CC BY-NC-ND 4.0 · Rev Bras Ortop (Sao Paulo) 2021; 56(04): 453-458
DOI: 10.1055/s-0040-1718950
Artigo Original
Coluna

Effectiveness of Fluoroscopy-Guided Percutaneous Vertebral Biopsy[*]

Article in several languages: português | English
1  Cirurgia de Coluna, Departamento de Neurocirurgia, Hospital Regional de Alta Especialidad del Bajío, Universidad de Guanajuato, León, Guanajuato, México
,
2  Departamento de Neurocirurgia, Hospital Regional de Alta Especialidad del Bajío, Universidad de Guanajuato, León, Guanajuato, México
,
3  Neurocirurgia Pediátrica, Departamento de Neurocirurgia, Hospital Regional de Alta Especialidad del Bajío, Universidad de Guanajuato, León, Guanajuato, México
,
4  Cirurgia Ortopédica, Departamento de Cirurgia Ortopédica e Traumatologia, Centenario Hospital Miguel Hidalgo, Aguascalientes, Aguascalientes, México
› Author Affiliations
 

Abstract

Objective To define the effectiveness of fluoroscopy-guided percutaneous vertebral biopsy.

Methods Prospective study of patients with vertebral destruction syndrome at one institution. Percutaneous transpedicular vertebral biopsies guided by fluoroscopy were performed, and bony tissue and intervertebral disc tissue were extracted; histopathology and microbiology studies were also performed. Age, sex, vertebral segment, neurologic status, and biopsy and culture results were analyzed.

Results The average age of the patients was 53.8 years (range: 2 to 83 years), and the main spine segment was the lumbar segment in 62% of the cases. According to the impairment scale of the American Spinal Injury Association (ASIA), preoperatively, 49% of the patients were classified as Asia E, and 100% had pain. Definitive etiology was identified in 83% of the sample. The etiology was grouped into three categories: infectious, neoplasia, and degenerative (osteoporotic). The infectious group was composed of 36% of the patients, in whom Staphylococcus aureus was the most common agent identified; in 34.9% the sample, the etiology was neoplastic, most commonly multiple myeloma and metastatic disease due to prostate cancer; 21.7% of the patients had osteoporosis. The average surgical time was of 47.5 minutes, the average blood loss was of 10 mL. No complications were reported.

Conclusion Transpedicular percutaneous biopsy guided by fluoroscopy had an effectiveness of 83% for the etiological diagnosis of vertebral destruction syndrome in the present series. It should be considered a useful minimally-invasive procedure, which is easy, economical, and reproducible, with low risk of short- and long-term complications.


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Introduction

Vertebral biopsy is essential in the diagnosis and planning of the definitive management of vertebral destruction syndrome.[1] [2] The etiology spectrum for this disabling condition can be divided into neoplastic, infectious or metabolic (osteoporosis) causes. Robertson and Ball[3] were the first to report the use of percutaneous vertebral biopsy, Ottolenghi[4] and Valls et al.[5] performed aspiration biopsy of the vertebral body, and, finally, Craig,[6] in 1956, developed a trephine for biopsy. Subsequently, the use of open biopsy has progressively decreased over time.

Percutaneous biopsy is a minimally-invasive, fast, low-cost, and minimally-complicated technique that enables vertebral bony and soft tissue to be obtained for histopathology and microbiology analyses. There are series that were able to identify an infectious causative agent in 60% of spine infections with this technique; in other papers, a histopathological conclusive diagnosis was obtained in 55% to 90% of the cases;[7] these results raise doubts about its diagnostic utility.

The use of transpedicular instrumentation systems as well as kyphoplasty and percutaneous instrumentation have made the vertebral biopsy technique a practical method for the spine specialist. At our hospital, since the establishment of the Spine Surgery Department, 11 years ago, percutaneous vertebral biopsy guided by fluoroscopy has been performed in patients with vertebral destruction syndrome; the present study assesses the effectiveness of this technique.

The objective of the present paper is to define the effectiveness of fluoroscopy-guided percutaneous vertebral biopsy in the diagnostic approach of vertebral destruction syndrome.


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Patients and Methods

A prospective study was performed in a single reference center, from January 2008 to March 2012, in a cohort of 100 patients chosen through the convenience method. All patients were sent from secondary-care hospitals from 7 different states in the country to be evaluated by the Spine Surgery Department as outpatients, and they were admitted until a procedure was scheduled or as needed. Those patients who presented vertebral destruction syndrome, without a definitive diagnosis, who accepted the percutaneous biopsy procedure and signed the informed consent were included; patients who had a history of prior surgery, who already had a diagnosis of primary disease directly related to vertebral destruction syndrome were excluded. Moreover, those with medical restrictions regarding being placed in a ventral position (hemodynamically decompensated chronic obstructive pulmonary disease, pregnancy, morbid obesity) were also excluded. All patients underwent a preset study protocol with basic laboratory exams such as blood count, blood chemistry, serum electrolytes, coagulation times, and special serum analysis, such as the rate of erythrocyte sedimentation, febrile reactions, Bence Jones protein, among others. Anteroposterior and lateral simple radiographs, computed tomography, both simple and contrasted, nuclear magnetic resonance, and bone scans were also obtained.


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Biopsy Technique

After anesthesia, the patients were placed on ventral recumbency position on the pectoral and iliac regions in a conventional surgical bed, with the thoracic limbs directed upwards in the soldier position. Under the arc of fluoroscopy in a C-model Arcadis Orbis (Siemens, Munich, Germany), the area to undergo the biopsy was located and marked on the skin, and submitted to asepsis and antisepsis, and to the placement of sterile fields. The anteroposterior fluoroscopic image corroborated the the affected segment, and the pedicle was located. A 5-mm skin incision was made for the passage of the trocar. The tissues inside the trocar were discarded. An 11G caliber Jamshidi (CareFusion, San Diego, CA, US) biopsy needle was inserted in the pedicle, and the fluoroscopic image was altered to the profile view as needed. The needle was introduced in the pedicle and in 80% of the vertebral body. Two samples were obtained: one by aspiration, and the other through bone puncture ([Fig. 1]). The needle was removed, as well as the bone-tissue cylinder, which was immediately sent to the pathology and microbiology service. The trocar was extracted, and the surgical technique was performed again to obtain another sample with the same pedicle entry site, but trying another path toward the vertebral body. After hemostasis and washing, the wound was closed according to the Sarnoff technique with 3/0 nylon thread, an covered with a sterile patch. After the end of the surgical procedure, the patients were placed on supine on a transfer stretcher. After anesthetic reversal and removal of the orotracheal tube, all patients were sent to a conventional recovery area.

Zoom Image
Fig. 1 Biopsy technique. (A) Insertion of the biopsy needle (Jamshidi), fluoroscopy in anteroposterior position; (B) fluoroscopy in lateral position to confirm the correct needle placement; (C) collection of bone and intervertebral disc cylindrical samples.

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Statistics

Descriptive statistics were performed to determine the average and standard or median deviations and percentiles for the numerical variables according to their distribution, as well as the frequencies for the nominal variables. The sensitivity and specificity of the fever in every etiologic group were analyzed. Finally, the effectiveness of the test was determined.


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Results

Among the 100 patients included, 57 of them were men (57%), while 43 patients were women (43%), aged between 2 and 83 years (average of 53.85 years; standard deviation: 17.5). The age distribution was mainly patients between the ages of 51 and 60 years, with 29 cases (29%), followed by patients aged between 61 and 70, with 28 cases (28%), and the groups aged between 41 and 50 years, and between 71 and 80 years, both with 12 patients (12%) each. The location of the vertebral destructive lesion had the following distribution; cervical in 2 patients (2%), thoracic in 35 patients (35%), lumbar in 56 patients (56%), thoracolumbar in 2 patients (2%), lumbosacral in 4 patients (4%), and sacral in 1 patient (1%) ([Table 1]). Upon admission to the study, a spinal neurological examination was performed to classify the patients according to the American Spinal Injury Association (ASIA scale); the most common classification was ASIA E (49%), followed by ASIA D (27%), and ASIA A (12%). Regarding the sensitivity below the injury, 12 patients (12%) were found with anesthesia. Pain was the predominant symptom in 98 (98%) patients. Fever was only present in 11 (11%) patients. After defining the etiology, an analysis of in the infectious group showed 22.2% of sensitivity and 95.3% of specificity. Of these, 10 patients (10%) developed a causative agent in the cultures: 7 (7%) with Staphylococcus aureus, 1 (1%) with Brucella abortus, and 2 (2%) with microbiota agents. The Bence Jones protein was positive in 3 patients (3%), all of them with a definitive diagnosis of multiple myeloma.

Table 1

CASE

SEX

AGE

SEGMENT

ASIA

FEVER

REPORT

ETIOLOGY

CASE

SEX

AGE

SEGMENT

ASIA

FEVER

REPORT

ETIOLOGY

1

F

64

L

C

YES

NSI

I

51

F

63

L

C

NONE

NSI

I

2

F

51

L

E

NONE

OT

M

52

M

56

L

E

NONE

NM

I

3

M

48

T

A

NONE

M

N

53

M

65

T

L

YES

NSI

I

4

F

42

T

E

NONE

M

N

54

F

75

L

E

NONE

NSI

5

M

69

T

D

NONE

PN

N

55

F

69

T

C

NONE

PN

N

6

M

45

L

D

YES

M

N

56

M

65

L

C

NONE

PN

N

7

M

58

T

D

NONE

NSI

57

F

53

T

A

NONE

PN

N

8

F

58

L

D

NONE

OT

M

58

M

56

T

A

NONE

NSI

I

9

M

59

T

C

NONE

NSI

59

M

2

T

E

NONE

GR

I

10

M

63

L

D

NONE

TB

I

60

M

49

T

D

NONE

NSI

11

M

37

L

D

YES

NSI

61

F

64

L

E

NONE

OT

M

12

F

57

L

E

NONE

OT

M

62

F

59

LS

D

NONE

NSI

I

13

M

67

T

E

NONE

OT

M

63

M

46

L

E

NONE

NSI

I

14

F

51

C

E

NONE

M

N

64

M

46

L

E

NONE

NSI

I

15

M

71

L

E

NONE

NSI

65

M

75

L

D

NONE

NSI

I

16

M

55

L

E

YES

NSI

I

66

M

74

T

E

NONE

OT

M

17

F

34

T

E

NONE

GR

I

67

M

74

T

A

NONE

NSI

18

M

60

T

E

NONE

M

N

68

F

16

L

E

NONE

NSI

I

19

F

40

T

B

NONE

M

N

69

M

18

T

E

NONE

TB

I

20

M

15

L

A

NONE

PN

N

70

M

28

L

E

NONE

NSI

I

21

F

44

C

D

NONE

M

N

71

M

65

L

E

NONE

NSI

I

22

M

58

L

D

YES

NSI

I

72

M

59

L

D

NONE

NSI

I

23

M

16

T

E

NONE

NSI

I

73

M

68

L

C

NONE

NSI

I

24

M

18

T

E

NONE

GR

I

74

F

62

S

E

NONE

NSI

25

F

58

T

B

NONE

NSI

75

M

49

T

A

NONE

PN

N

26

M

64

L

D

YES

NSI

I

76

M

64

L

E

NONE

PN

N

27

M

64

T

E

NONE

M

N

77

F

23

LS

E

YES

NSI

I

28

F

31

TL

D

NONE

NSI

78

F

71

LS

E

YES

NSI

I

29

M

18

L

D

YES

GR

I

79

F

67

L

E

NONE

OT

M

30

M

67

L

D

YES

NSI

I

80

M

24

L

D

NONE

NSI

I

31

M

59

T

A

NONE

GR

I

81

F

65

T

A

NONE

NSI

I

32

F

63

L

E

NONE

GR

I

82

M

54

L

E

NONE

NSI

33

M

83

T

D

NONE

PN

N

83

F

67

L

E

NONE

NSI

34

M

54

L

D

NONE

PN

N

84

F

67

L

E

NONE

OT

M

35

F

13

L

D

NONE

PN

N

85

F

61

L

E

NONE

OT

M

36

M

57

L

C

NONE

NSI

I

86

M

56

L

D

NONE

PN

N

37

M

57

T

A

NONE

M

N

87

F

71

L

E

NONE

OT

M

38

M

10

L

A

NONE

PN

N

88

M

41

L

E

NONE

M

N

39

F

79

L

E

NONE

OT

M

89

F

71

L

E

NONE

OT

M

40

F

40

T

A

NONE

NSI

90

F

64

L

E

NONE

NSI

I

41

F

70

L

E

NONE

OT

M

91

F

54

L

E

NONE

NSI

42

M

53

L

D

NONE

OT

M

92

M

44

LS

E

NONE

NSI

43

M

55

L

D

NONE

OT

M

93

F

59

L

C

NONE

NSI

I

44

F

47

L

D

NONE

NSI

I

94

F

78

L

E

NONE

OT

M

45

F

51

T

E

NONE

M

N

95

M

71

T

A

NONE

M

N

46

M

54

T

D

NONE

PN

N

96

M

69

T

D

NONE

PN

N

47

M

70

L

E

NONE

NSI

97

F

67

L

E

NONE

PN

N

48

M

25

TL

E

NONE

GR

I

98

F

67

L

D

NONE

PN

N

49

M

54

T

C

NONE

GR

I

99

F

57

T

E

NONE

OT

M

50

M

43

T

C

NONE

M

N

100

F

78

L

E

NONE

OT

M

The definitive diagnosis was obtained in 83 out of 100 patients, obtaining an effectiveness of 83% ([Table 2]).

Table 2

ETIOLOGIC GROUP

CASES

N

INFECTIOUS

43.37%

36

 Staphylococcus aureus

38.63%

17

 Brucella abortus

22.72%

10

 Mycobacterium tuberculosis

20.45%

9

 Escherichia coli

2.27%

1

NEOPLASTIC

34.94%

29

 PRIMARY TUMOR

55.1%

16

 MULTIPLE MYELOMA

31.03%

9

 PLASMACYTOMA

6.89%

2

 EWING TUMOR

6.89%

2

 NEUROBLASTOMA

3.44%

1

 GIANT-CELL TUMOR

3.44%

1

 CHONDROMA

3.44%

1

 METASTASIS

44.82%

13

 PROSTATE

13.79%

4

 LUNG

10.34%

3

 ESOPHAGUS

6.89%

2

 BREAST

3.44%

1

 OVARY

3.44%

1

 BILLIARY TRACT

3.44%

1

 SKIN (BASOCELLULAR CANCER)

3.44%

1

METABOLIC

21.69%

18

 OSTEOPOROSIS

100%

18

Overall, 36 patients (36%), presented a conclusive diagnosis with positive cultures, with the isolation of S. aureus in 17 patients (17%) followed by B. abortus in 10 patients (10%), and M. tuberculosis in 9 patients (9%).

In total, 29 patients (29%) presented a disease with a neoplastic etiology confirmed on the histopathological analysis; the most common primary tumor was multiple myeloma, with 9 cases (9%), followed by 2 patients (2%) with plasmacytoma, 2 (2%) with Ewing tumor, 1 case (1%) of neuroblastoma, 1 case (1%) of giant-cell tumor, and 1 case (1%) of chondroma. Regarding tumors of metastatic origin, prostate-cancer metastasis was diagnosed in 4 patients (4%), as well as lung cancer metastasis in 3 cases (3%); the remaining tumors found were breast, ovarian, and esophageal cancers, and basal-cell and bile-duct carcinomas.

In total, 18 patients (18%) were included in the osteoporosis etiology group due to the absence of microbiological development in the cultures and findings compatible with chronic degenerative changes, such as significant trabecular decrease in the histopathological study.

Overall, the average surgical time was of 47.5 minutes, with an average transoperative bleeding of 10 mL.

The patients with infectious etiology received antibiotics prescribed by the hospital's infectiology service. The patients with vertebral osteoporosis were submitted to kyphoplasty, and those in the neoplasm group were classified according to the Tokuhashi score to decide whether the surgery should be performed or not, and they were sent to the oncology service to undergo chemotherapy or radiotherapy.


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Discussion

The use of higher-definition imaging studies, such as computed tomography and magnetic resonance as well as the use of nuclear medicine, has allowed the spine specialist to detect with much more sensitivity smaller lesions that occur in patients with specific symptoms, enabling the performance of less invasive surgical approaches, such as percutaneous biopsy, instead of open biopsy. Even though open biopsies are associated with a longer surgical time, greater risk of bleeding, higher number of complications, and sometimes it is not possible to obtain an adequate biopsy by a traditional posterior access to the vertebral body, they are still considered the “gold standard.” With the improvement in the different types of vertebral instrumentation, the increasing use of transpedicular systems, and, lately, of the percutaneous transpedicular instrumentation make the technique of percutaneous vertebral biopsy an option that can be easily used by the spinal surgeon. Since there are more morphometric reports about the strength, structure, and anatomical situation with respect to the spinal level, it is known that a pedicle larger than 3 mm is able to safely house a needle for vertebral biopsy.[8]

B. Marré reported that, in 22 patients, he obtained 95% of diagnostic effectiveness, and microbiological identification in 50% of the cases. Rosales-Olivares et al.[7] reported diagnosis in only 55% of the cases studied by histopathology, and they concluded that, given the poor percentage obtained in their series of only 20 patients, “percutaneous fluoroscopy-guided biopsy is not a useful method in our environment”; this discrepancy with other works may be due to the small sample of patients, and although the methodology followed is not specified, it remains an operator-dependent technique. In general, the methodology of the study is not enough to rule out this technique. On the other hand, in the present series of 100 cases, a definitive etiological diagnosis was obtained in 83 patients (83%), which positions this modality of percutaneous biopsy technique as an effective tool within the vertebral destruction syndrome study protocol, given its wide availability and reproducibility.

Currently, there are works describing other imaging techniques used, such as tomography, with a reported effectiveness of 90.4%[9] to 94.4% for the histopathological analysis.[10] However, in our environment, even today, the availability of the tomography equipment for surgical procedures continues to be complicated given the number of other diagnostic procedures performed in imaging services. Thus, alternative methods, such as fluoroscopy, which has greater accessibility, continue to be part of our diagnostic arsenal for the diagnosis of patients with vertebral destruction syndrome. However, such methods should be compared to other minimally-invasive techniques.

Although the present series has considerable sample of patients in a prospective design, a comparative analysis of at least two different biopsy techniques is necessary to sustain stronger evidence-based recommendations.


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Conclusion

Percutaneous transpedicular fluoroscopy-guided biopsy is an effective method (83%) for the etiological diagnosis of vertebral destructive syndrome. It is a minimally-invasive procedure, with little intraoperative bleeding, minimal surgical time, short hospital stays, cheap, and feasible to the surgeon at any hospital with an image intensifier C arm.


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Conflito de Interesses

Os autores declaram não haver conflito de interesses.

* Work developed at Hospital Regional de Alta Especialidad del Bajío, Universidad de Guanajuato, Guanajuato, Mexico.


Financial Support

There was no financial support from public, commercial, or non-profit sources.



Endereço para correspondência

José Nicolás Mireles Cano
Apolo XI, 418, Col. Futurama Monterrey, León, Guanajuato, 37180
México   

Publication History

Received: 19 March 2020

Accepted: 06 July 2020

Publication Date:
30 August 2021 (online)

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Zoom Image
Fig. 1 Técnica de biópsia. (A) Inserção de agulha de biópsia (Jamshidi), fluoroscopia em posição anteroposterior; (B) fluoroscopia em posição lateral para a confirmação da colocação correta da agulha; (C) coleta de amostras cilíndricas de osso e disco intervertebral.
Zoom Image
Fig. 1 Biopsy technique. (A) Insertion of the biopsy needle (Jamshidi), fluoroscopy in anteroposterior position; (B) fluoroscopy in lateral position to confirm the correct needle placement; (C) collection of bone and intervertebral disc cylindrical samples.