Vertebral Biopsy

Vertebral Biopsy

Donald V. La Barge, III, MD

Parasagittal graphic depicts a diffuse neoplastic process image occupying a typical lumbar vertebral body. Note the anterior cortical breakthrough with tumor extension ventrally image.

Lateral fluoroscopic image shows transpedicular needle tip image at midportion of T6 vertebral body. Note the value of pre-procedure imaging, as lesions may be difficult to see at fluoroscopy.



  • Fine needle aspiration (FNA)


  • Image-guided percutaneous vertebral biopsy



  • Suspected tumor

    • Biopsy for pathology

    • ± vertebroplasty/kyphoplasty

  • Osteomyelitis

    • Identify responsible organism

    • Determine sensitivity to antimicrobials

  • Discitis

    • Identify responsible organism

    • Determine antimicrobial sensitivity


  • Coagulopathy

  • Anticoagulation

    • Patients with atrial fibrillation, TIA, etc.

  • Contraindication to sedation/anesthesia

    • Unable to tolerate prolonged prone positioning

  • Systemic infection

Pre-Procedure Imaging

  • Osteomyelitis/discitis

    • Radiography

      • Vertebral endplate irregularity

      • Disc space narrowing

      • Widening of paraspinal soft tissues

    • CT

      • Vertebral endplate irregularity

      • Disc space narrowing

        • Difficult to evaluate on axial imaging

        • Coronal and sagittal reformats helpful

      • Soft tissue swelling

    • MR

      • Hypointensity along vertebral endplates on T1WI

      • Hyperintensity in adjacent vertebrae on T2WI

      • Low T1/high T2 signal in intervertebral disc

      • Abnormal enhancement of disc/endplates

        • Low T1 signal surrounded by enhancement may reflect abscess

  • Neoplasm

Getting Started

  • Things to check

    • Review prior imaging studies

      • CT

        • Assess cortical breakthrough/destruction

        • Look for tumor extension beyond osseous margins

        • Look for retropulsed osseous fragments into spinal canal

      • MR

        • Better soft tissue delineation

        • Look for cord compression, neural impingement

        • STIR best for marrow edema (acute fracture), lytic bone metastases

        • Determine safest location to biopsy if multiple osseous lesions

    • Check laboratory data

      • Coagulopathy/anticoagulation

        • Complete blood count (CBC), prothrombin time (PT), activated partial thromboplastin time (aPTT), international normalized ratio (INR), bleeding time

      • Infection/inflammatory markers

        • White blood cell count (WBC), c-reactive protein (CRP), erythrocyte sedimentation rate (ESR), temperature

      • Cerebrospinal fluid (CSF) studies if applicable

        • Cytology or increased white blood cell count

    • Obtain informed consent

  • Medications

    • Local anesthetic

    • Conscious sedation

  • Equipment list

    • Radiopaque marker

    • Sterile prep/drape materials

    • 10 mL syringe + long 25-gauge needle for local anesthetic

      • Spinal needle is often helpful to anesthetize deep paraspinal tissue and pedicle

    • Scalpel

    • Biopsy needle (with stylette)

      • If using transpedicular access in lumbar or thoracic spine, 10-13-gauge transpedicular needle with coaxial biopsy system

      • If posterior elements or cervical spine, may use 15-18-gauge coaxial system

      • Aspiration syringe

      • Ensure biopsy system components are available in desired size(s)

    • Specimen container per institutional protocol

      • Formalin vs. saline (nonbacteriostatic)

    • Hydrogen peroxide

    • Bandage


Patient Position/Location

  • Best procedure approach

    • Prone

Equipment Preparation

  • Draw 10 mL of local anesthetic; attach long 25-gauge needle

  • Check biopsy system components

  • Make sure specimen container is readily available

    • For suspected tumor, prefer pathology representative in room to determine adequacy of sample(s)

Procedure Steps

  • Procedure “time out”

    • Correct patient

    • Correct level(s)

    • Correct procedure

    • All necessary equipment present

      • Ensure compatibility of biopsy/access needles

  • Under fluoroscopy or CT, localize optimal bone access point to reach lesion safely

    • Consult prior imaging to determine safest access to lesion

    • Transpedicular: Angle fluoroscopy tube toward pedicle to be accessed

      • Ensure good visualization of pedicle margins

    • CT: Localize lesion in axial plane

      • Sagittal reformatted images may assist in determining correct level/needle trajectory

  • Initiate conscious sedation

  • Carefully localize target with imaging

    • Mark overlying skin

  • Perform sterile prep and drape

  • Generously apply local anesthetic to skin, subcutaneous tissue, and cortex

    • Localize numbing needle with imaging to confirm trajectory

  • Make small skin incision to accommodate biopsy system

  • Anchor biopsy system in subcutaneous tissue, and confirm trajectory with imaging

  • Transpedicular

    • Prior to anchoring needle in pedicle cortex

      • Carefully guide needle to pedicle

        • Surgical clamps are helpful in holding needle without exposing hand in field of view

      • Ensure angle of entry is satisfactory

        • To reach biopsy target

        • To avoid medial pedicle cortex

        • Check lateral view to ensure craniocaudal angulation is satisfactory

    • Anchor transpedicular needle in pedicle

    • Advance carefully, checking frequently under fluoroscopy to ensure needle remains within pedicle

      • Frequent assessment of oblique, frontal, and lateral views is necessary

      • When posterior vertebra is reached, frontal and lateral views provide most accurate depiction of depth and position of needle within vertebra

    • Advance to margin of vertebral lesion to be sampled

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Sep 22, 2016 | Posted by in EMERGENCY RADIOLOGY | Comments Off on Vertebral Biopsy
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