On this episode of the BackTable MSK podcast, co-hosts Dr. Chris Beck and Dr. Aaron Fritts review the basics of bone lesion biopsy, including patient selection, imaging modalities, and procedural steps.

They begin with summarizing indications for bone lesions, which are most common in the setting of metastatic disease. Patients usually get referred for biopsy when a bone lesion is caught on CT imaging of the chest, abdomen, and pelvis. The doctors emphasize that imaging multiple areas is needed to find the most easily accessible lesion, which is sometimes located within a solid organ, rather than within bone. While PET imaging can be useful for confirmation of sclerotic bone lesions, patients usually cannot receive PET scans without an established cancer diagnosis.

Dr. Beck highlights the fact that lytic lesions with soft tissue components are technically easier to access than sclerotic lesions and result in higher yield. He occasionally uses a soft tissue biopsy needle for these lesions. For sclerotic lesions, he prefers the OnControl or Stryker bone biopsy coaxial systems. With the coaxial system, it can be hard to adjust the biopsy tract after you have already started drilling, but he recommends obtaining multiple cores at different angles of approach. He also advises listeners to choose the shortest needle possible, since this makes it easier to control and image the needle within the lesion.The doctors also discuss biopsy of tricky locations. Sternal lesions carry the risk of lung injury and pneumothorax, so when faced with these, Dr. Beck picks an oblique tract that has a longer trajectory. For lesions located in proximal extremities, he secures the limb to minimize movement.

Next, disc biopsies are discussed. Patients usually present with discitis osteomyelitis from prior back surgery, IV drug use, or idiopathic causes. It is important to distinguish between infection of the disc space versus chronic degenerative disc disease, which can be identified by comparison with prior imaging and lab workup. For the lumbar spine disc biopsy, fluoroscopy is Dr. Beck’s preferred imaging modality, and he reviews imaging landmarks. Dr. Fritts usually biopsies both bone and disc.

Finally, they discuss post-procedural complications to watch for, such as chest x-rays in checking for lung injury and neurological exams to assess for new deficits.

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Stryker Interventional Spinehttps://www.strykerivs.com

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SHOW NOTES

00:00 - Introduction03:12 - Referrals and Imaging Techniques for Bone Lesion Biopsy07:09 - Procedural Steps of Bone Lesion Biopsy12:32 - Choosing Biopsy Tools23:22 - Approach to Tricky Biopsy Locations28:19 - Workup and Indications for Disc Biopsy32:08 - Fluoroscopy vs. CT for Disc Biopsy40:15 - Handling Biopsy Samples48:03 - Post-Procedure Care and Complications

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RESOURCES

Arrow OnControl Powered Bone Biopsy System:https://irc.teleflex.com/oncontrolsystem/

Stryker Bone Biopsy Coaxial System:https://www.stryker.com/us/en/interventional-spine/products/bone-biopsy.html

BD Trek Powered Bone Biopsy System:https://www.bd.com/en-us/products-and-solutions/products/product-families/bd-trek-powered-bone-biopsy-system

Jamshidi Evolve Bone Marrow Needle:https://www.bd.com/en-us/products-and-solutions/products/product-families/jamshidi-evolve-bone-marrow-needle

BD Illinois Sternal/Iliac Bone Marrow Aspiration Needles:https://www.bd.com/en-ca/products-and-solutions/products/product-families/illinois-sternal-iliac-bone-marrow-aspiration-needles

BD Mission Disposable Core Biopsy Instrument:https://www.bd.com/en-us/products-and-solutions/products/product-families/mission-disposable-core-biopsy-instrument

Disc Biopsy Visualization Website:https://www.pediatricir.com/disc-aspiration-for-discitis.html