J.Orthopaedics 2005;2(6)e4
Introduction:
In the
era of evidence based medicine, to provide a histopathological
diagnosis for a radiological lesion in a vertebra, closed
vertebral biopsies are done with the help of Radiologist and
Pathologist . The Diagnosis of bone lesions by needle biopsy was
first introduced by Coley et al in 1931. The ease and safety of
the procedure, however, were not realized until 1970, when Lalli
simplified the procedure by using image intensified fluoroscopy.
Closed vertebral biopsies has long been recognized as a
valuable diagnostic tool, but its accuracy have been
questioned.
To
determine the accuracy of this procedure in our own practice, we
reviewed all patients who had a closed vertebral biopsies during
a 6 year period, which included 112 patients – a largest study.
Material and Methods :
All
closed vertebral biopsies that were performed in Sri Ramachandra
Medical College and Research Institute, Chennai between January
1998 to March 2004 were included in this study. For all 112
biopsies Age, Sex, Level of lesion, Imaging Modality used and
Pathological diagnosis were noted. Any radiological lesion (Osteolytic,
Sclerotic and doubtful) at any vertebral level were included.
Biopsies were done by Senior Radiologist using Jamshidi needle
by posterolateral approach and standard protocol were followed
for preservation, sectioning and staining of biopsied
specimens. All specimens were reported by Senior Pathologist .
Chi
square test was used to analyze the outcome of the study for
statistical significance.
Results :
All
biopsies were done under local anesthesia except in 7 patients
(6.25 %) who were less then 20 years of age. Out of 112 closed
vertebral biopsies 55 patients (49.1%) were males and 57
patients (50.9 %) were females. 7 patients (6.25 %) were
between 0 to 20 years, 23 patients (20.54 %) were between 21 to
40 years, 50 patients (44.64 %) were between 41 to 60 years and
32 patients (28.57%) were between 61 to 80 years.
Most
common biopsied spinal levels were in lumbar vertebra 62
patients (55.35 %), of which L 3 vertebra was the most vertebra
with 15 patients (16.07 %), followed by lower dorsal (D7-D12) in
38 patients (33.93 %). Jamshidi needle was used under CT Scan
guidance in 61 Patients (54.46 %), C arm guidance in 28 patients
(25 %) and Fluroscopy guidance in 23 patients (20.54 %).
On
analyzing the biopsy slides the diagnosis of Tuberculosis were
made in 19 patients (16.96 %), Secondaries in 17 patients
(15.18 %), non specific chronic osteomyelitis in 16 patients
(14.29 %), others (i.e) multiple myeloma, pagets etc., in 8
patients (7.15%), non specific / normal in 3 cases (2.67%) and
inadequate in 49 patients (43.75%).
Following Tables illustrates Sex, Age, Vertebral levels
involved, Imaging modality used and Diagnosis attained.
SEX
Male |
55
patients |
49.1% |
Female |
57
patients |
50.9% |
|
112 patients |
100% |
AGE
0
– 10 |
0 |
7
Patients |
6.25 % |
11
– 20 |
7 |
21- 30 |
11 |
23
Patients |
20.54 % |
31
– 40 |
12 |
41
– 50 |
16 |
50
Patients |
44.64 % |
51
– 60 |
34 |
61
– 70 |
21 |
32
Patients |
28.57 % |
71
– 80 |
11 |
|
112 Patients |
100 % |
VERTEBRAL LEVELS
C1 |
0
Patients |
|
D6 |
2
Patients |
C2 |
1
Patients |
D7 |
1
Patients |
C3 |
0
Patients |
D8 |
3
Patients |
C4 |
0
Patients |
D9 |
6
Patients |
C5 |
0
Patients |
D10 |
6
Patients |
C6 |
2
Patients |
D11 |
10
Patients |
C7 |
0
Patients |
D12 |
12
Patients |
D1 |
1
Patients |
L1 |
15
Patients |
D2 |
0
Patients |
L2 |
13
Patients |
D3 |
4
Patients |
L3 |
18
Patients |
D4 |
1
Patients |
L4 |
10
Patients |
D5 |
1
Patients |
L5 |
6
Patients |
IMAGING MODALITY
C
arm |
28
Patients |
25% |
CT
Scan |
61
Patients |
54.46% |
Fluoroscopy |
23
Patients |
20.54% |
|
112 Patients |
100 % |
DIAGNOSIS
Tuberculosis |
19
Patients |
16.96 % |
Secondaries |
17
Patients |
15.18 % |
Non Specific Chronic Osteomyelitis |
16
Patients |
14.29 % |
Others |
08
Patients |
7.15 % |
Non Specific / Normal |
03
Patients |
2.67 % |
Inadequate |
49
Patients |
43.75 % |
|
112 Patients |
100 % |
Discussion :
All
diagnosed cases were grouped together. A normal report,
although not diagnostic, may be of some value in the management
of patients and is included in diagnosed group. Inadequate
samples were grouped as inconclusive. On studying the datas by
Chisquare test for significance it was found out that
irrespective of age, level of lesion and imaging modality used,
nearly 44 % of the biopsies did not give any information
regarding the pathology.
SEX |
PATIENTS |
INCONCLUSIVE |
DIAGNOSIS |
Male |
55 |
18 |
37 |
Female |
57 |
31 |
26 |
|
112 |
49 |
63 |
AGE |
PATIENTS |
INCONCLUSIVE |
DIAGNOSIS |
0
– 20 |
7 |
3 |
4 |
21
– 40 |
23 |
10 |
13 |
41
– 60 |
50 |
26 |
24 |
61
– 80 |
32 |
10 |
22 |
|
112 |
49 |
63 |
P
Value > 0.05,Not significant
MODALITY USED |
PATIENTS |
INCONCLUSIVE |
DIAGNOSIS |
CT
Scan |
61 |
29 |
32 |
Fluoroscopy |
23 |
11 |
12 |
C
Arm |
28 |
9 |
19 |
|
112 |
49 |
63 |
P
Value > 0.05,Not significant
LEVEL |
PATIENTS |
INCONCLUSIVE |
DIAGNOSIS |
C
1 to C 7 |
3 |
1 |
2 |
D
1 to D 6 |
9 |
5 |
4 |
D
7 to D12 |
38 |
12 |
26 |
L
1 to L 5 |
62 |
31 |
31 |
|
112 |
49 |
63 |
P
Value > 0.05,Not significant
Because of
the simplicity of technique, extremely low morbidity rate and
less complications, closed vertebral biopsies were often used to
be the first step in the diagnosis. Considering the high
failure rate (44%) for this invasive procedure, this study
infers that closed vertebral biopsy is not a dependable modality
for diagnosing a vertebral lesion.
Suggestions:
The
identified disadvantage for this closed procedure were,
Relatively small amount of material leading to inadequate sample
for making pathological diagnosis.
Requires an experienced Pathologist who cooperates closely with
the Radiologist, however, for open biopsies a similar situation
exists, in which cooperation among a capable Orthopaedic
surgeon, Radiologist and Pathologist is required.
The
lesion must be identifiable on fluoroscopy to ensure proper
placement of the needle. Lesions that are positive on bone scan
but not on fluoroscopy or conventional radiography; often have
relatively healthy overlying cortical bone that is difficult to
penetrate and inadequate sampling results.
The
biopsy procedure is relatively blind in nature, so that the
ideal area of a lesion may not be biopsied.
Based
upon the observation made, this study strongly recommends,
-
Triple approach by Surgeon, Radiologist and Pathologist.
-
Careful selection of the patients by the Surgeon
-
Lesion identified only through bone scan and not through any
other conventional radiography should not be selected.
-
With
anticipated difficulty in targeting specific area of lesion in
vertebrae should not be selected.
-
Two
attempts of percutaneous biopsy is justified.
-
If a
definitive diagnosis is needed in one procedure – not to
select the patient for closed biopsy.
Expectant
technique for performing the procedure and elaborative study of
the histological specimens is needed, by using larger core
diameter needles, different approaches to get more tissue for
pathological study and by using special stains to give diagnosis
with high level of confidence.
Reference :
-
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-
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-
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-
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-
Diagnostic Technique- Closed needle biopsy; Evarts; Clinical
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-
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