Percutaneous Vertebral Biopsy Research Articles

P137. Minimally Invasive Surgery for Ablation of Osteoid Osteoma of the Spine

BACKGROUND CONTEXT: Given its success in the treatment of osteoid osteomas of the extremities, percutaneous radiofrequency ablation may offer a useful approach to such tumors involving the spine. Similarly the success of percutaneous transpedicular vertebral biopsy suggests its potential role in the treatment of osteoid osteoma of the spine.

Characteristics of patients with spinal tuberculosis in a French teaching hospital

Objective. – To investigate the characteristics of patients managed for spinal tuberculosis at the rheumatology department of the Tours Teaching Hospital, France, between 1986 and 2003. Methods. – Retrospective chart review. The incidence, epidemiology, clinical features, imaging study findings, and diagnostic procedures were recorded. Results. – The annual incidence of spinal tuberculosis was stable throughout the study period. There were 24 patients, 15 women and nine men with a mean age of 61 years; 15 patients were of French descent, three were of Portuguese descent, two were Asian, and four were North-African. Risk factors consisted of alcohol abuse in one patient, diabetes in two patients, glucocorticoid therapy in two patients, and a history of tuberculosis in six patients; none of the patients had AIDS. The cervical spine was involved in two patients, the thoracic spine in 11 patients, and the lumbar spine in 12 patients. Mean time from symptom onset to diagnosis was 4.3 months (range, 1–12 months). Percutaneous vertebral biopsy established the diagnosis in 16 of the 20 patients who underwent this procedure. Conclusion. – The annual incidence of spinal tuberculosis remained unchanged throughout the study period and was not influenced by immigration or the AIDS epidemic. The typical patient was an elderly Caucasian woman of French descent. Reactivation of untreated or inadequately treated tuberculosis was probably the main mechanism.

Charcot’s Disease of The Spine

Retrospective study. To report nine cases of Charcot's joint of the spine, to clarify the difficulty in diagnosis and treatment, and to analyze the literature. Charcot's joint of the spine, also known as spinal neuropathic or neurogenic arthropathy, is a destructive condition that affects the intervertebral disc and the adjacent vertebral bodies. It is the result of a loss of joint protection mechanisms, generally secondary to a spinal cord lesion. We report a series of nine patients treated surgically. Eight men and one woman suffering from paraplegia or tetraplegia were reviewed. The time interval between the neurologic disorder and the diagnosis of neuropathic spinal arthropathy was 10 to 36 years. The most frequent presenting symptom was an evolutive thoracolumbar kyphosis, sometimes associated with back pain or increased spasticity in the lower limbs. The neuropathic arthropathy involved the thoracic spine in four patients and the lumbar spine in four other patients. The remaining patient presented two arthropathies, one thoracic and one lumbosacral. A percutaneous vertebral biopsy was performed in five patients suspected to have an infection or a tumor. Treatment was always surgical. In eight cases, a circumferential fusion was performed in the area of the dislocated vertebral levels. The postoperative follow-up was from 3 years to 10 years. A solid and stable circumferential fusion of the spine was obtained in all patients. The functional status improved in all patients. Pain and sagittal imbalance were successfully treated. The increased spasticity observed at the initial examination improved in all patients who returned to the neurological deficit initially present before the onset of Charcot's arthropathy. The diagnosis of Charcot's arthropathy of the spine must be considered in paraplegic and tetraplegic patients with spinal deformity with bone destruction and vertebral dislocation in the absence of an infection or neoplastic disease. The treatment of a Charcot's spine is circumferential fusion and osteosynthesis. Monitoring by clinical and imaging examination must be continued, because multifocal vertebral lesions can occur in cases of extensive proprioceptive deficit.

Management of metastatic spinal cord compression.

Metastatic spinal cord compression, diagnosed in 3-7% of cancer patients, is one of the most dreaded complications of metastatic cancer. It is an oncologic emergency, which must be diagnosed early and treated promptly to achieve the best results and avoid progressive pain, paralysis, sensory loss and sphincter incontinence. Patients who are ambulatory at the time of the diagnosis have a higher probability of obtaining good response to treatment and a longer survival. In clinical practice, back pain accompanies metastatic spinal cord compression in most cases, even in patients with no neurologic deficits. Magnetic resonance imaging is the best tool for diagnosing metastatic spinal cord compression and is able to identify spinal cord compression in 32-35% patients with back pain, bone metastases and normal neurologic examination. Moreover, magnetic resonance imaging gives the extension of the lesion, can diagnose other unsuspected clinical metastatic spinal cord compression sites, and is useful for the radiation oncologist in defining the target volume. Radiotherapy is the treatment of choice in most cases, whereas surgery is advised only in selected patients (ie, if stabilization is necessary, if radiotherapy has already been given in the same area, when vertebral body collapse causes bone impingement on the cord or nerve roots, when there are diagnostic doubts, or when computed tomography-guided percutaneous vertebral biopsy cannot be performed). Laminectomy should be abandoned in favor of more aggressive surgery (ie, posterior, anterior, and/or lateral approach, tumor mass resection, and stabilization of the spine). Generally, radiotherapy must be administered 7-10 days after surgery. The optimal radiation schedule has not been defined. However, as recently suggested by some clinical trials, even the hypofractionated radiotherapy regimens are effective and can be used without increasing radiation-induced myelopathy. Moderate doses of dexamethasone should be used in the early phases of therapy. After radiotherapy, spinal recurrence is generally found in sites different from the first compression area. A close post-treatment follow-up is suggested using clinical parameters (pain, motor and sphincter function), and magnetic resonance imaging should be performed only when a second metastatic spinal cord compression and/or myelopathy are clinically suspected.

Management of nontuberculous infectious discitis. Treatments used in 110 patients admitted to 12 teaching hospitals in France

The optimal management of pyogenic discitis is not agreed on. No randomized clinical trials of short-course or oral antibiotic regimens have been published to date. To shed light on this issue, we reviewed the management of patients admitted for pyogenic discitis to one of 12 networked rheumatology departments. In this cross-sectional observational study, each department included the first ten patients admitted starting in January 1997 for treatment of pyogenic discitis. One hundred ten patients met the inclusion criteria, 67 men and 43 women, with a mean age of 60.6 ± 13.7 years (range, 17–86 years). Mean time from symptom onset to diagnosis was 39.6 ± 39.8 days (range, 24 h–240 days). Blood cultures were positive in 47.3% of patients, and the percutaneous discal and vertebral biopsy in 63.6% of cases; these two investigations identified the causative organism in 79 cases (72.8%). Mean duration of the rheumatology department stay was 31.3 ± 14.1 days (range, 4–78 days). Antibiotics were given intravenously to 103 (93.6%) patients, for a mean of 25.5 ± 17.6 days (range, 4–124 days); duration of intravenous antibiotic therapy was longer than 4 weeks in 36.5% of patients. Only seven (6.4%) patients received primary oral antibiotics with no parenteral antibiotics. One hundred patients were given oral antibiotics at the same time as and after intravenous antibiotics, for a mean duration of 87.2 ± 43.6 days (range, 20–278 days); Bracing was used in 98 (89.1%) patients. Although antibiotic selection was rational and in agreement with current recommendations, wide differences were noted across centers regarding intravenous treatment duration, hospital stay duration, and total treatment duration.

Percutaneous vertebral biopsy through intact bone: A coaxial bone transgressing technique with 18 gauge needle

Advancement of radiologic technologies allows the detection of vertebral lesions at an earlier stage, thereby increasing the proportion of vertebral lesions that are surrounded by intact bone when they are detected. While biopsy guns are effective in obtaining good-quality tissue samples of osteolytic bone lesions, lesions that are covered by intact bone are not accessible with a biopsy gun. For percutaneous biopsy of osteolytic vertebral lesions, an intact-bone transgressing technique is described in which a simple, inexpensive and small-calibre (18-gauge) instrument is used to allow multiple passage of 20-gauge biopsy guns for effective tissue sampling. In this series consisting of metastatic and myeloproliferative lesions, the effectiveness and safety of this well-tolerated technique are demonstrated in thoracic and lumbar vertebrae.

Treatment of Osteomyelitis of the Spine Using Percutaneous Suction/Irrigation and Percutaneous External Spinal Fixation

External skeletal fixation is a well-known tool in the management of infection of long bones. However, the application of external skeletal fixation in the treatment of spinal infection has not been previously reported. We have used percutaneous external spinal fixation (PESF) for the treatment of osteomyelitis of the spine in 23 patients since 1981. The treatment consists of percutaneous vertebral biopsy for bacteriologic diagnosis, installation of a suction/irrigation system into the intervertebral disk space, and posterior stabilization (and reduction if indicated) with an external fixator placed percutaneously. This treatment was conceived in 15 patients as definitive treatment. One patient died due to pulmonary embolism. In 12 patients, the infection healed without further operative treatment. Preoperative kyphosis averaged 15 degrees (range 0-30 degrees). At follow-up, kyphotic deformity also averaged 15 degrees (range 0-30 degrees). Two patients required anterior debridement and bone grafting because of progression of bony destruction. In eight patients, PESF was performed emergently, followed by planned anterior debridement and interbody grafting. The treatment was successful in all patients. All fusions healed. Preoperative kyphosis averaged 18 degrees (range 0-40 degrees). At follow-up, kyphotic deformity averaged 10 degrees (range 0-22 degrees). Our present indications are listed below and comprise pyogenic and tuberculous osteomyelitis of the spine localized between T3 and S1. The procedure is an alternative to conservative or more invasive operative treatment modalities in the following conditions: (a) painful lesions of the spine with minimal bone loss, not amenable to efficient orthotic stabilization (thoracic spine from T3 to T9, lumbosacral junction, elderly patients, or presence of deleterious general conditions); (b) osteomyelitis of the spine from T3 to S1, when emergency decompression of the spine is mandatory because of neurologic deterioration due to the kyphotic deformity or to a noncapsulated epidural abscess and anterior decompression is not possible emergently; (c) pyogenic osteomyelitis of the spine at L5/S1, when operative treatment is indicated. In addition, percutaneous insertion of external skeletal fixation is indicated in the presence of infected wounds, making internal posterior stabilization unsuitable (e.g., after open decompression of epidural abscess, postoperative infections).