Fluoroscopy Guided Percutaneous Transpedicular Biopsy for Thoracic and Lumbar Vertebral Body Lesion: Technique and Safety in 23 Consecutive Cases.

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1 Fluoroscopy Guided Percutneous Trnspediculr Biopsy for Thorcic nd Lumr Verterl Body Lesion: Technique nd Sfety in 23 Consecutive Cses. Shresth D, Shresth R, Dhoju D ABSTRACT Bckground Deprtment of Orthopedic nd Trumtology Dhulikhel Hospitl, Kthmndu University Hospitl School of Medicl Sciences Dhulikhel, Kvre, Nepl. Though some verterl lesions hve typicl imging findings, histologicl/ microiologicl evidence re required for definitive dignosis nd mngement, specilly for tumor nd infective lesions so tht wrong dignosis nd wrong tretment cn e voided. Conventionlly, open iopsy methods re used. With vilility of CT scn, fluoroscopy nd MRI, percutneous trnspediculr verterl iopsy hs now ecome populr s minimlly invsive technique for iopsy of verterl lesion. Ojective Corresponding Author Dipk Shresth Deprtment of Orthopedic nd Trumtology Dhulikhel Hospitl, Kthmndu University Hospitl School of Medicl Sciences Dhulikhel, Kvre, Nepl. E-mil: dsmsortho@gmil.com To descries technique nd to nlyzes sfety nd fesiility of percutneous trnspediculr verterl iopsy with fluoroscopy guidnce for thorcic nd lumr verterl ody lesions. Method Twenty three ptients who underwent percutneous trnspediculr verterl iopsy under fluoroscopy guidnce were retrospectively evluted for demogrphic dt, indiction for iopsy, ntomicl loctions, histologicl/microiologicl dignosis, complictions nd finl outcome of tretment. True positive, true negtive, flse positive nd flse negtive cses were defined. Result Cittion Shresth D, Shresth R, Dhoju D. Fluoroscopy Guided Percutneous Trnspediculr Biopsy for Thorcic nd Lumr Verterl Body Lesion: Technique nd Sfety in 23 Consecutive Cses. Kthmndu Univ Med J 2015;51(3): There were 17 mles nd 6 femle ptients of men ge 47 (rnge yers). Biopsies were performed in 17 dorsl nd six lumr verterl odies. Adequte smple were otined in ll cses. Seventeen ptients (12: tuerculr pthology, 1: primry tumor, 3: metstsis, 1: osteoporotic frcture) hd definitive histologicl/ microiologicl dignosis. Four ptients hd no grnulom nd tumor. Two hd histologicl fetures of chronic non specific inflmmtion. True positive cses were 17, true negtive were four nd flse negtive cse were two. Overll ccurcy ws 92%. One ptient developed smll hemtom t iopsy site. Conclusion Fluoroscopy guided percutneous trnspediculr iopsy of is sfe procedure with high dequcy nd ccurcy nd low compliction rte for thorcic nd lumr verterl ody lesion. KEY WORDS Fluoroscopy, trnspediculr iopsy, verterl ody. Pge 265

2 KATHMANDU UNIVERSITY MEDICAL JOURNAL INTRODUCTION Dignosis of verterl lesion remins chllenge. Rdiologicl investigtions like plin X rys, CT scn, MRI scn nd one scn re primry test to investigte for underlying pthology in verter. Though some verterl lesions hve typicl imging findings, histologicl nd microiologicl evidence re required for definitive dignosis nd mngement, specilly for tumor nd infection. In developing countries with high prevlence rte of tuerculosis, tuerculr spondylitis re often dignosed nd treted empiriclly on clinicl nd rdiologicl criteri. However, its sensitivity nd specificity of these criteri re low. 1 In the view of incresing incidence of multi drug resistnce tuerculosis, HIV co-infection nd higher percentge of typicl tuerculosis (up to 30%), histologicl nd microiologicl dignosis re crucil for proper dignosis nd tretment of spinl tuerculosis to void wrong dignosis nd wrong tretment. 1-3 Conventionlly, open methods re used for verterl lesion for dequte smpling. Duncn et l. in 1928 used first time trnspediculr pproch for verterl iopsy. 4 With dvent of etter imging modlities such s CT scn, fluoroscopy nd MRI, percutneous trnspediculr verterl iopsy hs now ecome populr minimlly invsive technique for iopsy of verterl lesion. The current study descries technique nd nlyzes sfety nd fesiility of percutneous trnspediculr verterl iopsy with fluoroscopy guidnce for thorcic nd lumr verterl ody lesions. METHODS Twenty three consecutive ptients who underwent percutneous trnspediculr verterl iopsy under fluoroscopy guidnce in etween July 2013 to June 2015 were retrospectively evluted for demogrphic dt, indiction for iopsy, ntomicl loctions, histologicl nd microiologicl dignosis, procedure relted complictions nd finl outcome of tretment during susequent follow up. Dt were retrieved from hospitl record system of Dhulikhel hospitl nd the hospitl where uthor (DS) performed iopsy s visiting spine surgeon. Two ptients who were lredy on tretment for tuerculr spondylitis without improvement were lso included in the present study. True positive (clinicl nd histologicl/microiologicl dignosis re sme), true negtive (norml one), flse positive (dignosis mde y the iopsy ut susequently ruled out) nd flse negtive (no definitive histologicl/ microiologicl dignosis ut showed improvement on tretment ccording to clinico-rdiologicl dignosis) cses were defined s descried y Kmei Y et l. 5 Technique All the procedures were performed in prone position on rdiolucent opertion tle under generl nesthesi. The trget pedicle ws mrked in oth true nterio-posterior (AP) nd lterl view. After st incision on skin, trct ws creted into deep fsci nd muscle y hemostt. Entry point into the pedicle ws creted y gentle tpping of 3 mm Kirschner wire under fluoroscopy guidnce so the entry point lies on supeiro-lterl mrgin of pedicle in AP view or Bull s eye view (Fig. 1). The correct position of entry point ws lso confirmed in lterl view nd cephlocudl inclintion ws djusted to rech trget re for iopsy of verterl ody (Fig. 1, 1c). Once correct entry point ws ensured, Kirschner wire ws gently tpped into the pedicle under fluoroscopy guidnce. Once Kirschner wire reched t posterior order of verterl ody in lterl view, AP imge ws otined to mke sure tht the tip of the wire ws t the center of pedicle nd hd not reched the medil edge of pedicle (Fig. 2, 2). Now, iopsy cnnul of dimeter 3.5 mm with serrted edge ws pssed over the Kirschner wire with rottory movement up to the tip nd its position ws ensured once gin oth in AP nd in lterl views (Fig. 3,3,3c). Kirschner wire ws removed nd iopsy trocr ws dvnced into to the verterl ody with rottory movement into trget re (Fig. 4,4). Gentle cephlocudl nd medio-lterl rocking movements of the cnnul dislodged the one from the ody. Biopsy cnnul ws withdrwn nd specimen trpped into the cnnul ws c Figure 1. Entry point t superio-lterl edge of pedicle in AP view (1,1) nd confirmtion of cephlo -cudl trjectory in lterl view (1c). Pge 266

3 Figure 2. Kirschner wire tpped up to posterior order of verterl ody (2) nd position confirmed on AP view (2). Figure 3. Biopsy cnnul pssed over Kirschner wire up to posterior order of verterl ody (3, 3) nd its position confirmed in AP view. c Figure 4. Kirschner wire removed (4) nd iopsy cnnul dvnced into trget re (4). removed with lunt trocr (Fig. 5). Imprint cytology ws prepred y rolling specimen on glss slide. Aspirtion of cnnul with 10 ml syringe provided mteril to prepre slides for cytology. If sufficient mteril ws not otined, the iopsy trct ws chnged with similr technique. Alterntively, we used n rthroscopic punch or grsper through the sme trct under fluoroscopy guidnce nd specimens were retrieved (Fig. 6). If required, different re of the verterl ody could e reched for iopsy y rotting lde of rthroscopic punch or grsper. The specimens were sent for histologicl nd microiologicl investigtions in different continer fter proper leling. Wound ws closed with single stich. RESULTS There were 15 mle nd eight femle ptients with men ge of 47(rnge yers). Antomicl loction, clinicrdiologicl dignosis nd indiction for iopsy, histologicl nd/microiologicl dignosis re shown in the tle 1. One ptient developed smll hemtom t the iopsy site ut did not required evcution. None of the ptients hd neuro-vsculr injury, pneumothorx nd instrument relted complictions or sinus trct formtion during follow up. Pge 267

4 KATHMANDU UNIVERSITY MEDICAL JOURNAL Figure 5. Biopsy specimen retrieved from cnnul. Figure 6. Alterntively rthroscopic punch cn e used to get specimen. Tle 1. Totl no ptients, ntomicl loctions, clinico-rdiologicl dignosis nd histologicl/microiologicl dignosis Gender No. of ptients Mle 15 Femle 8 Antomicl loction Dorsl spine 17 Lumr spine 6 Clinico-rdiologicl dignosis Infective lesion 16 Primry tumor 2 Metstsis 5 Histologicl/microiologicl dignosis Infective lesion 12 Primry tumor 1 Metstsis 3 Osteoporotic frcture 1 Chronic non specific inflmmtion 2 No grnulom nd no tumor lesion 4 None of the smples were reported indequte y pthologist. Out of 23 ptients, 17 (74%) hd histologicl dignosis mong which 12 (71%) hd tuerculr pthology, 4 (24%) hd tumor lesion nd one ptient (5%) hd dignosis of osteoporotic frcture. Four ptients hd no evidence of tuerculosis nd tumor nd hence considered norml one nd two hd histologicl fetures of chronic non specific inflmmtion. In the view of strong clinicl nd rdiologicl suspicion of tuerculr pthology, those two ptients with chronic non specific inflmmtion were put on nti-tuerculr therpy nd showed improvement in susequent follow up. True positive cses were 17, true negtive were four nd flse negtive cse were two. Overll ccurcy ws 92%. Two ptients with previous cliniordiologicl dignosis of metstsis reveled tuerculr pthology. Only one ptient hd stin nd culture positive for Mycocterium tuerculosis. DISCUSSION Trnspediculr iopsy is recommended technique for otining verterl ody specimens. Better imging modlities nd etter understnding of pedicle morphology nd ntomy hs mde percutneous trnspediculr iopsy sfe nd ccurte technique for verterl iopsy Accurcy hs een reported up to 93.8% which is comprle to the present study (92%). 6 The procedure cn e performed under locl nesthesi s dycre procedure nd is minimlly invsive technique. However, we performed ll the procedure under generl nesthesi in the present study. Though there re definitive dvntges of locl nesthesi, orthopedic surgeons who re in the initil phse of this technique, generl nesthesi provide etter control over the pin thn locl nesthesi. The most importnt enefit of performing this technique under locl nesthesi is immedite recognition of ny indvertent injury to neurl structure during the procedure. Other possile compliction such s pneumothorx, vsculr injury, pseudo-neurysm, sinus trck formtion, trnsient presis hs een reported in literture. Bleeding dithesis is contrindicted for this procedure. 5,7 CT scn, fluoroscopy or MRI hs een used for imge guidnce. CT scn provides etter imge qulity nd smll lesion cn e reched more ccurtely. However, incresed rdition exposure to the ptients nd physicin, cost, vilility nd difficulty on djusting into CT gntry mchines during iopsy re some of the issues relted with CT guidnce. Fluoroscopy is esily ville in most of the centers, provides rel time imge while pssing the guide wire nd iopsy trocr. When this procedure is performed in opertion thetre either in generl nesthesi or locl nesthesi, ny unexpected complictions such s leeding, pneumothorx or vsculr injury cn e immeditely ddressed which could e difficult in CT scn room in rdiology deprtment. Nourkhsh A et l. compred CT scn fluoroscopy for percutneous verterl iopsy for dequcy, ccurcy nd compliction in met nlysis nd reported CT scn slightly superior thn Pge 268

5 fluoroscopy (dequcy: 92.6% Vs 90.1.%, ccurcy: 90.2% Vs 88.1%, nd complictions: 3.3% Vs 5.3%) ut none of them were sttisticlly significnt. 8 Even in thorcic spine, ccurcy hs een reported up to 93.8% y Kmei Y et l. 5 Vrious kinds of iopsy instruments re ville for percutneous verterl iopsy. Adequte one smple with miniml crushing effect should e primry trget of iopsy instruments. In the present study, we designed iopsy cnnul with serrted tip to cut the one. We routinely used 3.5 mm dimeter cnnul. A 3 mm Kirschner wire of suitle length ws used s guide pin to pss iopsy trocr. Chooi YS et l hd used 2 mm Steinmn pin s guide pin. 9 These instruments re chep nd reusle s compred to expensive disposle instruments. We did not encounter instrument relted compliction in our series. Though Fyfe IS et l, sed upon cdveric study, reported higher ccurcy when core dimeter of iopsy specimen ws 2 mm, the choice of dimeter of iopsy trocr should e sed up on ntomicl site nd suspected underlying pthology. 10 Diffuse involvement of verterl ody is less likely to e missed out even y smll dimeter iopsy cnnul. Smll dimeter iopsy cnnul my e sufficient for infective nd metsttic lesions ut lrger dimeter required for sclerotic one metllic one disese or primry one tumor. 6 Wtt JP et l. hve found no impct on culture yield for tuerculr spondylitis on iopsy core length. Similrly lrger dimeter cnnul oscures imge, mcertes soft tissue nd increses chnce of reeching of pedicle wll. Hence primry im of percutneous trnspediculr iopsy is to otin dequte specimen without incresing the potentil complictions. In the current study, none of the specimens were reported indequte y pthologist. Kim BJ et l. hd reported 97.1% dequte smpling y fluoroscopy guided trnspediculr iopsy. 11 In certin occsion, first ttempt of percutneous trnspediculr iopsy my fil to otin dequte specimen or my fil to rech trget re. In such sitution, repeted ttempt of trnspediculr iopsy with different trct is recommended. However, we used rthroscopic punch or grsper through the sme trnspediculr trct to get specimen. Certin re of verterl ody re considered inccessile for trjectory of percutneous trnspediculr iopsy such s verterl ody just nterior to spinl cnl nd inferior nd superior edge of posterior ody. 5,12 Since the mouth of rthroscopic punch or grsper cn e rotted in different direction, lrger re of verterl ody could e ssessed. But ones otined with rthroscopic punch or grsper cn give rise to crush rtifcts in histologicl exmintion nd should e discussed with pthologist efore reporting. In six cses, rthroscopic punch or grsper ws used to retrieve when initil specimen ws thought to e indequte in the present series. This study, s retrospective study with few numers of ptients crries selection is nd should e interpreted crefully. However, the min ojective ws to descrie technique nd evlute sfety nd fesiility of technique of fluoroscopy guided percutneous trnspediculr iopsy of verterl lesion. \Lrge numer of ptients involving multiple surgeons nd centers should e studied for more precise results. CONCLUSION Fluoroscopy guided percutneous trnspediculr iopsy of is sfe procedure with high dequcy nd ccurcy nd low compliction rte for thorcic nd lumr verterl ody lesion. REFERENCES 1. Colmenero JD, Ruiz-Mes JD, Snjun-Jimenez R, Sorino B, Mort P. Estlishing the dignosis of tuerculous verterl osteomyelitis. Eur Spin J 2013; 22(4):S579-S Dunn R, Zondgh I. Spinl tuerculosis: Dignostic iopsy is mndtory. S Afr Med J 2008;98(5): Wtt JP, Dvis JH. Percutneous core needle iopsies: The yield in spinl tuerculosis. S Afr Med J 2014;104(1): Duncn GA, Ferguson AB. Benign gint cell tumor of the fourth lumr verter: cse report. J Bone Joint Surg (Am) 1936; 3: Kmei Y, Nishid J, Mimt Y, Shirishi H, Ehr S, Stoh T, et l. Core Needle Percutneous trnspediculr Verterl Body Biopsy : A Study of 128 Cses. J Spinl Disord Tech 2015;28:E394 E399S. 6. Moller S. Kothe R, Wiesner L, Werner M, Ryther W, Delling G. Fluroscopy-guided trnspediculr trocr iopsy of spine-results, review nd technicl notes. Act Orthopædic Belgic 2001;67(5): Mifune Y, Ygi M, Iwski Y, Doit M. Pseudoneurysm of Lumr Artery following Verterl Biopsy: A Cse Report. Cse Reports in Rdiology 2012;127124:4. 8. Nourkhsh A, Grdy JJ, Grges KJ. Percutneous Spine Biopsy: A Met-Anlysis. J Bone Joint Surg (Am) 2008;90(8): Chooi YS, M Kmil OI, Fzir M, Ko SC. Percutneous trnspediculr iopsy of spine. Med J Mlysi 2007; 62(1): Fyfe IS, Henry APJ, Mullhollnd RC. Closed verterl iopsy. J Bone Joint Surg (Br) 1983;17: Kim BJ, Lee JW, Kim SJ, Lee GY, Kng HS. Dignostic Yield of Fluoroscopy-Guided Biopsy for Infectious spondylitis. AJNR Am J Neurordiol 2013:34: Dve BR, Nnd A, Anndjiwl JV. Trnspediculr percutneous iopsy of the verterl lesions: series of 71 cses. Spinl Cord. 2009;47: Pge 269