Biomed Imaging Interv J 2006; 2(3):e25
© 2006 Biomedical Imaging and
CT-guided percutaneous biopsy of spinal lesions
WCG Peh, FRCP, FRCR
Programme Office, Singapore Health Services, Singapore
Accurate diagnosis of spine lesions is important for its
successful management. Imaging�guided percutaneous biopsy is gaining increasing
acceptance as a means for obtaining tissue for diagnosis. Most biopsies can be
rapidly performed under local anaesthesia, with little patient discomfort and
improved safety. Spinal anatomy is, however, complex with many adjacent vital
structures. Good knowledge of anatomy and precise needling technique is,
therefore, important. Today, biopsy of spinal lesions is best performed under
computed tomography (CT) fluoroscopic guidance. Indications for imaging-guided
biopsy include confirming metastasis in a patient with a known primary tumour,
determining the nature of a solitary bone lesion, excluding malignancy in
vertebral body compression, and investigating for infection. Among the various
issues to be considered are site of lesion, location of adjacent vital
structures, approach, and type and size of needle. Complications are rare,
particularly when a meticulous technique is applied. In summary, CT-guided
percutaneous biopsy is a safe and an effective technique for the evaluation of
spinal lesions and useful in planning therapy. � 2006 Biomedical Imaging and
Intervention Journal. All rights reserved.
Keywords: Biopsy, Computed tomography, Intervention,
Percutaneous biopsy, Spine, Vertebral lesions
Biopsy entails the removal of tissue from a living body with
the aim of establishing a precise diagnosis, usually by microscopic examination
or culture. It can be performed during surgery (open biopsy) or percutaneously
(closed biopsy). Percutaneous biopsy of bony lesions may be performed under the
guidance of a variety of imaging modalities, such as, fluoroscopy [1-4],
computed tomography (CT) [5-19], ultrasonography [20-24], and magnetic
resonance (MR) imaging [25-28]. Open biopsy is a major surgical procedure that
is associated with morbidity and a host of complications. There are several
advantages of imaging-guided biopsy, including avoidance of overnight hospital
stay, cost and time saving, earlier commencement of radiation therapy, biopsy
of surgically-inaccessible sites, and lower morbidity. The last mentioned
advantage includes avoidance of general anaesthetic-related complications,
less risk of postoperative wound infection, and decreased likelihood of
development of pathological fracture [29-31].
Imaging- guided biopsy of bony lesions is a safe procedure,
with development of major complications being rare. Reported accuracy ranges
from 68% to 97% [1-4,7,8,10,12,14,16,17,19,21,28,29,32-38]. Fluoroscopy is most
often used to guide biopsy of lesions in long bones.� Ultrasonography can be
used for lesions on or near the surface of bone and, particularly, if there is
an associated soft tissue mass or an adjacent cortical destruction [20-24]. MR
imaging has been advocated for biopsy of musculoskeletal lesions, particularly
for those that are not clearly visible on fluoroscopy or CT [25-28].� The
choice of imaging guidance modality to be employed is determined by individual
operator preference and the availability of equipment and facilities, e.g.,
open MR magnet and MR-compatible accessories.
Although the use of fluoroscopy [3,4], ultrasonography ,
and MR imaging  has been described, CT is currently the modality of choice
for guiding biopsy of lesions of the spine [5,6,8,10-12,14-19]. Ultrasonography
has been advocated for guiding biopsy of cervical spine lesions, and in the
thoracic and lumbosacral regions its use is limited to lesions affecting the
posterior elements . Compared with fluoroscopy, CT more precisely shows the
needle position and is potentially safer as there is less likelihood of injury
to adjacent structures, such as, major vessels and nerve roots. With CT
fluoroscopy, near real-time imaging is possible (Figure 1). The radiation
dosage in CT fluoroscopy is also relatively small, compared with conventional
diagnostic CT . This review highlights the utility of CT fluoroscopy to
guide percutaneous biopsy of spinal lesions.
Figure 1 Photograph of a CT fluoroscopy
unit. The radiologist stands behind the lead glass shield
in the foreground and moves the CT couch-top either manually
or via remote control. The CT images are observed on the monitor.
GENERAL PRINCIPLES AND PREPARATION
A well-planned and executed biopsy is essential for accurate
diagnosis and enables appropriate treatment. For a suspected primary tumour,
biopsy should be performed at centres that specialise in the treatment of bone
tumours. At these centres, joint management decisions are taken by a
multidisciplinary team that includes surgeons, oncologists, pathologists, and
radiologists. All imaging, particularly MR imaging, should be completed prior
to biopsy. The radiologist should review the clinical data and all imaging
studies to ensure that a biopsy is indicated and to determine the most
appropriate biopsy site. Radiographs provide an overview of the lesion and its
characteristics, and they are probably the best single modality for providing a
diagnosis or short list of differential diagnoses. In complex-shaped bones,
such as, the spine, CT aids in showing lesion details and the presence of
associated calcification. Bone scintigraphy helps determine the extent and
distribution of the disease. MR imaging is best for defining the local extent
of the disease, particularly for radiographically-occult or subtle lesions,
marrow involvement, and associated soft tissue components .�
The biopsy route should be planned such that it does not
compromise the neurovascular bundles, and uninvolved tissue compartments should
not be crossed. The biopsy should be done in consultation with the surgeon who
will be performing the definitive surgery and ideally also with the pathologist
who will be examining the specimen. The radiologist should aim to obtain at
least three specimens during biopsy, particularly if a cytotechnologist is not
present during the procedure to confirm adequacy of the biopsy specimen.
Anticoagulants should be discontinued prior to biopsy, and for assessment of
infection antibiotics should be stopped at least 48 hours before the biopsy.
Other factors to be considered prior to biopsy are blood tests for coagulopathy
(prothrombin time, activated partial thromboplastin time, international
normalised ratio), platelet counts, need for sedation or anti-anxiety
premedication, and written informed consent .
Indications for biopsy of spinal lesions include [14,40-43]:
Confirm or exclude metastasis in a patient with a known primary
Determine the nature of a solitary bone lesion with non-specific
Exclude malignancy in vertebral body compression, especially
metastases or myeloma (Figure 2).
Evaluation for tumour recurrence.
Investigation for infection to confirm diagnosis and to obtain
sample of organism, e.g., discitis or osteomyelitis (Figure 3).
Figure 2 Severe L4 vertebral body compression
in a 77-year-old woman. (a) Sagittal SE T1-W MR image shows
severe compression of the L4 vertebral body. (b) Axial CT
fluoroscopic image taken with the patient lying prone shows
the Ostycut needle inserted into the right side of the L4
vertebral body via the transpedicular route.
Figure 3 L4/5 infective spondylodiscitis
in a 64-year-old man. (a) Sagittal SE T1-W MR image shows
an ill-defined hypointense lesion involving most of the L5
vertebral body, with irregularity of the superior endplate.
(b) Sagittal fat-suppressed FSE T2-W MR image shows hyperintense
signal in the L5 vertebral body and the L4/5 disc, with anterior
subligamentous and posterior extradural extension. Appearances
are typical of L5 vertebral osteomyelitis with L4/5 discitis.
Axial CT fluoroscopic images taken with the patient lying
prone show the Ostycut needle inserted into the (c) L4/5 disc
and (d) L5 superior subchondral vertebral body via a left
posterolateral paravertebral approach.
Contraindications include [40-43]:
Decreased platelet count (<50,000/mm3).
Suspected vascular lesion in the thoracic vertebra. Haemorrhage
leading to cord compression may occur.
Infected soft tissues surrounding bony lesion to be biopsied,
particularly when a non-infective lesion is suspected.
Inaccessible sites, e.g., C1 and odontoid lesions.
Uncooperative patient. General anaesthesia may be required.
TECHNIQUE AND EQUIPMENT
During CT fluoroscopy the patient is positioned to
facilitate needle access to the lesion and, ideally, also to ensure as much
comfort as possible. For biopsy of thoracic and lumbosacral spine lesions, the
patient usually lies in a prone position. For the cervical spine, patients may
be placed prone for lesions located in the pedicles and posterior elements. For
anteriorly-located cervical spine lesions, the patient lies in a supine
position. Sometimes, the patient may have to be placed in a lateral decubitus,
semi-prone or semi-supine position, to ensure patient comfort and to minimise
patient movement. Although the radiation dosage in CT fluoroscopy is relatively
small, compared with conventional diagnostic CT , care should still be
taken to minimise irradiation to both the patient and the operator. Adopting
very short bursts of intermittent CT fluoroscopic screening, using �last image
hold� to study the needle position on the monitor, and saving a few
representative CT fluoroscopic images from the monitor for reporting purposes
will help reduce radiation dosage to the patient. It is possible for the
operator to avoid radiation exposure altogether. The operator stands behind a
lead glass shield in the CT suite and moves the CT couch-top via remote
control. My own preference is to move the couch-top manually, screen
intermittently only while standing behind the lead glass shield, and make
several fine adjustments to the needle position after studying the images on
the monitor, until the needle tip is in the correct position (Figure 1).����������
The patient�s vital signs should be continuously monitored
during the procedure. Following preliminary axial CT scanning, the most
appropriate slice is selected to plan the most ideal route for directing the
needle into the lesion (Figure 4). Generally, if there are multiple
lesions, the largest and most superficial lesion is chosen. Any soft tissue
mass related to the bony lesion should also be biopsied. For suspected
discitis, in addition to the disc, the adjacent subchondral bone should also be
biopsied as this is the site of origin of haematogeneous spondylodiscitis 
(Figure 3). In planning the needle route, vital anatomical structures,
e.g., major blood vessels, nerves, peritoneal cavity, and spinal canal and its
contents, should be avoided. In the cervical spine, important structures to
avoid include the trachea, oesophagus, internal jugular vein, and carotid
artery. In the thoracic spine, care must be taken to avoid the pleural cavity,
thoracic aorta, and superior vena cava. In the lumbar spine, the abdominal
aorta, inferior vena cava, renal vessels, nerve roots, and organs, such as, the
kidneys should not be punctured.
Figure 4 Planning of the approach and
the needle route. (a) Preliminary axial CT image shows measurement
of the distance between the proposed puncture site and the
midline, as well as the depth and the angulation to targeted
biopsy site in L5 vertebral body. (b) Axial CT fluoroscopic
image taken with the patient lying prone shows the Ostycut
needle inserted into the same vertebral body via the right
The lesion depth, entry point, and angle of the chosen
needle route should be estimated or measured on the most appropriate CT image.
The point of entry at the patient�s skin is estimated or, alternatively, a grid
of radio-opaque skin markers may be placed to help determine the entry point (Figure 5).
The selected slice is surface marked, and the skin cleaned and draped (Figure 6).
After administration of local anaesthesia (1% lignocaine), a small skin
incision is made and the biopsy needle is directed into the lesion under intermittent
CT fluoroscopy guidance. Some practitioners advocate infiltrating the paraspinal
muscles and spinal periosteum as well with local anaesthetic, prior to
insertion of the biopsy needle.
Figure 5 Grid method of surface marking
for a lumbar biopsy. (a) Photograph shows placement of a grid
of radio-opaque skin markers to help determine the needle
entry point. (b) Preliminary axial CT image taken with the
patient prone shows the grid of skin markers at the selected
level. The most appropriate entry point can then be selected
Figure 6 Free-hand method
of surface marking for a lumbar biopsy. (a) Photograph shows
the cleaned and draped patient lying in a prone position.
A sponge forceps is used to indicate the estimated skin puncture
point. (b) CT fluoroscopic image taken with the patient lying
prone shows the tip of the sponge forceps at the proposed
needle entry point. A right posterolateral paravertebral approach
was planned for biopsy of the L4/5 disc.
In biopsy of anteriorly-located lesions in the C3-C7 vertebrae,
an anterolateral approach is usually adopted. As in the cervical
discographic technique, the radiologists� fingers are used to
guard the carotid artery, together with the internal jugular
vein and adjacent nerves, while the needle is directed towards
the vertebral lesion. The needle should be inserted towards
the vertebral body during the first pass, preferably from the
patient�s right side, taking care to avoid puncturing the oesophagus
and the trachea (Figure 7). Anteriorly-located lesions
in C1 and the odontoid peg usually require a trans-oral approach,
and in my opinion they should be preferably referred to the
otolaryngological surgeon for biopsy.
Figure 7 Biopsy of the C4/5 infective
spondylodiscitis in a 50-year-old man using the anterolateral
approach. (a) Lateral radiograph shows irregular narrowing
of the C4/5 disc space with mild anterior wedging of C4 and
C5 vertebral bodies and mild kyphotic deformity. (b) Photograph
shows the patient lying in a supine position with the neck
being cleaned after the selected level was surface-marked.
(c) Photograph taken after the patient was draped shows the
radiologist’s fingers palpating the carotid pulsation
and guarding the right major neurovascular bundle. (d) Photograph
shows the skin incision being made following administration
of local anaesthetic. (e) Photograph shows insertion of the
Ostycut biopsy needle. Note that the radiologist’s fingers
are guarding the adjacent major neurovascular bundle during
needle insertion. (f) CT fluoroscopic image taken with the
patient lying supine shows the tip of the Ostycut needle within
the inferior C4 vertebral body osteolytic lesion.
For posteriorly-located cervical spine lesions (Figure 8)
and lesions in the thoracic and lumbar spine, the transpedicular (Figures 2
and 9), transcostovertebral (Figure 10), or posterolateral paravertebral
(Figures 3, 6 and 11) approaches are usually used. The accuracy rates of
biopsies using the transpedicular and posterolateral approaches are similar .
A lateral approach that enables access to the lumbar vertebral body,
intervertebral disc, and paravertebral mass has been described. The patient
lies in a lateral decubitus position within the CT scanner. In this position,
the abdominal viscera are displaced forwards, providing a clear view of the
lateral aspect of the lumbar spine for needle insertion. An advantage of this
approach is that the needle tip is away from the nerve roots. The lateral
approach should not be used, however, if forward displacement of abdominal
contents is insufficient to safely avoid puncture of the abdominal viscera by
the biopsy needle . A transforaminodiscal approach has been reported to be
a safe alternative to the posterolateral approach . The approach to be
adopted depends on the exact site of the lesion and should be appropriately
tailored for each patient.
Figure 8 Biopsy of the C2 vertebra in
a 61-year-old man with nasopharyngeal carcinoma complicated
by C2 vertebral osteomyelitis. Axial CT fluoroscopic image
taken with the patient in a lateral decubitus position shows
the tip of the Ostycut needle within the right C2 lateral
mass. A right posterolateral approach was used.
Figure 9 Biopsy of the
T8 vertebra using the transpedicular approach in a 73-year-old
man with metastasis. CT fluoroscopic image taken with the
patient lying prone shows the tip of the Ostycut needle within
the right side of T8 vertebral body.
Figure 10 Biopsy of the
T12 vertebra using the transcostovertebral approach in a 40-year-old
woman with breast carcinoma. CT fluoroscopic image taken with
the patient lying prone shows the tip of the Ostycut needle
passing through the costovertebral junction towards the right
T12 vertebral body osteolytic lesion.
Figure 11 Biopsy of the
L4/5 disc using the posterolateral paravertebral approach
in a 66-year-old woman with infective discitis. CT fluoroscopic
image taken with the patient lying prone shows the tip of
the Ostycut needle within the right side of L4/5 disc. Note
the streak artefact indicating the tip of the needle.
The type of needle used depends on the nature of the lesion
and the operator�s personal preference. A large variety of needles are
available commercially . They can be broadly classified into aspiration
(e.g. spinal or Chiba), cutting or tru-cut (e.g. Quick-core or Temno), and
trephine (e.g. Ostycut, Craig or Ackerman) needles. They range in size from 11G
to 22G. In general, the needle should be long enough to reach the lesion and
have the appropriate bore size to obtain an adequate amount of specimen.
Aspiration needles have a fine gauge and are best used to aspirate fluid, soft
tissue lesions, or disc contents for culture or cytology (Figure 12).
Cutting needles may be used for obtaining solid specimens from bone or, more
usually, soft tissue (Figure 13). Both aspiration and cutting needles may
also be used in bony lesions with overlying cortical destruction (Figure 14).
Trephine needles have a serrated cutting edge and are usually required to
obtain bone specimens for histopathology (Figure 15). A coaxial technique
may also be used and decreases the need to re-puncture the patient as several
samples may be obtained via a single tract  (Figure 16). Whichever
needle type is used, CT fluoroscopy should be intermittently done to ensure
that the needle tip is in a safe position during its insertion and to confirm
its placement within the lesion.
Figure 12 Photograph shows a Chiba aspiration
needle (top) and an Ostycut trephine needle (bottom).
Figure 13 Quick-core cutting
needle (Cook Medical Inc, Bloomington, IN, USA) used to obtain
core biopsies of soft tissue. (a) Photograph shows the needle
set that has a handle, which enables one-handed control and
a spring-loaded trigger with a rapid-firing mechanism. (b)
Close-up photograph of the needle tip shows the bevelled-point
stylet that enables easy penetration into the lesion with
minimal trauma to the surrounding tissue. Firing of the sharp
cutting edge of the cannula facilitates obtaining an intact
core tissue sample within the slotted stylet.
Figure 14 Use of a Temno
cutting needle (Bauer Medical International, Santo Domingo,
Dominican Republic) for biopsy of a large L4 vertebral lesion
in a 79-year-old man with hepatocellular carcinoma. CT fluoroscopic
image taken with the patient lying prone shows the tip of
the cutting needle within the soft tissue component of the
destructive osteolytic lesion that has extended into the right
psoas muscle. Note that the bevelled-point stylet has been
advanced in preparation for firing of the cutting cannula.
Figure 15 Ostycut trephine
needle (Angiomed/Bard, Karlsruhe, Germany) used to obtain
core specimens of bone. (a) Photograph shows the components
of the needle set, comprising cannula (top), stylet (middle),
and probe for dislodging the specimen at the end of the procedure
(bottom). (b) Close-up photograph of the needle tip shows
the threaded cannula and trocar-point stylet that facilitates
penetration of cortical bone.
Figure 16 Coaxial technique
in a patient undergoing lumbar spine biopsy. Photograph shows
placement of a Chiba needle (black hub) within an Ostycut
needle (white hub).
Ideally, the needle should be placed into different parts of
the lesion to ensure representative sampling (Figure 17). In tumours, the
necrotic or cystic areas should be avoided and the radiologist should try to
identify these areas on CT or MR images prior to biopsy. Ideally, a
cytotechnologist or cytopathologist should be present during the procedure to
determine the adequacy of the tissue specimen. All material obtained should be
sent for cytology, culture, and histopathological examination. CT-guided needle
aspiration has been found to be accurate for identifying active bacterial disc
infections, but is less reliable for fungal infections. Adding cytopathological
analysis to microbiological analysis improves the sensitivity of infective
lesions [12,19,45]. Blood clots may contain cells or organisms and should not
be discarded . Aspiration and core biopsy specimens have a complementary
Figure 17 Multiple biopsies in a 61-year-old
with T3/4 infective spondylodiscitis. CT fluoroscopic images
taken with the patient lying prone show different placements
of the needle tip to obtain specimens from both (a) bone and
(b) soft tissue.
The radiologist should be familiar with smear preparation on
glass slides (Figure 18) and the various types of containers to be used
for culture and histopathological specimens (Figure 19). All these
specimens should be carefully labeled and dispatched promptly by a responsible
person (Figure 20). The accuracy of the biopsy outcome depends on the type
and location of the lesion, as well as the type of needle used. Core biopsy is
more accurate than fine needle aspiration, while biopsies of malignant lesions
have a higher accuracy rate compared with benign tumours and infection [7,13,18].
Compared with osteolytic malignant lesions, the diagnostic accuracy is
decreased and the false-negative rate is higher for sclerotic lesions .
Thoracic level biopsies have been reported to have a lower diagnostic rate than
lesions at other spinal levels .
Figure 18 Photograph shows the biopsy
specimen being smeared onto a glass slide for cytological
Figure 19 Photograph shows
a bone core specimen being dislodged from the biopsy needle
into a formaldehyde-filled container for histopathological
Figure 20 Photograph shows
various containers, all of which are well-labelled, with accompanying
request forms for the various tests.
After biopsy, the puncture site should be dressed and
checked for possible complications. Prophylactic pain medication should be
given to the patient. The length of the post- biopsy observation period depends
on whether or not sedation was given. If the pleura is inadvertently punctured,
further imaging to exclude a pneumothorax is indicated. The patient is sent
home with instructions for pain medication, warned about possible
complications, and told what to do if any occur.
The types and incidence of complications depends on the type
of needle used and on the anatomical location of the lesion. Reported incidence
rates are 0 to 10%, with serious complication rates being less than 1% [1-4,6-8,10-11,15-18,21,28].
Risks for imaging- guided biopsy are acknowledged to be less than those
associated with surgical open biopsy under general anaesthesia. The most
frequently reported complications are pulmonary, neurological, and infective [1,16,17,40-43,46-49]
Bleeding requiring transfusion. Excessive local bleeding may be
controlled by gelfoam insertion.
Neurological injury, including paresis or paralysis. Cord
compression may rarely occur after biopsy of hypervascular spinal lesions,
e.g., metastatic renal cell carcinoma or haemangioma.
Pneumothorax. Rates of 4 to 11% after thoracic spine biopsy have been
Tumour seeding along the needle track.
Infection spread along the needle track, with resultant formation
of a draining sinus.
CT-guided percutaneous biopsy has a useful role in the
diagnosis and the management of patients with spinal lesions. Most biopsies can
be safely and rapidly performed under local anaesthesia. Meticulous technique,
knowledge of the spinal anatomy and of indications and contraindications, and
awareness of possible complications are essential for success.
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Received 7 May 2006; received in revised form 1 September 2006, accepted 16 September 2006
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(Wilfred CG Peh).
Please cite as: Peh WCG,
CT-guided percutaneous biopsy of spinal lesions, Biomed Imaging Interv J 2006; 2(3):e25
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