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Lateral Access for CT-Guided Percutaneous Biopsy of the Lumbar Spine

¹ Department of Radiology, Hospital Metropolitano, Av. Mariana de Jesús y Occidental, Quito, Ecuador.
² Department of Pathology, Hospital Metropolitano, Quito, Ecuador.

Received May 14, 1999; accepted after revision July 9, 1999.

 
Address correspondence to J. Garcés.

Introduction

Top Introduction Subjects and Methods Results Discussion References

 
Current techniques for CT-guided percutaneous biopsy of the lumbar spine [1, 2, 3, 4, 5] originate from the paravertebral technique described by Walls et al. in 1948 [6] and from the transpedicular technique described by Roy-Camille et al. in 1983 [7]; both techniques use a posterior approach. Lateral decubitus abdominal CT shows the anterior displacement of abdominal viscera, thereby providing a clear view of the lateral aspect of the lumbar spine (Figs. 1A and 1B). Additionally, this view provides a direct lateral approach to the lumbar spine. We describe a new and possibly safer lateral access route for CT-guided percutaneous biopsy of the lumbar spine.

View larger version (96K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A. —18-year-old man with lytic lesion of L3. CT scan with patient in prone position shows bowel viscera impeding lateral route of access to spine. Only posterior approach is possible in this decubitus position.

View larger version (139K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B. —18-year-old man with lytic lesion of L3. CT scan with patient in right lateral decubitus position shows colon to be anteriorly displaced, allowing lateral access to spine.

Subjects and Methods

Top Introduction Subjects and Methods Results Discussion References

 
We studied 12 patients, nine male and three female, ranging in age from 17 to 82 years. All patients had lesions in the lumbar spine visible on CT. Lesions were located in the following regions: two in L2, four in the L2-L3 disk, three in L3, one in the L3-L4 disk, and two in L4. Lesions included one instance of vertebral collapse, three of lytic lesion, two of osteoblastic lesion, and six of narrowing disk space. All patients complained of lumbar pain. Three patients had known malignancies; three patients had lesions suggestive of metastasis with no known primary site; three patients had fever and leukocytosis; and four patients had lesions suggestive of degenerative disk disease.

Examination before biopsy included complete blood count, erythrocyte sedimentation rate, activated partial thromboplastin time, and prothrombin time. Biopsies were performed with the patient in the lateral decubitus position, eight on the right side and four on the left side.

A lateral scout view was taken and CT images were obtained. Next, we selected the image in which the lesion was best seen and the anterior visceral displacement was large enough to allow a lateral approach. The CT table was moved to locate the selected site and a metal marker was placed on the lateral abdominal wall. With this image on the CT scan monitor, we located the puncture site and measured the distance between the skin and the target lesion using a vertical line perpendicular to the lateral aspect of the vertebra (Fig. 2A). Once the puncture site was identified, CT-guided biopsy was performed with the patient under local anesthesia (Fig. 2B).

View larger version (166K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2A. —85-year-old man with collapse of L2. CT scan with patient in right lateral position shows left kidney to be anteriorly displaced, allowing lateral access to vertebral body.

View larger version (127K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2B. —85-year-old man with collapse of L2. CT scan shows needle introduced into core of lesion to obtain biopsy sample.

Biopsies for osteoblastic lesions were performed using Ackerman needles (Cook Medical, Bloomington, IN) 14-gauge, 17.2 cm long. Biopsies for lytic lesions were performed using the Ackerman needle and an 18-gauge, 20-cm-long spinal needle. Sixteen core biopsy samples were sent for pathologic analysis, eight aspiration biopsy samples for cytologic analysis, and five specimens for culture and sensitivity analysis.

Results

Top Introduction Subjects and Methods Results Discussion References

 
We report 12 instances of CT-guided percutaneous biopsy of the lumbar spine successfully performed using the lateral approach. Diagnoses included three instances of malignancy, two of Staphylococcus infection, one of Mycobacterium tuberculosis infection, four of degenerative disk disease, and two of no diagnosis. All patients complained of discomfort and required analgesics after the procedure; we did not find evidence of bleeding, neurologic deficit, or internal organ damage.

We performed follow-up examinations for 10 patients (from 6 to 12 months after their biopsies). Patient outcomes were consistent with the pathologic diagnosis. We did not find evidence of needle tract contamination by infection or malignancy. Two patients were lost to follow-up.

Discussion

Top Introduction Subjects and Methods Results Discussion References

 
The literature describes two approaches for lumbar spine biopsy: the paravertebral approach and the transpedicular approach. The paravertebral route, initially performed under fluoroscopy [6, 7, 8] and currently under CT guidance [1, 2, 3], is a posterior approach. It is performed with the patient in the prone position. The needle is introduced a few centimeters lateral to the midline, using an oblique angle to avoid the nerve roots, kidney, renal pedicle, and large vessels. The tract through which the needle must be inserted is narrow and the angle of penetration is very precise.

The CT-guided transpedicular approach [4, 5] is limited to vertebral lesions located immediately anterior to the pedicle; lesions of the intervertebral disks cannot be reached using this route. Complications of this technique occur when the medial or inferior walls of the pedicle are punctured, resulting in spinal canal damage or nerve root injury. Also, if the biopsy needle penetrates too deeply, it can puncture the aorta or inferior vena cava [4].

Our lateral access route provides a wide field for needle insertion allowing access to the lateral wall of the vertebral bodies and the intervertebral disks. The perpendicular direction of the needle is easy to maintain and the needle is a safe distance away from the nerve roots, kidneys, renal pedicle, and large vessels. This approach should not be used if the forward displacement of abdominal contents is too small for a safe procedure.

There were no postprocedure complications in our study nor were infection or tumor cells found in the needle tracks.

Our lateral approach is appropriate for lesions located in the vertebral bodies, disks, and paravertebral areas. It should not be used for lesions of the pedicles or vertebral arches.

In conclusion, our lateral access route provides a safe approach to lumbar vertebrae and intervertebral disks. Use of this new route may decrease the risk of accidental injury to nerves, vessels, or other structures.

References

Top Introduction Subjects and Methods Results Discussion References

 

1. Babu NV, Titus VT, Chittaranjan S, Abraham G, Prem H, Korulas RJ. Computed tomographically guided biopsy of the spine. Spine 1994;19:2436-2442[Medline]
2. Ghelman B, Lospinuso MF, Levine DB, O'Leary PF, Burke SW. Percutaneous computed tomography guided biopsy of the thoracic and lumbar spine. Spine 1991;16:736-739[Medline]
3. Brugieres P, Revel MP, Dumas JL, Heran F, Voisin MC, Gaston A. CT-guided vertebral biopsy: a report of 89 cases. J Neuroradiol 1991;18:351-359[Medline]
4. Stringham DR, Hadjipavlou A, Dzioba RB, Lander P. Percutaneous transpedicular biopsy of the spine. Spine 1994;19:1985-1991[Medline]
5. Jelinek JS, Kransdorf MJ, Gray R, Aboulafia AJ, Malawer NM. Percutaneous transpedicular biopsy of vertebral body lesions. Spine 1996;21:2035-2040[Medline]
6. Walls J, Ottolenghi CE, Schajowicz F. Aspiration biopsy in diagnosis of lesions of vertebral bodies. JAMA 1948;136:376-382
7. Roy-Camille R, Saillant G, Mamoudy P. Biopsie du corps vertébral par voie postérieure transpédiculaire. Rev Chir Orthop Reparatrice Appar Mot 1983;69:147-149[Medline]
8. Siffert RS, Arkin AM. Trephine biopsy of bone with special reference to the lumbar vertebral bodies. J Bone Joint Surg Am 1949;31-A:146-149[Abstract/Free Full Text]

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