Complications

The overall complication rate of PB is low. In a series of 500 biopsies, Laredo et al. (1) reported only one paravertebral hematoma that resolved spontaneously. Murphy et al., in a large review of 9500 percutaneous skeletal biopsies reported in the English literature, identified approximately 22 complications (0.2%) considered important enough to mention. They reported nine pneumothoraxes, most of them treated conservatively. There were also more serious complications such as transient or permanent paraplegia or quadriplegia, and other neural injuries, such as those with resultant footdrop. Five spinal cord injuries were recorded, including one case of meningitis and two with resultant deaths. Therefore, serious neurologic injury occurred in 0.08% of procedures and death in 0.02% (10).

In primary tumors, open or closed biopsy may result in complications and also adversely affect the care of the patients (13). In the cooperative study reported by Mankin et al., a problem with the biopsy forced the surgeon to carry out a different and often more complex operation or to use adjunctive irradiation or chemotherapy in 19.3% of patients. This resulted in a change in

FIGURE 26 Tuberculous osteomyelitis of the sacral wing. (A) A preoperative computed tomography scan shows a central lytic area to biopsy. (B) Biopsy of this lytic area.

the outcome (disability, loss of function, local recurrence, or death) in 10.1% of patients. Errors and complications were much greater when the biopsy was done in a nonspecialized treatment center instead of in a referral institution (13). In the same study, closed needle biopsy was found to be less accurate than open biopsy (60% vs. 76% of correct diagnosis), but also much less likely to cause complications. Therefore, biopsy technique is of great importance in primary musculo-skeletal tumors and should be achieved only in centers with a multidisciplinary team able to manage the pretherapeutic evaluation and the whole treatment of primary bone tumors. Puncture site and approach have to be selected in consultation with the orthopedic surgeon who will operate on the patient. He will have to resect the needle track during surgery to avoid tumor seeding. During the biopsy, an external sheath placed up to the tumor margin should be used to protect the path from the cutting needle. It is also wise to mark the biopsy track with carbon, which is amorphous and persists for several weeks, and to tattoo the skin entry point with india ink to allow easy location during surgery (11).

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