Open biopsy is the gold standard procedure with 98% accuracy but associated with additional morbidity [8]. For two decades, percutaneous procedures have gained popularity. CT-guided percutaneous core needle biopsy is a quick, economical and safe procedure. Yang et al. showed that core needle biopsy had an accuracy of more than 90% for detecting highly malignant lesions [9, 10]. In case of bone, an induced stress fracture by rotation of the JN usually gives an adequate sample. But, specially in very soft lesion the sample procured does not always adequate. Brugieres et al. also found this intervention more reliable in diagnosing osteolytic lesions but the accuracy dropped to 75% when dealing with sclerotic lesions [1]. With our technical modification, even a cannulated drill bit, with stopper and with a core opening can be drilled through the cannula to retrieve safe adequate sample. Thus, the spectrum of TPB will range from hard sclerotic lesions to soft lesions with this modification. Nourbakhsh et al. described adequacy of the sample which is stated to be the percentage of sample required for the pathologist to make the diagnosis [11]. In a study by Kornblum et al. CT guided biopsy showed promise in terms of sample adequacy; however, they found a lower accuracy rate in the thoracic spine [12]. Rimondi et al. in one the largest studies on CT guided biopsies of the spine showed an improvement in histopathological diagnostic accuracy of 93.3%. However, 5% of their cases needed repeat biopsies due to sample inadequacy and they also reported a complication rate of 2.1%. They concluded that the success of CT guided biopsy is higher in malignant lesions both primary and secondary but is low in chronic inflammatory lesions [13]. We have used this technique previously where we used a self-designed trocar and cannula in our study of 71 cases & reported an accuracy of 88.7% with no reported complications. This is a modification of the same technique where we additionally introduce a pituitary forceps that helps for biopsy of vertebral lesions as well as discal level pathologies [2]. Also, the multi-planner adjustment of the cannula after the initial Stealth O-Arm navigation helps in sampling of different regions of the vertebral body by reinsertion of the pituitary forceps with simple manipulation of the cannula without withdrawing it. This minimizes the risk of fracturing the pedicle. Our institutes biopsy success report has increased even further (unpublished) by the above technique. Another major problem with C-arm guided biopsy is its limited visibility in the upper thoracic lesions due to shoulder, scapula and lung shadows with respiratory movements. In obese and osteoporotic patients, the 2D image is unpredictably poor.
With adequate knowledge of the vertebral morphometry and experience with TP fixation, the TP route is an important passage for obtaining biopsy. It can accommodate a variety of instruments and has made the entire vertebral body accessible. The safety angulation of instruments in both sagittal and axial planes is significantly increased if it is done with navigation, especially under GA, while definitive fixation is also being carried out. When performed percutaneously it reduces the morbidity and minimizes complications. In a similar previous report, Basu et al. in their analysis of 26 patients had a sample adequacy of 88.4% using the eleven-gauge J needle. However, additional instruments like the curette or disc forceps were used in 14.2% patients when the sample was inadequate. Basu et al. used the J trocar biopsy set in their study of 39 cases. Their sample adequacy was 84.6% which improved to 100% by adopting intra-operative cytology which allowed repeating the biopsy in the same sitting [14]. This is due to the use of the drill and the pituitary forceps which are easily passed through the kypho-plasty cannula thus obtaining adequate samples. Diagnosing soft tissue lesions (Discitis) using this simple technique is superior as adequate disc material can be obtained with the pituitary forceps passed through the cannula trans-foraminally which would otherwise be difficult when a trocar is passed and also would largely depend on the surgeon’s experience. Krishnan et al. in their technical note and review on percutaneous endoscopy discectomy and drainage (PTELDD) have stated the superiority of the intervention over CT guided biopsy in terms of success rate and culture bacterial recovery [15]. Another similar technique under navigation is also reported by Takata et al. [16]. They also did biopsy under GA but the diameter of cannula was 5 mm with special pituitary forceps with stopper.
Our technique has limitations being experience driven and also enabling technology (Stealth-O Arm Navigation) dependent. Performing this procedure does not require multiple CT scans as against in CT guided biopsy. Thus, radiation exposure to the patient is reduced. Also, CT-guided biopsy has the biggest disadvantage of not being done in the sterile operating room environment. We usually in 3D navigated TPB, use a small field of view, low-dose mode for the O-arm 3D scan to reduce radiation to the patient. With this technique, we can reduce radiation exposure to operating room staff too. There were similar findings reported in a study by Tanaka et al. in 2021 [16]. However, the same method can be applied using 2D fluoroscopy without navigation [17, 18]. Oblique “scotty dog” view can be used by novice surgeons and routine AP can be also used by experienced surgeons. This was a technique description and not a series description, which would have given more diagnostic accuracy statistically regarding the size, location, region, tissue disease and hard-soft morphology. Also, we cannot comment on the quality/ quantity of the specimen without having a comparative study with a control group and that is a potential limitation. Biopsies being integral for diagnosis at times are misdiagnosed as well. As per our institutional protocol, we always send the primary slide reporting for a second pathos-microbiologist opinion for reconfirmation especially in a precious biopsy. At times, simultaneous two laboratory/institute tissue processing is also done as there is no dearth of material procured by our method, making the tissue diagnosis even more reliable. A navigated cannula with stopper, scale markings integrated with the Original Equipment manufacturers would be a better standardized solution though.
The TPB has proven to be an important intervention in the spine surgeons armamentarium with excellent accuracy [19]. We hope that with our technical modification, the diagnostic yield, accuracy of sampling and adequacy of sample will improve even further.
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