15.1 CT-Guided Bone Biopsy

Indication:

Characterization of bone lesion by histologic, cytological, and bacteriological analysis [1, 2]

  • Diagnosis and staging of primary neoplasms

  • Characterization of histological type of metastases in patients with known disease or multiple tumors

  • Assessment of tumor response to chemotherapy or radiation therapy

  • Characterization of vertebral collapse (benign or pathologic fractures)

  • Confirmation of osteomyelitis, spondylodiscitis or joint infection, and bacteriological characterization (Gram stain, culture, antibiogram)

Contraindication:

  • General contraindications (see Chap. 1.)

  • Specific contraindications:

    • Spinal cord compression at the puncture level

    • Epidural involvement at the puncture level

Pre- and per procedural medications:

  • Usually outpatient procedure.

  • Local anesthesia (subcutaneous layer, muscles, and periosteum) with water-soluble anesthetic lidocaine 1% (maximal dose 300 mg).

  • Long-acting anesthetic (ropivacaine maximal dose of 225 mg) eventually mixed with lidocaine in painful or longer procedures.

  • Intravenous sedoanalgesia recommended with large needle sizes or anxious patients, with midazolam IV (maximal dose of 5 mg) and paracetamol IV (1–2 g).

  • An anesthesiologist may be required in complex procedures and toddlers and small children or with non-collaborating patients.

Equipment:

  • CT scanner.

  • Mobile C-arm fluoroscopy may be used in combination to offer real-time visualization.

Sterile equipment:

Syringe:

  • 10 mL syringe for local anesthetic (lidocaine 1%)

  • 5–10 mL syringe for vacuum aspiration

Needle:

  • 22 G spinal needle to inject local anesthetic along the whole pathway

  • Selected bone biopsy system:

    • Direct puncture needle 13–15 G (Ostycut, Bonopty).

    • Coaxial needle 11–14 G (Laredo-Bard, Optimed).

    • Surgical biopsy set 10–12 G may be used when significant drilling is requested.

    • Coaxial soft tissue biopsy device 17–21 G used in lytic lesions (Temno, Cook).

Surgical scalpel is used for skin incision.

Surgical hammer may be used for cortical perforation.

Injection drugs:

  • Lidocaine 1% (maximal dose 300 mg)

  • Ropivacaine (maximal dose of 225 mg)

Anatomy of the region:

  • Spine

    • Lumbar spine:

      • Transpedicular approach is preferred.

      • Posterolateral extrapedicular approach may be suited for lateral lesions with the risk of spinal nerve puncture [1].

    • Thoracic spine:

      • Transpedicular approach is recommended for primary bone lesions that will require surgical excision [1].

      • Costovertebral or costotransversal extrapedicular approach is otherwise preferred (Fig. 15.1) [1].

    • Cervical spine:

      • Anterolateral approach is the preferred route for the anterior structures.

      • Posterior or posterolateral approach is used for the posterior elements.

    • Intervertebral disc:

      • Posterolateral approach is used in the lumbar spine.

      • Costovertebral approach is used in the thoracic spine.

  • Flat bones (skull, sternum, ribs, scapula, clavicle):

    • Tangential oblique approach is recommended to reduce the risk of damage to underlying structures (brain, mediastinum, pleura, etc.) (Fig. 15.2).

  • Pelvis:

    • Sacral lesions: posterior approach avoiding the sacral nerves and canal

    • Acetabular lesions: direct anterior or posterior route depending on the site of the lesions

    • Pubic lesions: direct anterior or oblique route depending on the site of the lesions (Fig. 15.3)

    • Iliac wing lesions: transosseous approach avoiding muscular involvement

  • Upper and lower limbs:

    • The needle pathway must be planned with the surgeon in case of primary bone tumor.

    • The route of the biopsy needle must cross only anatomical compartments involved with the lesion and avoid contaminating uninvolved compartments [3].

    • Joint penetration should be avoided as capsular contamination would lead to total joint excision.

    • The shorter route that stays in the anatomical compartment of the lesion is usually preferred.

    • The skin entry point must be either tattooed with sterile permanent ink (methylene blue) or marked with a scar made along the long axis of the limb.

    • The needle route must be imaged clearly to allow surgical resection of the needle pathway (Fig. 15.4).

Fig. 15.1
figure 1

(a) CT-guided bone biopsy of a purely lytic metastatic lesion involving the vertebral body of TH7 (arrow). A 22 G spinal needle for local anesthesia of the whole pathway. (b) A coaxial bone biopsy system is introduced using a right-sided costovertebral approach (b, arrowhead)

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Fig. 15.2
figure 2

(a) CT-guided bone biopsy of an expansile sclerotic metastatic lesion involving the right 5th rib (arrow). (b) A coaxial bone biopsy system is introduced using a tangential oblique approach to reduce the risk of damage to the pleura (arrowhead)

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Fig. 15.3
figure 3

(a) CT-guided bone biopsy of a lytic and sclerotic metastatic lesion involving the pubis (arrow). (b) A coaxial bone biopsy system is introduced using an oblique approach (arrowhead)

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Fig. 15.4
figure 4

(a) CT-guided bone biopsy of a lytic lesion involving the distal femur (a). (b) The needle pathway was planned with the surgeon, and the needle route was imaged clearly to allow surgical resection of the needle pathway (arrowhead). Final diagnosis was giant cell tumor

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Patient positioning:

  • Patient is appropriately positioned on the CT table (prone, supine, or lateral position; head or feet first).

Technique:

  • Bone biopsy system is selected based on the following criteria:

    • lytic or sclerotic lesion

    • thickness of the cortical bone surrounding the lesion

    • location of the lesion

    • experience of the operator

  • Coaxial technique:

    • Limits the risk of tumoral or infectious dissemination (higher risk in chondral lesions).

    • Reduces damage to the surrounding normal tissue.

    • Allows several core biopsies in one line through a single pathway.

  • Tandem technique:

    • A first 22 G spinal needle is placed next to the lesion and used to deliver local anesthesia to the periosteum and along the needle route.

    • The biopsy needle is then introduced as close to and as parallel as possible to the 22 G needle.

  • Bone penetration

    • Thin cortical bone surrounding the lesion is penetrated through direct percussion with a surgical hammer.

    • Thick cortical bone surrounding the lesion or dense ossification is penetrated by drilling, which is more successful and safer with an orthogonal approach to the bone surface (Fig. 15.5).

  • Retrieval of samples

    • The bone biopsy system is advanced to the margin of the lesion.

    • The stylet or drill is removed when it is in contact with the lesion.

    • The cannula is advanced within the lesion with continuous rotation to acquire the samples.

    • A syringe is kept in negative pressure by withdrawing the plunger when the cannula is advanced.

    • Then the sample is expelled from the cannula by an obturator.

  • Examination of tissue samples

    • Solid or semisolid samples are placed within formaldehyde solution (please contact the pathology department for department specific preferred fixative solutions).

    • Immediate pathologic analysis can be obtained from fresh frozen specimens if treatment is to begin rapidly (please contact the pathology department for department specific preferred fixative solutions).

    • Blood clots and bone marrow obtained in the sample should not be discarded as they may provide significant information.

    • Aspiration products are sent in a sterile tube sealed with a sterile cap for bacteriological analysis.

Fig. 15.5
figure 5

(a) CT-guided bone biopsy of a small lytic lesion involving the medial cortex of the right femur diaphysis with thick cortical bone surrounding the lesion. (b) Penetration by drilling using a lateral approach with an orthogonal, safer, approach to the bone surface (arrowhead). (c) Multiplanar reformatted images may allow better visualization of the needle pathway in small lesions (arrowhead). Final diagnosis was osteoid osteoma. A thermal ablation was performed immediately after the bone biopsy

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Aftercare:

  • Adhesive bandage covering the skin incision. The bandage is kept dry for 1 week.

  • Patient kept under observation for 60 min.

  • Monitoring of general parameters (blood pressure, heart rate, respiration).

  • Patient can be discharged into the care of an accompanying person and is advised not to drive or to perform any task for 24 h.

  • Information brochure with information on the procedure, procedure-related symptoms and treatment of the symptoms, symptoms of possible complications, name of the radiologist, contact telephone number, and information about follow-up appointment.

Procedure-related symptoms and treatment:

  • Pain at the puncture site could be treated with cold compression.

  • Additional analgesics may be given for 1–2 days (paracetamol, tramadol).

15.2 Pet-CT-Guided Bone Biopsy

Indication:

  • Hypermetabolic bone lesion not visible on CT (PET-positive lesions with no morphological correlation)

Technique:

  • Nonreal-time PET/CT biopsies use co-registration of a prior PET image with a procedural CT image (Fig. 15.6).

  • Real-time PET/CT biopsy may present benefits over conventional biopsy techniques in terms of accuracy of locating the correct biopsy site.

Fig. 15.6
figure 6

(a and b) PET/CT demonstrating a hypermetabolic bone lesion of the right ischium not visible on CT (arrow). (c) Nonreal-time PET/CT bone biopsy of the left ischium using co-registration of a prior PET image with a procedural CT image (arrowhead). Final diagnosis was ethmoidal carcinoma metastasis

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15.3 MR-Guided Bone Biopsy

Indication:

  • Pregnancy

  • Bone marrow replacement not visible on CT

Technique:

  • Skin entry point determined by a specific grid placed successively in the craniocaudal and horizontal axis. Another less specific but quicker method is to point with a finger directly at the entry point [1].

  • MR compatible needles and biopsy system are required.