Preoperative Evaluation of the Patient
We have already emphasized the importance of reviewing any available imaging studies to assess the indication for the biopsy, as well as to select an appropriate guiding technique and plan the route of access and the final target. Equally important, the patient must be screened for systemic conditions and medications that may interfere with the performance of the biopsy. Often, this preoperative contact can be established over the telephone. Any pertinent clinical information relating to past and present diseases is recorded. Patients are questioned about any history of allergic reactions. A list of current medications is also obtained, with special emphasis on anticoagulants and aspirin. If the patient is on aspirin, the biopsy is postponed for six days. In urgent cases, a period of three days may be sufficient to prevent a problem with bleeding. Alternatively, the use of fine needles, or simply the assumption of risk, may be adequate when there is a true medical urgency, and appropriate consent has been obtained from the patient. These situations tend to be limited to patients with suspected spine infection, or when there is an impending threat to the spinal cord, and emergency radiotherapy is considered without prior histologic confirmation of a malignant lesion. Coumadin can always be circumvented by administering fresh frozen plasma before the procedure. Heparin has a short half-life (30-60 minutes for unfractioned heparin), and simply waiting 10 half-lives will negate its effects, which usually allows for the discontinuation of heparin and the performance of the biopsy on the same day. We obtain a platelet count, prothrombin time and partial thromboplastin time, and INR before undertaking a deep-bone biopsy (11). Care should be utilized if the patient is on Lovenox as the anticoagulation may be greater than the usual laboratory tests suggest.
We perform the majority of our biopsies under conscious sedation with midazolam and fentanyl. These medications tend to depress respiration, and therefore, preoperative screening for asthma, sleep apnea, or other respiratory problems becomes important. Also, they may affect the patient's ability to remain supine throughout the procedure. Conscious sedation requires arrangements to be made for someone to drive the patient home after the procedure.
In our department, this initial contact is carried out by the musculoskeletal fellows, and a log book is kept with all the data gathered for each patient, including contact telephone numbers and addresses of the patient and referring physician, imaging studies available, and pertinent clinical and laboratory information obtained.
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