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ORIGINAL ARTICLE

Analysis Of 112 Closed Vertebral Biopsies A Retrospective Study

*Dr. V.Vimal Kumar, Dr. Senthilnathan, Dr. Gopinath Menon

*Dept. of Orthopaedics, Sri Ramachandra Medical College and  Research Institute (Deemed Institute), Chennai, India.

Address for Correspondence
Dr. V Vimal Kumar,
Dept. of Orthopaedics,
Sri Ramachandra Medical College and  Research Institute (Deemed Institute),
Chennai, India.

 

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 :

  1. Cytological diagnosis of vertebral TB with fine needle aspirate biopsy; Modal 1994; JBJS; 76A, 181-184.

  2. Fine needle aspiration biopsy of spine; El Tchoury, Terepka, Mickelson, Raenivlle, Zaleski; JBJS; 65A; 522-525.

  3. Percutaneous needle biopsy of musculoskeletal lesion, effective accuracy and diagnostic utilities; Fraser and Hill; American Journal of Radiology; 158; 809-812.

  4. Image guided percutaneous biopsy of musculoskeletal tumours; Logen, Connell, Munk Janzen; American Journal of Radiology; 166; 137-141.

  5. Biopsy of bone and soft tissue lesions; Simon, Biermenn; JBJS; 75A; 616-621.

  6. Diagnostic accuracy and charge savings of outpatients core needle biopsy compared with open biopsy of musculoskeletal tumour; Skerzynski, Biermann, Mortegen, Simon; JBJS; 78A; 644-649.

  7. Needle biopsy of musculoskeletal lesions; Stoker, Gobb, Pringle; JBJS; 73B; 498-500.

  8. Primary bone tumour Percutaneous needle biopsy; Ayala, Zornosa; Radiology; 149; 675-679.

  9. Closed biopsy of musculoskeletal lesion; Moore, Neyers, Patzakis, Terg, Harvey; JBJS; 61A; 375-380

  10. Diagnostic Technique- Closed needle biopsy; Evarts; Clinical Orthopaedics; 1975; 107; Page 100.

  11. Aspiration Biopsy; Dollalute, Tatum; JBJS; 71A; 1989; 1166-1169.

 

 This is a peer reviewed paper 

Please cite as :Vimal Kumar: Analysis Of 112 Closed Vertebral Biopsies A Retrospective Study

J.Orthopaedics 2005;2(6)e4

URL: http://www.jortho.org/2005/2/6/e4

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