Bone Trephine Needles

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We will only review disposable bone trephine needles (BTN) available. There are two main types of BTN, which differ by their type of placement against bone through the soft tissue. BTN may be placed using a coaxial Seldinger technique or directly. Needles that are placed using a Seldinger technique are useful for deep bone biopsy, especially vertebral biopsy through a posterolateral route (Table 1). Seldinger technique allows coaxial placement of an external biopsy cannula and BTN in the same track as the thin anesthetic needle using a blunt guide-wire. This reduces the risk of wounding the anatomical structures with the large BTN.

BTN placed directly are simpler to use, easier to handle, and more convenient for superficial bone biopsies or bone biopsy in anatomical areas where there is no vital structure such as bone biopsy of pelvic bones (Table 2).

Most BTN include an external cannula that remains in place, whereas the trephine needle is withdrawn with the sample. This allows multiple sampling without need for needle repositioning.

Some bone needles have a special cutting tip designed to penetrate hard cortical or sclerotic bone (Table 3). Manual cutting needles and semiautomatic or automatic biopsy guns with either a side notch or an end notch are used to sample osteolytic or soft-tissue lesions (Table 4). These needles may be used alone or introduced through an introducer for coaxial use (for example Tru-Guide Bard, 7-18cm, 12-20 G).

TABLE 1 Disposable Bone Trephine Needles for Direct Approach

Diameter (outer

Needle name

Manufacturer

Length (cm)

needle) (G)

Osteosite M1 (side bevel)

COOK, Bloomington,

10, 15

11

U.S.A.

Osteosite M2 (diamond

COOK, Bloomington,

10, 15

11

bevel)

U.S.A.

Manan

Manan, Northbrook, U.S.A.

Lar1000

Laurane Medical, Saint

10, 15

11

Arnoult, France

Jamshidi

Baxter Healthcare,

Valencia, U.S.A.

Source: From Refs. 22-33.

TABLE 2 Disposable Bone Trephine Needles Placed with a Seldinger Technique

Diameter (outer

Needle name

Manufacturer

Length (cm)

needle) (G)

Geremia

COOK, Bloomington, U.S.A.

15

16

Elson

COOK, Bloomington, U.S.A.

6.5, 14

12

Cook guided bone

COOK, Brisbane, Australia

20

14

biopsy set

KyphX bone biopsy set

Kyphon Inc., Sunnyvale,

18.5

10

U.S.A., Kyphon Europe,

Zaventem, Belgium

Lar2000

Laurane Medical, Saint

10, 15

11

Arnoult, France

Cardinal Health, Maurepas,

France

Source: From Refs. 22-33.

Source: From Refs. 22-33.

TABLE 3 Disposable Bone Trephine Needles for Cortical and Sclerotic Bone

Needle name

Manufacturer

Length (cm)

Diameter (outer needle) (G)

Bonopty

Bard Inc., Covington, U.S.A.

12-16

15

Ostycut

Bard Inc., Covington, U.S.A.

5-15

14-17

Lar4000

Laurane Medical, Saint Arnoult,

10, 15

11

France; Cardinal Health,

Maurepas, France

Source: From Refs. 22-33.

Source: From Refs. 22-33.

TABLE 4 Disposable Needles for Biopsy of Osteolyse or Soft-Tissue Lesions

Needle name

Manufacturer

Length (cm)

Diameter (outer needle) (G)

MAX CORE (side notch) QUICK-CORE

(side-notch) ASAP-18 (side notch)

Manan (side notch)

Achieve (side notch) Sure-Cut (end notch) Biopince (end notch) Coaxial Temno (end notch)

Medi-Tech, Boston Scientific,

Watertown, U.S.A. Manan Medical, Northbrook, U.S.A.

Cardinal Health, U.S.A. 6-20 14-20

Nycomed, Princeton, U.S.A. 7-23 15-22

Amedic, Sweden 18

Cardinal Health, U.S.A. 11-20 14-20

Source: From Refs. 22-33.

PREOPERATIVE ASSESSMENT (SEE ALSO CHAPTER 2)

Each decision is made in consultation with the referring physician. Prior to PB, the patient's file should be evaluated to determine whether noninvasive procedures might yield the desired diagnosis. Patient hemostasis must be checked in the days before the procedure. The most accessible skeletal lesion and the proper anatomic approach are chosen on the basis of all available imaging procedures. Bone scintigraphy and MRI may identify additional lesions more accessible to PB than the initial detected abnormality (2). In all cases, radiographs in two projections, CT and MRI of the lesion are required prior to biopsy. In our experience, however, CT scan is indispensable in the selection of an appropriate biopsy site, because biopsy of an osteo-lytic area of soft-tissue tumor usually provides better results than sampling of sclerotic bone. Areas of sclerotic bone are often less easily detected with an MRI. In musculoskeletal malignant tumors, gadolinium-enhanced MRI scan also helps delineate areas of osteolytic bone or soft-tissue mass, which show the most enhancement and are more likely to be high grade. On the contrary, cystic areas, which often correspond to necrotic tissue, should be avoided (3). Contrast-enhanced CT or MRI may be useful when a highly vascular lesion is suspected: frank hyper-vascularization may call for needle aspiration rather than trephine biopsy. If a primary bone tumor is thought to be a possible diagnosis, the site of skin incision and lesion approach should be decided in consultation with the orthopedic surgeon so as to not compromise surgical treatment, and the biopsy track is marked with carbon to be able to resect it at time of surgery.

Immediate Preparation

Skeletal biopsies are usually performed under local anesthesia or conscious sedation (see Chapter 1 on Conscious Sedation), with the exception of children, restless patients, especially drug-addicted patients, and patients with lesions that are expected to be very painful at biopsy, who are placed under general anesthesia or heavy sedation. In our experience, some infectious lesions such as postoperative disc space infection and osteomyelitis of the shaft of long bones are often very painful and may require deep analgesia or even general anesthesia. Hospitalization for at least 24 hours is required following a vertebral biopsy. In most other locations, the biopsy can be done on an outpatient basis. Percutaneous bone biopsies are performed under strict aseptic conditions, including the use of sterile drapes, gloves, and gowns.

TECHNIQUE OF BONE TREPHINE BIOPSY UNDER FLUOROSCOPIC GUIDANCE (4) Lumbar Spine Posterolateral Approach

The lumbar spine is approached through a posterolateral route either right- or left-sided depending on the location of the lesion (Fig. 1). The needle is inserted at 7-10 cm (close to 7 cm

FIGURE 1 Posterolateral approach for lumbar spine percutaneous biopsy. Point of skin puncture is at 7 to 10 cm from the midline. The lumbar spine is approached at an angle of 40° to 60° with the sagittal plane. In this case, the left colon (curved arrow) is very close. This points out the usefulness of computed tomography scan prior to biopsy.

FIGURE 1 Posterolateral approach for lumbar spine percutaneous biopsy. Point of skin puncture is at 7 to 10 cm from the midline. The lumbar spine is approached at an angle of 40° to 60° with the sagittal plane. In this case, the left colon (curved arrow) is very close. This points out the usefulness of computed tomography scan prior to biopsy.

FIGURE 2 Approach to the lumbar spine. Lateral (A) and upper (B) views of the patient placed on their side. The point of skin puncture is at 7 to 9 cm from the midline (line A-B). Both level of needle insertion (1) and angle of cephalad or caudal approach (2) are determined using a metallic ruler (M) under fluoroscopic control.

FIGURE 2 Approach to the lumbar spine. Lateral (A) and upper (B) views of the patient placed on their side. The point of skin puncture is at 7 to 9 cm from the midline (line A-B). Both level of needle insertion (1) and angle of cephalad or caudal approach (2) are determined using a metallic ruler (M) under fluoroscopic control.

for the upper lumbar spine and close to 9-10 cm for the lower lumbar spine) from the midline figured by the spinous processes, depending on the biopsy level and patient's build (Fig. 2). Angle of approach is at 40° to 60° with the sagittal plane (Fig. 1).

The patient is placed on his side on the X-ray table and must be made comfortable and stable. A radiolucent block is placed beneath the flank in order to correct a lateral deviation of the spine. Perfect lateral positioning of the patient is crucial to a correct approach and is carefully checked by fluoroscopic control at each step of the procedure. The gantry is tilted to profile the disc space. The exact level of skin puncture and the angle of cephalad or caudad approach are determined using a metallic ruler placed on the patient's side in order to simulate the approaching needle on the lateral fluoroscopic view. In disc biopsies, the approach must be as parallel as possible to the vertebral end plates (Figs. 3 and 4). Both disc and vertebral end plates must be sampled in cases where there is a suspicion of disc-space infection. On the other hand, vertebral bodies are preferably biopsied with a cephalad or caudad angulation approach to sample the entire vertebral body (Figs. 3 and 5). Tl2 and L1 must be approached through an ascending route (Fig. 6). Once the point of skin puncture and the optimal approach have been determined, the skin is prepared, and the superficial planes are anesthetized. The needle is inserted and advanced under fluoroscopic control toward the lumbar spine at an angle of 40° to 60° with the sagittal plane (depending on patient build and lesion site) and in a cephalad or caudad direction (as determined above). The nature of any obstacle encountered can be determined from the lateral view fluoroscopic screen (transverse processes at the level of the pedicles or facet joints at the level of the disc space or lower half of the vertebral body). In this event, the needle is withdrawn 2-3 cm and then advanced in a more sagittal direction. If needed, the patient may be turned to a prone-oblique position to profile the needle with the X-ray beam. This view allows clear assessment of the needle tip position in regard to the spine. In most cases, contact with the spine should be obtained when the needle reaches the posterior third of the vertebral body or disc space. When proper placement of the needle is verified on both anteroposterior and lateral views, the periosteum is carefully anesthetized, and the trephine needle is inserted in the track of the anesthesia needle.

FIGURE 3 (A) Approach for lumbar disc biopsy should be parallel to the disc space (B) approach for lumbar vertebral body biopsy is oblique in order to avoid transverse processes and to sample the entire vertebral body.

FIGURE 4 Spinal infection: postoperative contamination at L5-S1 interspace. (A) Computed tomography scan demonstrates a prevertebral abscess. (B) The appropriate level of puncture and caudal inclination of the approach are determined in order to orientate the biopsy needle parrallel to the disk space.

FIGURE 4 Spinal infection: postoperative contamination at L5-S1 interspace. (A) Computed tomography scan demonstrates a prevertebral abscess. (B) The appropriate level of puncture and caudal inclination of the approach are determined in order to orientate the biopsy needle parrallel to the disk space.

FIGURE 5 (A) Metastatic nodule of L5 with high-signal intensity on T2-weighted magnetic resonance image (B) oblique descending approach.
FIGURE 6 Biopsy of L1 using an ascending route in a patient with bone metastasis.
vertebral pedicle. (B) Penetration of the vertebral body and final position. Source: Reproduced with the kind permission of Kyphon Inc.

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