Effectiveness and pitfalls of percutaneous transpedicle biopsy of the spine.

Seventy-one percutaneous transpedicle biopsy specimens were taken from 68 patients with cervical, thoracic, lumbar, or sacral vertebral lesions, with the patients under local anesthesia. Sixty-one procedures were done with fluoroscopic guidance and seven procedures were done with computed tomography guidance. Twenty-one patients were diagnosed as having infectious spondylodiscitis, three had tuberculosis, two had coccidiomycosis, two had brucellosis, one had blastomycosis, one had an echinococcus cyst, six had primary neoplasms, 14 had metastatic neoplasms, five had osseous repair for insufficiency fractures, seven had osteoporotic fractures, and one had Paget's disease of bone. In the four remaining patients, the biopsy initially was negative but it was proven to be false-negative because of faulty biopsy technique. The percutaneous transpedicle approach for biopsy is safe, efficacious, and cost-effective. False-negative results and complications can be avoided when adhering to the technical details of this procedure.

Preoperative embolization and intraoperative cryocoagulation as adjuncts in resection of hypervascular lesions of the thoracolumbar spine.

OBJECT: The purpose of this study was twofold. First the authors evaluated preoperative embolization alone to reduce estimated blood loss (EBL) when resecting hypervascular lesions of the thoracolumbar spine. Second, they compared this experience with intraoperative cryotherapy alone or in conjunction with embolization to minimize further EBL. METHODS: Twelve patients underwent 13 surgeries for hypervascular spinal tumors. In 10 cases the surgeries were augmented by preoperative embolization alone. In one patient, two different surgeries involved intraoperative cryocoagulation, and in one patient surgery involved a combination of preoperative embolization and intraoperative cryocoagulation for tumor resection. When cryocoagulation was used, its extent was controlled using intraoperative ultrasonography or by establishing physical separation of the spinal cord from the tumor. In the 10 cases in which embolization alone was conducted, intraoperative EBL in excess of 3 L occurred in five. Mean EBL was of 2.8 L per patient. In one patient, who underwent only embolization, excessive bleeding (> 8 L) required that the surgery be terminated and resulted in suboptimum tumor resection. In another three cases, intraoperative cryocoagulation was used alone (in two patients) or in combination with preoperative embolization (in one patient). In all procedures involving cryocoagulation of the lesion, adequate hemostasis was achieved with a mean EBL of only 500 ml per patient. No new neurological deficits were attributable to the use of cryocoagulation. CONCLUSIONS: Preoperative embolization alone may not always be satisfactory in reducing EBL in resection of hypervascular tumors of the thoracolumbar spine. Although experience with cryocoagulation is limited, its use, in conjunction with embolization or alone, suggests it may be helpful in limiting EBL beyond what can be achieved with embolization alone. Cryocoagulation may also assist resection by preventing spillage of tumor contents, facilitating more radical excision, and enabling spinal reconstruction. The extent of cryocoagulation could be adequately controlled using ultrasonography or by establishing physical separation between the tumor and spinal cord. Additionally, somatosensory evoked potential monitoring may provide early warning of spinal cord cooling.