherwise. A p-value lower than 0.05 was considered statistically significant.

Results

Patient characteristics

From 2018 to 2022, a total of 17397 diagnostic punctures of bone lesions from 214 centers in Germany, Austria, and Switzerland were recorded in the DeGIR registry. The number of interventions reported to the registry increased each year from 2018 to 2022, tripling overall during this period ([Table 2]). 52.0% (9046/17397) of interventions were performed in female patients. The median age was 64 years (IQR 51–75 years). About one third of all interventions (34.1%, 5924/17397) were performed as outpatient procedures. There were significant differences in the proportion of inpatient procedures across the different body regions: spine (93.0%, 4022/4323) and pelvis (83.1%, 4714/5676) had particularly high rates of inpatient procedures. Inpatient procedures were much less common in the upper extremities (11.6%, 194/1669) and joints (12.9%, 246/1909, p<0.0001). About 0.9% (157/17397) of interventions were multiple or repeat interventions. 86.6% (15072/17397) of interventions were conducted under local anesthesia, while analgosedation was used in 10.0% (1732/17397) and general anesthesia in 3.1% (535/17397).

Table 2 Frequency of percutaneous image-guided bone biopsies from 2018 to 2022.

	2018	2019	2020	2021	2022	All years
Number of diagnostic punctures (%)	1458 (8.38%)	2932 (16.85%)	4036 (23.20%)	4378 (25.17%)	4593 (26.40%)	17397 (100%)
Inpatient	527 (36.15%)	1974 (67.33%)	2903 (71.93%)	2977 (68.00%)	3092 (67.32%)	11473 (65.95%)
Outpatient	931 (63.85%)	958 (32.67%)	1133 (28.07%)	1401 (32.00%)	1501 (32.68%)	5924 (34.05%)
Anatomical region
Spine		773	1185	1128	1237	4323 (24.85%)
Cervical		15	26	23	23	87 (0.50%)
Thoracic		255	438	392	441	1526 (8.77%)
Lumbar		503	721	713	773	2710 (15.58%)
Chest	307	416	397	502	484	2106 (12.11%)
Ribs	131	155	153	189	183	811 (4.66%)
Sternum	86	89	83	109	101	468 (2.69%)
Shoulder girdle	90	172	161	204	200	827 (4.75%)
Pelvis		932	1540	1629	1575	5676 (32.63%)
Ilium		663	1025	1089	1071	3848 (22.12%)
Pubis		49	73	102	78	302 (1.74%)
Ischium		41	75	80	76	272 (1.56%)
Sacrum/Coccyx		153	305	285	283	1026 (5.90%)
SI-joint		14	39	51	51	155 (0.89%)
Symphysis		12	23	22	16	73 (0.42%)
Upper extremity	430	332	253	320	334	1669 (9.59%)
Humerus	31	50	52	50	73	256 (1.47%)
Forearm	6	5	21	48	38	118 (0.68%)
Hand	393	277	180	222	223	1295 (7.44%)
Lower extremity	374	288	323	357	372	1714 (9.85%)
Femur	170	148	183	197	221	919 (5.28%)
Lower leg	46	44	58	79	56	283 (1.63%)
Foot	158	96	82	81	95	512 (2.94%)
Joint, unspecified	347	191	338	442	591	1909 (10.97%)

Lesion and biopsy characteristics

In 78.6% (13666/17397) of cases, the bone lesion density was reported, with 73.2% (9997/13666) being categorized as sub-solid/solid and 26.8% (3669/13666) as necrotic-cystic. The majority of bone biopsies in the pelvis were performed in the ilium (22.12%, 3848/17397), followed by the sacrum and coccyx (5.90%, 1026/17397, [Table 2]). Bone biopsies of the spine were most frequently performed in the lumbar region (15.58%, 2710/17397), followed by the thoracic spine (8.77%, 1526/17397), with only a few biopsies in the cervical spine (0.50%, 87/17397). Biopsies in the chest revealed varying frequencies, with the highest number observed in the shoulder girdle (4.75%, 827/17397), followed by the ribs (4.66%, 811/17397), and the sternum (2.69%, 468/17397). Most upper extremity biopsies were performed in the hand (7.44%, 1295/17397), followed by the humerus (1.47%, 256/17397), and the forearm (0.68%, 118/17397). Regarding lower extremity biopsies, the femur was biopsied most often (5.28%, 919/17397), followed by the foot (2.94%, 512/17397), and the lower leg (1.63%, 283/17397).

Complications

We found a low overall complication rate of 0.62% (108/17397). According to the SIR classification, 23.1% (25/108) were major complications with 40% (10/25) being parenchymal bleeding. Most of the major complications were classified as category C (80% (20/25), need for therapy, short hospital stay <48h) and only 20% (5/25) as category D (need for therapy, unplanned increase in treatment level, prolonged hospital stay >48h) ([Table 3]). No deaths were reported. Minor complications accounted for 76.9% (83/108) of all complications and were classified as category A (no need for therapy, no sequelae) and category B (symptomatic treatment and overnight observation if needed) with 39 and 44 cases, respectively. Here, especially venous bleeding was reported (45.8%, 38/83). The complication rate for outpatient procedures was significantly lower (0.15%, 9/5924) than for inpatient procedures (0.86%, 99/11473; p<0.0001, [Table 4], [Fig. 1]). This difference may reflect stricter patient selection for outpatient procedures and a tendency to biopsy less complex lesions in this setting. Specifically, the rate of major complications was significantly lower for outpatient procedures at 0.017% (1/5924, 1 category D complication), whereas inpatient procedures had a higher rate of 0.21% (24/11473, 20 category C complications, 4 category D complications, p=0.0015). The complication rate for necrotic-cystic bone lesions was significantly lower at 0.46% (17/3669) compared to 0.85% (85/9997) for sub-solid/solid bone lesions (p=0.0266, [Table 4], [Fig. 1]). The complication rate was significantly higher in patients with a pathological partial thromboplastin time (PTT) (pathological PTT: 2.69%, 13/484; normal PTT: 0.75%, 89/11908, p<0.0001) and a pathological international normalized ratio (INR) (pathological INR: 4.43%, 24/542; normal INR: 0.66%, 79/11962, p<0.0001). However, the complication rate for patients with a pathological platelet count was 1.40% (11/786), which was not significantly higher compared to 0.78% (90/11574) for those with a normal platelet count (p=0.095).

Table 3 Complications of percutaneous image-guided bone biopsies differentiated by complication type.

		Classification of complication*
		Minor		Major
*According to the SIR Classification System for Complications by Outcome [20]
Type of complication	n (%)	A	B	C	D	E	F
Arterial bleeding	14 (13.0%)	0	9	3	2	0	0
Material malposition	2 (1.9%)	1	0	1	0	0	0
Drug side effect	3 (2.8%)	2	1	0	0	0	0
Organ dysfunction	1 (0.9%)	0	0	0	1	0	0
Parenchymal bleeding	25 (23.1%)	5	10	10	0	0	0
Pulmonary complication	10 (9.3%)	4	4	1	1	0	0
Venous bleeding	41 (38.0%)	21	17	3	0	0	0
Venous occlusion	2 (1.9%)	2	0	0	0	0	0
Others	10 (9.3%)	4	3	2	1	0	0
All complications	108 (100%)	39 (36.1%)	44 (40.7%)	20 (18.5%)	5 (4.6%)	0 (0%)	0 (0%)

Table 4 Complications of image-guided bone biopsies differentiated by body region, bone lesion density, and coagulation-related laboratory parameters.

	Procedures	Complications		Complication rate
	n	Total (n)	Major according to SIR classification* (n)	Total	Major according to SIR classification*
*According to the SIR Classification System for Complications by Outcome [20]
Inpatient	11473	99	24	0.86%	0.21%
Outpatient	5924	9	1	0.15%	0.02%
Imaging modality
CT	11951	103	23	0.86%	0.19%
Fluoroscopy/DSA	2064	1	1	0.05%	0.05%
MRI	120	1	1	0.83%	0.83%
Ultrasound	3213	3	0	0.09%	0%
Combined imaging	49	0	0	0%	0%
Body region
Spine	4323	40	7	0.93%	0.16%
Chest	2106	17	4	0.81%	0.19%
Pelvis	5676	44	13	0.78%	0.23%
Upper extremity	1669	0	0	0%	0%
Lower extremity	1714	3	0	0.18%	0%
Joint, unspecified	1909	4	1	0.21%	0.05%
Bone lesion density
Sub-solid/solid	9997	85	19	0.85%	0.19%
Necrotic-cystic	3669	17	4	0.46%	0.11%
Coagulation-related laboratory parameters
Platelet count normal	11574	90	21	0.78%	0.18%
Platelet count pathologic	786	11	1	1.40%	0.13%
International Normalized Ratio (INR) normal	11962	79	17	0.66%	0.14%
International Normalized Ratio (INR) pathologic	542	24	6	4.43%	1.11%
Partial thromboplastin time (PTT) normal	11908	89	19	0.75%	0.16%
Partial thromboplastin time (PTT) pathologic	484	13	3	2.69%	0.62%

Fig. 1 Complications of percutaneous image-guided bone biopsy by procedure type (inpatient vs. outpatient), body region, bone lesion density, and coagulation-related laboratory parameters. Total and major complications according to the SIR Classification System for Complications by Outcome [20].

Technical success and image guidance

For image guidance, CT was used in 68.7% (11951/17397) of cases, fluoroscopy/DSA in 11.9% (2064/17397), MRI in 0.7% (120/17397), ultrasound in 18.5% (3213/17397), and combined imaging (e.g. ultrasound + CT) in 0.3% (49/17397). In 56.6% (9841/17397) of cases, the number of samples taken was reported, which was a median of 2 samples (IQR 1–3). Visually, the needle could be successfully placed in the bone lesion in 98.9% (17201/17397) of cases during the sampling procedure. In 63.6% (11071/17397) of cases, the histopathological result was recorded in the database. Here, the obtained sample was considered as histologically representative in 93.2% (10316/11071) of cases. Outpatient procedures had a slightly higher technical success rate (99.32%, 5884/5924) compared to inpatient procedures (98.63%, 11316/11473, p<0.0001, [Table 5], [Fig. 2]A). However, histological representativeness was higher for inpatient procedures (93.48%, 9031/9661) than for outpatient procedures (91.06%, 1284/1410, p=0.001, [Fig. 2]B). The technical success rate was high for all analyzed body regions ranging from 98.17% in the spine (4244/4323) to 99.63% in the joints (1902/1909). Histological representativeness was highest in the pelvis (93.88%, 4388/4674) and lowest in the joints (87.83%, 166/189). For bone lesion density, sub-solid/solid and necrotic-cystic lesions had similar technical success rates (sub-solid/solid: 98.62%, 9859/9997; necrotic-cystic: 98.86%, 3627/3669, p=0.32, [Fig. 2]A). However, the histological representativeness for sub-solid/solid lesions was significantly higher at 94.01% (7846/8346) compared to 90.32% (1558/1725) for necrotic-cystic lesions (p<0.0001). The intervention was not completed in 0.5% (91/17397): in 60.4% of cases (55/91), the intervention was aborted as the biopsy was not considered technically possible. In all other cases, the intervention was not completed due to a lack of patient compliance (24.2%, 22/91), intervention-related (8.8%, 8/91), or non-intervention-related complications (5.5%, 5/91) and because of a device defect (1.1%, 1/91).

Table 5 Technical success and histological representativeness of image-guided bone biopsies.

	Procedures	Technical success		Histological representativeness
	n	n	Rate	Report available (n)	Diagnosis possible (n)	Rate
Inpatient	11473	11316	98.63%	9661	9031	93.48%
Outpatient	5924	5884	99.32%	1410	1284	91.06%
Imaging modality
CT	11951	11814	98.85%	10219	9546	93.41%
Fluoroscopy/DSA	2064	2042	98.93%	456	394	86.40%
MRI	120	119	99.17%	114	108	94.74%
Ultrasound	3213	3178	98.91%	323	305	94.43%
Combined imaging	49	48	97.95%	23	21	91.30%
Body region
Spine	4323	4244	98.17%	3677	3409	92.71%
Chest	2106	2080	98.77%	1421	1332	93.74%
Pelvis	5676	5622	99.05%	4674	4388	93.88%
Upper extremity	1669	1662	99.58%	224	204	91.07%
Lower extremity	1714	1690	98.60%	886	816	92.10%
Joint, unspecified	1909	1902	99.63%	189	166	87.83%
Bone lesion density
Sub-solid/solid	9997	9859	98.62%	8346	7846	94.01%
Necrotic-cystic	3669	3627	98.86%	1725	1558	90.32%

Fig. 2 Technical success (A) and histological representativeness (B) by procedure type (inpatient vs. outpatient), body region, and bone lesion density.

Discussion

This analysis of the multinational DeGIR registry data from 2018 to 2022 investigates the use, technical success, and complications of image-guided diagnostic biopsies of bone lesions in central Europe and yields three key findings. First, our study shows that percutaneous image-guided bone biopsies consistently achieve a high technical success rate and histological representativeness, underscoring their effectiveness in clinical practice. Second, complication rates are overall low, with significantly fewer complications occurring in outpatient procedures and in patients with normal coagulation parameters, indicating that a high percentage of these biopsies can be safely performed in an outpatient setting. Third, sub-solid/solid lesions show higher histological representativeness compared to necrotic-cystic lesions, reflecting the inherent differences in sampling challenges across various lesion densities.

Biopsies are essential in clinical care, and the pressure to reduce healthcare costs is increasing [5] [6] [10] [13]. Bone biopsies represent a very heterogeneous group, as they are performed at various sites on the body with different risk and difficulty profiles. This raises questions about which procedures should be performed inpatient versus outpatient. Therefore, analyzing large databases like the DeGIR registry is extremely helpful, as it allows for exploratory analysis to determine the best settings for different types of biopsies. It also helps in understanding how often complications occur and what technical success rates can be expected.

Registries, including the DeGIR registry, play an instrumental role in elucidating procedural trends and outcomes in procedures considered as standard of care in the clinical routine such as image-guided bone biopsies. By pooling data from numerous centers, these registries furnish invaluable insight that informs clinical practice and contributes to the continual refinement of patient care standards in the realm of bone lesion management.

Our study demonstrates a high diagnostic yield and accuracy for percutaneous image-guided bone biopsies, with an excellent overall technical success rate of 98.9% and histological representativeness of 93.2%, consistent with the rates reported in the recent literature, which range from 84.3% to 96.0% [11] [21] [22] [23]. Outpatient procedures have a slightly higher technical success rate but lower histological representativeness compared to inpatient procedures. However, the observed difference in technical success rates between inpatient and outpatient procedures, although statistically significant, is relatively low. This could be attributed to the fact that more difficult procedures that require extensive histopathological sampling are more likely to be performed as inpatient procedures.

These findings have important implications for clinical practice. Our data suggest that outpatient biopsies can be safely and effectively performed in suitable patients with normal coagulation parameters, potentially reducing the burden on the healthcare system. Technical success is high across all body regions, with the highest success in the joints and the lowest in the spine. It is noteworthy that sub-solid/solid lesions have higher histological representativeness compared to necrotic-cystic lesions, which may reflect the different tissue structures and the associated challenges in sampling. In necrotic-cystic lesions, architectural heterogeneity and liquefied components can impede core integrity and increase the risk of sampling non-viable or non-representative tissue. The slightly lower histological representativeness in outpatient procedures may be related to lesion selection (e.g., more peripheral or smaller lesions), patient comorbidities affecting procedure planning, or time constraints within the outpatient workflow.

Complication rates are low, particularly for outpatient procedures. Our results confirm the rare occurrence of complications. Major complications are observed in only 0.14% of cases. This low complication rate in image-guided bone biopsy is advantageous compared to open biopsy with a complication rate of up to 16%, which can result in delayed wound healing and infection [13] [23] [24] [25] [26]. Furthermore, open biopsies often require crossing compartmental barriers and anatomic planes or tissue areas around a neurovascular bundle, which can complicate patient care and sometimes even prolong the initiation of several treatment options [9] [15]. In contrast, surgery, radiation and chemotherapy can be performed immediately after confirmation of pathological diagnosis after percutaneous image-guided bone biopsy [23].

Although our analysis underscores the generally safe nature of image-guided percutaneous bone biopsies, image-guided bone biopsies can still lead to complications. Here, bleeding is the predominant complication observed in our study [27]. According to the SIR Consensus Guidelines, bone biopsies represent a heterogeneous group of procedures, categorized by their bleeding risk as either low (<1.5% bleeding risk, such as in superficial bones) or high (>1.5% bleeding risk, such as in the spine) (see SIR classification in [Table 1]) [28]. However, our findings generally indicated lower rates, with rates exceeding 1.5% seen only in patients with pathological PTT or INR. These findings may help refine pre-procedural coagulation assessment protocols and support the definition of safe laboratory cutoff values, especially in the context of outpatient biopsy procedures. Furthermore, this underscores the need for careful patient selection and potentially adjusted preventive strategies.

Limitations of our study include the reliance on data reported to the DeGIR registry, which may be subject to reporting biases and have been already discussed in-depth in prior publications [17] [18] [29]. Additionally, not all centers consistently reported all variables, leading to incomplete data in some cases. Another limitation is the observational nature of the study, which limits the ability to establish causal relationships. Furthermore, the registry data were not independently validated due to the lack of monitoring, which may cause a sampling bias. Additionally, since the study is a retrospective observational study, causality cannot be definitively established. This was particularly evident in 2018, when the ratio of outpatient to inpatient procedures was reversed in comparison to the other years ([Table 2]). Nevertheless, the registry provides a unique overview of the use of image-guided bone biopsies in a large patient cohort.

Conclusion

The DeGIR registry provides valuable insight into the performance and outcomes of image-guided bone biopsies, highlighting their importance in the evolving landscape of interventional radiology. These important diagnostic procedures are a highly effective and safe method for obtaining histologic diagnoses of bone lesions. The high technical success rates and low complication rates underscore their utility in clinical practice. The low complication rates reported in this analysis, particularly for patients with normal coagulation parameters, might be a key consideration in increasing the number of outpatient procedures in appropriately selected patients.

Clinical relevance statement

Image-guided bone biopsies are effective procedures with high technical success rates and low complication rates, indicating the possibility to offer these interventions as outpatient procedures.

Conflict of Interest

The authors declare that they have no conflict of interest.

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Publication History

Received: 01 March 2025

Accepted after revision: 29 April 2025

Article published online:
23 May 2025