Table 51 Indications for spine biopsy

1. Suspected secondary spine tumor (i.e., metastasis) with either a known or an unknown primary tumor

2. Suspected secondary spine tumor, with a history of two or more preexisting primary tumors

3. Suspected primary spine or paraspinal tumor

4. Pathological compression fracture

5. Suspected infectious spondylitis

6. Suspected inflammatory condition that involves the spine with noninvasive imaging modalities, such as computed tomography (CT) or magnetic resonance imaging (MRI), are also often referred for spine biopsy. In every instance, the decision to proceed with a biopsy procedure is based upon a thorough analysis of risks and benefits. The overall benefit of the information gained by the procedure should always favor its performance. The results of the biopsy will affect the subsequent clinical management of the patient and influence treatment decisions in such areas as surgery, chemotherapy, radiation therapy, and antibiotic therapy.

The immediate contraindication to percutaneous biopsy is coagu-lopathy. Yet even this condition, when properly anticipated and managed, can be corrected long enough to permit a surgeon to perform the procedure. When a vascular tumor such as a renal metastasis is suspected, a catheter angiogram should be considered in the diagnostic workup. These vascular lesions, however, can be carefully sampled with smaller gauge core needle biopsy systems and with fine-needle aspiration techniques (Figure 5.1).

Informed consent must be obtained prior to the procedure after the patient has received an explanation of the benefits and risks of image-guided percutaneous spine biopsy. The procedure offers the benefit of supplying diagnostic information that will guide subsequent treatment decisions. The alternative procedure is an open spine biopsy.

The general risks of percutaneous spine biopsy include bleeding at or deep to the puncture site manifested as active hemorrhage or hematoma formation (Table 5.2). Infection is another potential complication associated with spine biopsy, hence the requirement for strict aseptic technique when the procedure is performed. The spread of disease by the biopsy procedure, an extremely rare complication that has been described,7 is related to tumor implantation or spread of infection along the biopsy tract.5 The development of coaxial biopsy techniques and transcortical approaches with shorter needle trajectories has decreased the incidence of these complications. Site-specific biopsy complications that have been reported are related to the spine level (cervical, thoracic, or lumbar spine) that was sampled and the proximity to critical structures. Pneumothorax can occur not only during thoracic spine biopsy but also during the attempted biopsy of thora-columbar or cervicothoracic lesions. Neural injury, particularly to the spinal cord, is a devastating complication that has been reported. Nevertheless, the incidence of reported complications in percutaneous skeletal biopsy is low, estimated at less than 0.2%.5 The combination

Figure 5.1. Axial CT image shows a lytic lesion (arrows) that is centered primarily within the posterior elements of the thoracic vertebra. Since the patient had a history of kidney resection, this lesion was sampled by fine-needle aspiration with a 22-gauge spinal needle. A single pass showed positive cytology for metastatic renal cell carcinoma.

of image guidance, small-gauge biopsy needle systems, and operator experience should result in an overall major complication rate that is much less than 1%.

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