Cervical Spine Biopsy Anterolateral and postero-lateral approaches are used in cervical vertebral biopsy. Fluoroscopic, CT, and MRI guidance has been used with cervical biopsy (29,32,33,77). Fluoroscopic guidance requires adequate knowledge of cervical anatomy to be performed safety. CT and MRI allow visualization of the soft tissue structures of the neck during needle placement
and CT is preferred by most interventional radiologists. Coaxial trephine systems are typically used to provide a more accurate and safe needle placement. If an extraosseous soft tissue component is present, smaller cutting or FNA needles are preferred to ensure greater safety and diagnostic accuracy. Many authors recommend surgical and anesthesia backup if expanding precervical or epidural hematomas develop following cervical biopsy (40).
The cervical vertebrae have large articular masses and posterior elements that limit a posterolateral approach to the vertebral body. The position of the carotid sheath in the cervical spine determines whether a posterolateral or anterolateral approach is used.
An anterolateral approach is recommended for lesions located in the upper cervical spine and allows access to the anterior vertebral body and disc space. Typically a 22-gauge needle using a tandem or coaxial guiding technique is introduced medial to the anterior margin of the sterno-cleidomastoid muscle. The carotid sheath and sternocleidomastoid muscle are manually retracted laterally and the needle is advanced between the airway and the carotid sheath to the desired location (Fig. 13). A coaxial trephine needle system can be placed over the guiding needle and subsequent core biopsy can be performed. Once the core is obtained, the trephine system can remain in place and cutting or FNA needle biopsy can be performed.
The posterolateral approach is used for lesions of the lower cervical spine (C4-C7) and posterior elements (29,77). Needle systems similar to those used for the anterolateral approach can be used and are introduced posterior to the sternocleidomastoid muscle.
A transoral or pharyngeal approach has been recommended by several authors for C1-C3 biopsies. Fluoroscopic and MRI-guided biopsies under general anesthesia have been described using fine needle and core biopsy techniques at this location. Such areas are often difficult if not impossible to access surgically and a transoral approach represents an alternative (40,77).
Thoracic Spine Biopsy The transcostovertebral and transpedicular approaches using fluoroscopic or CT guidance are typically used in the thoracic spine (34,36,78) (Figs. 14 and 15). The close proximity of the lung, aorta, and dural sac presents the dominant challenge to biopsy at this level. The use of CT or fluoroscopy is operator dependent based on personal experience and comfort with each imaging modality. This author prefers fluoroscopic guidance when a transpedicular approach is used because the movement of the needle through the pedicle into the vertebral body is visualized in real time. The transpedicular approach is recommended for lesions involving the pedicle and the posterior half of the vertebral body (Figs.
14 and 15). The transcostovertebral approach is recommended for lesions of the disc space and the lower aspect of the vertebral body (Fig. 14). If a paraspinal mass or extraosseous extension of tumor is present, CT-guided biopsy with FNA or cutting needles is preferred. Transcostovertebral biopsies can be performed with either CT or fluoroscopy but many radiologists prefer CT guidance because of the close proximity of the lungs. For very small or complex lesions, CT guidance is recommended
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