Neuro--

Neuroradiology (1992) 34:358360

radiology 9 Springer-Verlag 1992

CT-guided percutaneous biopsy of the cervical spine: a series of 12 cases P. Brugi6res 1, A. Gaston t , M. C. Voisin 2, E Ricolfi 2, and N. Chakir 1 Departments of 1Neuroradiology and 2Morbid Anatomy, H6pital Henri Mondor, Creteil, France Received: 12 September 1991

Summary. Twelve patients underwent biopsy of cervical vertebral bodies under CT guidance. A n accurate diagnosis was obtained in 11. No complications were observed, except for a transitory recurrent laryngeal nerve palsy. Technical problems of the cervical spine biopsy are discussed and the utility of bone biopsy with a coaxial trephine system is emphasized. Key words: Biopsy - Cervical spine - C o m p u t e d tomography

Biopsy is usually necessary to decide upon the appropriate treatment for an isolated lesion of the spine. Closed percutaneous biopsy appears to be adequate for histological diagnosis and is safer and cheaper than surgical biopsy [1]. Nevertheless, biopsy of the cervical spine under fluoroscopic guidance remains a relatively dangerous procedure because of the proximity of vital structures such as the spinal cord and the cervical portions of the cerebral arteries. To improve the safety of the procedure several authors have suggested percutaneous fine-needle biopsy unter CT guidance which minimizes hazards but allows only cytological aspirates [2], a soft tissue core [3] or rarely, b o n e samples. Recently, L a r e d o et al. [4, 5] introduced a new trephine needle for coaxial vertebral biopsy similar to the Seldinger technique for arterial puncture. The "dorsal" trephine is small (2 m m diameter) c o m p a r e d to the classical M a z a b r a u d trephine and produces no major artefact on CT. O u r experience with this apparatus in CT-guided biopsy in the thoracic [6] and lumbar regions encouraged us to experiment with biopsy of the cervical spine. Materials and methods Twelve patients underwent CT-guided between 1988 and 1991 percutaneous biopsy of the cervical spine in our department. All had a solitary lyric, mixed or sclerotic lesion. Their ages ranged from 41 to 83 years (mean 71 years). Prebiopsy bleeding and clotting parameters were normal in all cases.

The biopsy route was determined on a contrast-enhanced CT study so as to avoid puncture of the cervical vessels and the hypopharynx, special attention being paid to the pyriform fossa. The biopsy was carried out under aseptic conditions with the patient supine for the anterolateral approach or prone for the posterolateral transpedicular approach. The posterolateral route was preferred when puncture of the vertebral artery or the pharynx appeared likely. An anterolateral approach was used in 9 cases for biopsy of the C4 to C7 vertebral bodies (Figs. 1, 2). Two patients had a posterior transpedicular approach for lesions at C2 and C3 (Fig.3). The transpedicular approach was preferred for biopsy at the C7 level because of prominent clavicles in a patient with a short neck. The first step of the biopsy is simple puncture under local anaesthesia with an 18 G needle advanced to the vertebral body between the pharynx and the carotid sheath in the case of an anterolateral approach and to the posterior part of the pedicle for a transpedicular approach. The position of the needle is confirmed by CT. After the periosteum has been anaesthetized, the trephine is advanced on a guide wire, according to the coaxial procedure described by Laredo et al. [4]. A bone biopsy is then performed with a cutting cannula after verification of the position of the trephine. When the vertebral appeared to be extremely lytic or haemorrhagic, samples were obtained with a 22 G needle introduced through the trephine for a cytological examination. Results Cervical vertebral biopsies represented 10% of the percutaneous biopsies under CT guidance p e r f o r m e d in our dep a r t m e n t during the study period. A bone core sample was obtained in all cases and in 4 a 22 G needle aspiration was a t t e m p t e d through the trephine at the end of the procedure. A correct histological and/or cytological diagnosis was possible in 11 of the 12 cases. The levels and the radiological appearances of the vertebral lesions and the biopsy diagnoses are summarized in Table 1. Lytic lesions were p r e d o m i n a n t (8/12) and were due in 2 cases to chordoma. Metastatic disease was found in 7 of 11 positive histological or cytological diagnoses. In 5 cases (patients 3, 5, 10-12) the primary lesion was unknown at the time of biopsy. Patient 7 was strongly suspected of having discitis and had been treated with antibiotics for i week at the time of

359 Table 1. Summary of clinical and radiological data Patient Sex/age Level Radiological Biopsy result (years) appearances

Ag support

1 2 3 4 5 6 7 8 9 10 11 12

H+ H+ H+ H- C+ H+ H+ H + BH + CH - CH+ H+ H + C-

M 57 M 57 M 64 M 83 F59 F 65 F 44 F 41 M 58 M 73 M 73 M 78

C7 Lytic C5 Lytic C3 Lytic C5 Mixed C7 Lytic C4 Lytic C6-C7 Mixed C6 Lytic C6 Lytic C7 Sclerotic C6 Mixed C2 Lytic

M~arynx Chordoma ~ ? c/-d~olorecta M 1 M~reast Chordoma Discitis ~reast ? M/@prostate M/@prostate M~idney

M Metastatis; C, cytological diagnosis; H, histological diagnosis; B, bacteriological diagnosis

biopsy: a diagnosis of acute spondylitis was made on the histological specimen but bacteriological examination was negative. H e r progress supported the diagnosis of spondylodiscitis. Using local anaesthetic the pain was mild to moderate in 10 cases. In 2 patients (1 with spondylodiskitis, 1 with a lytic lesion at C2) neuroleptanalgesia was necessary. The procedure took about 30 min. No complication was observed except transient ( < 24 h) recurrent laryngeal nerve palsy on the side of the biopsy, presumably due to the local anaesthetic, in 3 cases.

cal diagnosis was available, which was fortunate, as histological examination was negative. This emphasizes the value of bone samples for histological diagnosis in infections as well as in neoplastic disease. Kattepuram et al. [3] used a trephine needle for biopsy through an intact vertebral cortex in only 1 of their 7 cases. Most of their patients had a soft-tissue biopsy with a Trucut needle. This procedure may be of value in lytic lesions but the size of the bone sample is, in our experience, often inadequate. Furthermore Kattepuram et al. [4] recommend not more than two passes with a large calibre needle due to "the hazards of bleeding in the anatomic confines of the neck, the close proximity to major nerves and vessels and the frequent necessity of transgressing the thyroid using the anterolateral approach". This emphasizes the value of a coaxial system which allows several biopsies without increasing the risks of nervous or vascular damage. Biopsy with the Laredo trephine needle set requires only one puncture and allows several successive samples to be taken by gently tilting the trephine. The risk of damage to vessels is then limited to the first puncture with an 18 G needle. It is still possible to complete the procedure when necessary with fine-needle aspiration. A Tru-cut needle may also be introduced through the trephine for soft tissue samples. The equipment does not cause major artefacts on CT. For these reasons we consider that using the Laredo

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Discussion

Percutaneous biopsy of the cervical spine is thought to be difficult and hazardous procedure. Very little has been published about the specific technical problems [5, 7, 8], and especially about the complication rate. Vallee et al. [9] recommend the classical anterolateral approach under fluoroscopic guidance. Nevertheless, it seems to us that, with this blind procedure, the risk of vascular damage is real and that fluoroscopy does not allow a sufficient safety in avoiding the risks of infection following possible puncture of the hypopharynx. Furthermore, this technique does not allow biopsies at C2 or C3. Tampieri et al. [2] suggested fine needle aspiration under fluoroscopic guidance, which may be useful in lytic lesions. They suggested the anterolateral approch for lesions between C2 and C7 but the technique used for biopsies at C2 and C3 is not clear. The high rate of discitis and the high rate of positive bacteriological results in their series are very impressive. In our experience bacteriological examinations of bone and disc samples in spondylodiscitis were positive in slightly more than 50%, which is in agreement with the literature [7, 8, 10]. Moreover Pott's disease is often diagnosed on histological data only. We performed 4 fine needle aspirations for cytological examination in addition to bone biopsy: in 1 case only cytologi-

b

f Fig. 1 a-f. Steps of trephine biopsy with the set described by Laredo et al [4]. The fine needle is advanced to the vertebral body (a). After anaesthesia of the periosteum, the fine needle is replaced by the guide wire (b, c). The trephine needle set on the handle is advanced over the guide wire (d). The handle and the guide are removed (e), and bone biopsy can be accomplished with the cutting cannula (f)

360

3a Fig.2, Percutaneous biopsy with an anterolateral approach: note the proximity of the trephine to the hypopharyax

Fig.3. The posterolateral "transpedicular" route avoids the risk of vertebral artery puncture

system u n d e r C T guidance constitutes the best w a y of obtaining an accurate biopsy of the cervical spine in safety.

6. Brugieres R Gaston A, Heran F, et al (1990) Percutaneous biopsy of the thoracic spine under CT guidance: transcostovertebral approach. J Comput Assist Tomogr 14:446-448 7. Chevrot A, Godefroy D, Horreard R et al (1980) Biopsie osseuse profonde disco-vert6brale au trocart sous contrSle de la radioscopie tdldvis6e. Ann M6d Intern 131:448-451 8. Laredo JD, Chevrot A, Godefroy D, et al (1985) La ponction biopsie disco-vert6brale radioguid6e. Encycl Med Chir Radiodiagnostic II, 30660 A 10. Masson, Paris p 3 9. Vall6e C (1990) Biopsies disco-vert6brales sous controle t616vis6. Feuill Radio130:255-261 10. Cotty R Fouquet B, Pleskof L, et al (1988) Vertebral osteomyelitis: value of percutaneous biopsy. J Neuroradio115:13-21

References 1. Murphy WA, Destouet JM, Gilula LA (1981) Percutaneous skeletal biopsy: a procedure for radiologists. Results, review, and recommendations. Radiology 139:545-549 2. Tampieri D, Weill A, Melanson D, Ethier R (1991) Percutaneous aspiration biopsy in cervical spine lytic lesions. Indications and technique. Neuroradiology 33:43-47 3. Kattapuram SV, Rosenthal DI (1987) Percutaneous biopsy of the cervical spine using CT guidance. Am J Roentgeno1149: 53%541 4. Laredo JD, Bard M, Patrux C (1984) Int6rSt d'un nouveau mat6riel pour biopsie osseuse vert6brale per-cutan6e. J Radiol 65: 297-300 5. Laredo JD, Bard M (1986) Thoracic spine: percutaneous trephine biopsy. Radiology 160:485-489

Dr. R Brugidres Department of Neuroradiology HOpital Henri Mondor Creteil, France