AJR 2001; 177:1387-1389
© American Roentgen Ray Society
"Bull's-Eye" Modification for Transpedicular Biopsy and Vertebroplasty
Noah B. Appel1 and
Louis A. Gilula
1
Both authors: Mallinckrodt Institute of Radiology, Washington University
School of Medicine, 510 S. Kingshighway Blvd., St. Louis, MO 63110.
Received April 23, 2001;
accepted after revision July 2, 2001.
Address correspondence to L. A. Gilula.
Introduction
Percutaneous biopsy of vertebral bodies was first described in 1934 by Ball
[1]. Since that time, many
articles have been published on the subject
[2,
3]. The paravertebral approach
to vertebral biopsy was used exclusively for years and was described in many
of these articles. Transpedicular access to the vertebral body was first
described in 1963 and was revisited in a 1983 article by Roy-Camille et al.
[4]. This approach has gained
popularity during the past decade since the initial reports of its usefulness
and low complication rate [5].
It has also gained new importance as a result of the rapid spread of
percutaneous vertebroplasty for treatment of compression fractures.
Although the "bull's-eye" approach ("looking down the
barrel") has previously been described for placing a needle for
vertebroplasty [6], we could
find no literature describing use of this approach for fast needle exchange if
the needle becomes plugged during hardening of polymethylmethacrylate. Also,
reports of needle placement describe using the first placed needle as a
coaxial system
[6,7,8],
placing a new needle through the first placed needle for obtaining biopsy
material. We present a noncoaxial fluoroscopic technique that allows multiple
biopsy cores to be taken from the same entry site and eliminates the need for
additional needles. The technique also aids in the rapid replacement of a
needle down a previously created tract when speed or duplicated positioning is
required for the success of a procedure.
Materials and Methods
After reviewing pertinent images obtained before the procedure, we placed
patients undergoing transpedicular vertebral body biopsy or vertebroplasty
prone on the fluoroscopy table. Monitored conscious sedation was provided. The
vertebral level for intervention was determined with fluoroscopy; the pedicle
to be traversed was identified first in frontal and then in oblique
projections. As much of an oblique ("Scottie-dog") projection as
possible was used while still being able to see the full outline of the
pedicle (aligning the pedicle along its anteroposterior axis)
(Fig. 1A). The pedicle was next
centered over the middle, top, or bottom of the vertebral body as indicated by
the desired needle tip end location for each individual case. Superficial
anesthesia was achieved using lidocaine 1% (Elkins-Sinn, Cherry Hill, NJ) and
deep local and periosteal anesthesia with a 1:1 mixture of lidocaine 1% and
bupivacaine 0.25% (Abbott Laboratories, North Chicago, IL). A 3- to 5-mm
incision was made in the skin at the appropriate level. With the fluoroscopic
tube remaining in oblique projection, an 11- or 13-gauge disposable bone
biopsy needle with handle was aligned parallel to the X-ray beam (imaging down
the barrel of the needle), thus creating a bull's-eye
(Fig. 1B). The needle was
advanced to the level of the periosteum. Positioning was confirmed using
fluoroscopy before advancing the needle into and through the pedicle. Care was
taken to remain as close to the midline within the pedicle as possible.
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Fig. 1A. —83-year-old woman with history of breast and oral cancer who
presented for bone biopsy as part of vertebroplasty. Fluoroscopic spot
radiograph shows pedicle placed between superior and inferior end plates in
oblique position.
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Fig. 1B. —83-year-old woman with history of breast and oral cancer who
presented for bone biopsy as part of vertebroplasty. Fluoroscopic spot
radiograph shows bull's-eye alignment of needle over pedicle. Black center
(arrow) of needle creates bull's-eye. Semitransparent object
(arrowhead) around needle shaft is handle of needle.
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With this technique, needle advancement depth is dictated by lesion
location (in the case of biopsy) or vertebral configuration (in
vertebroplasty). Fluoroscopy in the lateral projection enables the needle's
depth to be determined while it is being advanced
(Fig. 1C). Fluoroscopy in the
frontal projection allows determination of the central positioning of the
needle tip (Fig. 1D).
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Fig. 1C. —83-year-old woman with history of breast and oral cancer who
presented for bone biopsy as part of vertebroplasty. Fluoroscopic spot
radiograph shows needle advanced to depth for removal of biopsy specimen.
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Fig. 1D. —83-year-old woman with history of breast and oral cancer who
presented for bone biopsy as part of vertebroplasty. Fluoroscopic spot
radiograph shows needle tip near midline in vertebral body for vertebroplasty
(frontal projection).
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If the same tract is to be reselected, the fluoroscopy unit is positioned
in the bull's-eye view—that is, looking down the needle barrel before
each needle removal (Fig. 1E).
Once the needle is removed, the tract is visualized as a round radiolucency
(Fig. 1F) projecting over the
traversed bone (in this case, the pedicle). The image intensifier is not moved
in relation to the patient. When replacing the trocar, fluoroscopy is used for
placement of the trocar tip back into the tract by guiding it to the
radiolucency left from the initial placement (using a long straight clamp or
other instrument to keep the operator's hand out of the beam). In this
fashion, the original tract is readily identified for rapid needle replacement
(Figs. 1G and
1H).
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Fig. 1E. —83-year-old woman with history of breast and oral cancer who
presented for bone biopsy as part of vertebroplasty. Fluoroscopic spot
radiograph shows needle in bull's-eye position before needle removal.
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Fig. 1F. —83-year-old woman with history of breast and oral cancer who
presented for bone biopsy as part of vertebroplasty. Fluoroscopic spot
radiograph shows needle tract as radiolucency (arrow) over
pedicle.
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Fig. 1G. —83-year-old woman with history of breast and oral cancer who
presented for bone biopsy as part of vertebroplasty. Fluoroscopic spot
radiograph shows fluoroscopy-guided replacement of needle in its original
tract with long straight clamp.
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Fig. 1H. —83-year-old woman with history of breast and oral cancer who
presented for bone biopsy as part of vertebroplasty. Fluoroscopic spot
radiograph shows needle seated in original needle tract.
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For vertebral biopsy, with or without subsequent vertebroplasty, we
typically retrieve three core samples, each of which is 8-15 mm long. The
first core sample is obtained with the needle passing from the middle of the
pedicle to the posterior margin of the vertebral body; the second, while
advancing the needle to the middle of the vertebral body (as seen on the
lateral projection); the third, while advancing the needle to the anterior one
third of the vertebral body (Fig.
1I). This final position is the site for the replaced needle for
vertebroplasty (Figs. 1I and
1J). After the needle is
replaced and intraosseous venography is performed, vertebroplasty may proceed.
The needle can be advanced farther anterior from this position for
vertebroplasty if desired. Should the needle clog during vertebroplasty, the
bull's-eye position can be obtained again as in
Figure 1C, the clogged needle
removed, and the described procedure followed for reselecting the needle tract
with a new needle.
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Fig. 1I. —83-year-old woman with history of breast and oral cancer who
presented for bone biopsy as part of vertebroplasty. Fluoroscopic spot
radiograph obtained in lateral projection shows needle advanced farther
anteriorly in preparation for performing vertebroplasty.
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Fig. 1J. —83-year-old woman with history of breast and oral cancer who
presented for bone biopsy as part of vertebroplasty. Fluoroscopic spot
radiograph in frontal projection shows needle tip localized in center of
vertebra before vertebroplasty.
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Results
We used this transpedicular approach to vertebroplasty in more than 400
needle placements performed from June 9, 1998, to July 14, 2000, with two
complications, neither causing problems for the patient. In one patient, the
needle was placed outside the pedicle in a paravertebral location. This
complication has subsequently been avoided by insisting on checking the needle
position in the oblique bull's-eye position in every case after the needle has
been advanced under lateral fluoroscopy to the posterior surface of the
vertebral body. This practice ensures that the needle remains within the
pedicle. In the second patient, the needle was too lateral and went to the
vertebral body cortex next to the aorta. When the needle is suspected to be
through or into the vertebral body cortex, its position can be confirmed under
fluoroscopy by moving the C-arm fluoroscopic unit around the vertebral body to
see if the needle tip projects through or within 1-2 mm of the vertebral body
cortex.
Discussion
Appropriate obliquity for needle entry into each pedicle is affected by
individual vertebral pedicle and body anatomy. In the case of central
vertebral depression, it is usually desirable to stay more lateral in the
vertebral body, decreasing the chance of injecting polymethylmethacrylate into
the disk. However, if disk biopsy is desired, the needle may be purposely
directed into the desired disk. Two other points can also be mentioned in
relation to vertebroplasty needle tip positioning. Placing the needle into the
lateral part of a vertebral body increases the chance of needle placement
through the side of the body, especially if the vertebral body is more narrow
anteriorly than posteriorly in its transverse diameter (more common in the
thoracic spine than in the lumbar spine); and increasing obliquity for needle
entry increases the chance of needle placement in the center of the vertebral
body anteriorly. When the needle tip reaches midline in the anterior one third
to one fourth of the vertebral body, it is more likely that the entire
vertebral body can be filled from a single pedicle rather than having to fill
each hemivertebra from its respective pedicle (Barr M, personal
communication). This finding has been verified in our practice.
Bone biopsy (vertebral and otherwise) and occasionally vertebroplasty
require replacement of needles or a needle down the original tract. We
developed this technique when needing to make multiple passes in the same
lesion during bone biopsy when not using a coaxial needle. This bull's-eye
technique is particularly valuable when applied to vertebroplasty. If the
trocar becomes obstructed by bone cement, a new trocar can be exchanged within
30-60 sec, before an entire batch of cement hardens to the point of being
uninjectable. In addition, biopsy of a vertebra is sometimes indicated before
vertebroplasty when a compression fracture is thought to be due to a neoplasm
or other nonosteoporotic cause. The bull's-eye technique allows biopsy at the
start of the vertebroplasty with easy transition to instilling the
polymethylmethacrylate. The bull's-eye alignment of a needle, as described by
prior researchers, speaks only about alignment of the needle to create a
bull's-eye during initial needle placement
[6].
To obtain biopsy material, Jensen et al.
[6] and others
[7,
8] mention placement of another
needle through the first needle as a coaxial-type technique. Performing such a
procedure requires using a second needle at additional procedural cost. Using
a coaxial needle system for transpedicular vertebral biopsy without
vertebroplasty is another alternative. A resterilizable coaxial needle system
used over a period of time would be less expensive than using a disposable
bone biopsy needle. However, a disposable coaxial needle system for bone is
more expensive than a disposable bone biopsy needle with a handle.
Transpedicular vertebral body access has become of key importance, not only
for safe biopsy of vertebral body lesions, but also for performance of
vertebroplasty. We describe a simple technique modification that allows a bone
biopsy to be performed with fewer or less expensive needles and that makes
possible the salvage of a vertebroplasty procedure in which the needle has
become plugged.
Acknowledgments
We give credit to Avery Evens for bringing to the attention of the senior
author the bull's-eye approach to placing a needle through the pedicle for
vertebroplasty.
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Introduction
Materials and Methods
