Bone biopsy: a most important approaxh in bone diseases.

by Daniel CHAPPARD

GEROM-LHEA, CHU Angers          Updated: june 2015

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Introduction 

Bone biopsy is a simple technique which harvests one (or several ones, -see below) bone cylinders through the iliac bone. The technique appeared in the ‘60s and was considerably popularized and developed after 1970 with the development of bone histomorphometry as a most useful tool in the diagnosis of metabolic bone diseases. Bone biopsy of the iliac crest provides transfixing cores (i.e., containing the inner and outer cortex, and the trabecular network). The technique was of considerable interest in the understanding of fundamental bone biology and in the interpretation of pathologic changes in metabolic and neoplastic bone diseases. Harvesting bone from the iliac wing is simple, fast and painless under local anesthesia and the biopsy technique has been proposed to obtain autogenous bone grafts in some surgical indications when the bone volume is limited (e.g., dental implantology or maxillofacial surgery). In these cases, the general shape of the iliac wing is not altered after healing, thus avoiding some of the complications reported after a surgical approach.

For the study of human bone diseases the trephine must be of sufficient diameter (i.e., ≥ 7mm inner diameter) to correctly preserve bone microarchitecture and to provide enough marrow for a satisfying cytological analysis (1). A revolutionary histological technique that was extensively popularized in the ‘70s was the use of plastic embedding without decalcification. Polyester resins (“Bioplastic Wards”) were first used, quickly followed by the development of methylmethacrylate-based mediums. The study of undecalcified bone allows a clear identification of non-mineralized (osteoid tissue) and mineralized subparts of the bone matrix. In addition, when patients had received a double tetracycline labelling, histodynamic parameters (such as mineral apposition rate, active fraction of bone surfaces undergoing mineralization, bone formation rates…) can be measured.

Numerous trephines have been proposed during these last decades (2-10). In France, the Bordier’s trephine (with a 4 mm inner diameter) was first proposed. The Jamshidi’s needle, extensively used for the diagnosis of haematological disorders and bone metastases appears useful to harvest bone marrow biopsies but is unadapted to study bone since microarchitecture cannot be satisfactorily observed on a 1.4mm in diameter bone core. Near 1970-80, the Bordier’s trephine was modified by Meunier and others by increasing the inner diameter up to 7.5mm but the general shape of the trephine was not modified (11). We have proposed several modifications concerning the ergonomy of the Meunier’s trephine making it easier to handle and providing better preserved bone cores (12). The trephine developed in our laboratory can be proposed by Commeca (see the web site and details of the company at  http://www.commeca.com/anglais/cadresoma.html)

 

How to perform a bone biopsy  ?

Premedication

Premedication is used to make the patient quiet and stressless. The recommended premedication consists in:

-         analgesia with morphin sulphate per os 10 mg, 90 min before the biopsy (Sevredol®)

-         and anti-stress treatment with diazepam 20-30mg per os, 90 min before the biopsy (Valium®).

Local anaesthesia

A local infiltration of both the inner and outer cortices with lidocaine hydrochloride (1%, without adrenaline) ensures a perfect anaesthesia of the 2 sides of the iliac wing. Forty ml of lidocaine are necessary to achieve a complete infiltration.

Anaesthesia of the inner cortex
After a local disinfection of the skin (the patient lying supine), the area of the biopsy is located by the operator. Using a 20ml syringe, 15ml of lidocaine are injected directly on the periosteum of the iliac wing. The needle must come in direct contact with bone and a large area around the injection point is thus infiltrated.

Anaesthesia of the outer cortex
The patient is then placed in the lateral decubitus position. The operator gently adapt the position of the left and right leg to expose the iliac wing and the area of the bone biopsy is relocated at 2cm under the iliac crest and 2 cm behind the antero superior iliac spine.

In this exact position, the operator injects 20ml of lidocaine as follows:

-   15ml are injected directly in contact with the periosteum of the cortex while moving laterally the needle to cover a small area,

-   5ml are injected inside the muscles and fascias in the future trajectory of the incision. This is done by moving upward/downward the needle while injecting.

Anaesthesia of the skin
A third injection of 5ml lidocaine is done subcutaneously to obtain a local anaesthesia of the future skin incision. It is recommended to produce a well-defined papula.

Because lidocaine anaesthesia needs 2-3min to complete, this time is used to prepare the surgical table. It comprises: the trephine (with its 4 different parts: punch, guide, cutting part an extractor), a lancet (with blade #11 or #21), forceps and scissors…

The table should also comprise ancillary material: a vial with a local disinfectant (e.g., chlorexidine), gauzes and thread. The operator also wears with a sterile gown and use sterile gloves.

 

The biopsy technique

The patient staying in the lateral decubitus position, a fenestrated drape is stuck on the biopsy area (i.e., at the site of the 2nd and 3rd injection of lidocaine). After having controlled that skin anaesthesia is obtained (absence of pinprick sensation) a 1.5 cm incision is done. The operator sections the skin and muscles and the lancet must come in direct contact with the periosteum. The periosteal fibres are also sectioned.

The punch and guide are then inserted through the incision. The sharp extremity of the guide comes in direct contact with the external cortex of the iliac wing. The guide is then move down to come in contact with the bone and it is firmly immobilized with the operator’s hand. The punch is then taken off; the trephine is inserted in the guide and the cutting teeth of the trephine are in contact with the bone. The design of the instrument with a T shape, allows a good grip with 3 fingers. The biopsy is done by exerting shearing movements; usually it needs 10 to 30 seconds to section the outer cortex, trabecular bone and inner cortex. It is important to understand that bone is not cut by the instrument but sheared off by the teeth. So, do not try to cut bone by exerting complete rotations of the trephine; this provokes the accumulation of bone debris and impairs sectioning by filling the instrument’s teeth. Sectioning the different parts of the iliac wing can be easily appreciated by the operator. When the biopsy is complete, the bone core remains in the trephine.

 

Expelling the bone biopsy from the trephine

The operator takes off the guide and cutting part of the trephine from the patient. He must expel the biopsy as soon as possible to better preserve histological quality of the specimen. A piece of gauze is placed at the tip of the trephine (“top-hat” gauze) and the extractor is placed inside the trephine. The operator should strike a dry blow to expel the biopsy which remains in the gauze and can easily be handled and transferred to the fixative.

 

Suture and bandaging

The skin is sutured with non resorbable surgical thread (usually 2 suture points are sufficient). A compressive bandage is necessary and a 24 hours bed rest must be recommended to avoid local haematoma. Patients must not stand up or sit down in bed during 24 hours even for meals and toilet. The bandage can be taken off on the day following the biopsy and the threads after a time interval of ≈ 8 days.

 See the video:

 

 

a 64 Mo film in avi/mp4 format (in English).

Incidents and accidents of bone biopsy(13)

  • The most frequent incident is breaking the bone core in severally osteoporotic patients or when the operator has tented to exert strong pressure during the biopsy instead of shearing movements. It is why inspecting the biopsy immediately after harvesting is especially important. If the biopsy is broken, it is preferable to try to obtain a new bone core in the vicinity of the first biopsy. For histological purposes, it is very important to get a full and uncrushed specimen?

  • Morbid obesity is certainly a risk factor and the iliac crest is sometimes impossible to locate by palpation.

  • Sectioning a small artery may very rarely occur. Do not try to stop bleeding by compression; do not hesitate to insert the guide and punch through the incision and to perform the biopsy. The local surgical trauma will release large amounts of tissular thromboplastins that will stop bleeding.

  • Local haematomas are classical, especially if the patient is indocile and has not follow bed rest recommendations.

  • Local infections have never been reported.

  • Star fractures of the iliac crest have been described in severely osteoporotic patients. The fracture heals after local immobilization by bandaging.

  • Meralgica paresthetica, due to a local trauma of an abnormal branch of the femoro-cutaneous nerve have been sometimes reported.

Is bone biopsy a painful procedure?

Despite an increased availability of non invasive procedures to assess bone mass, histological examination of undecalcified transiliac bone biopsies remains a very valuable tool in the diagnosis of metabolic or malignant bone disorders. Nonetheless clinicians are sometimes reluctant to perform this "invasive" examination, arguing that it might be a painful procedure. We have designed a clinical study to evaluate pain and anxiety described by patients in the months following the biopsy and to characterize potential early or late side effects (14).
A same interviewer conducted a phone survey (19 items questionnaire) in 117 patients in whom a bone biopsy had been performed by two experienced physicians, with the same material and similar anaesthetic and technical procedure. The topics covered pain during or after the biopsy, anxiety, comparison of other potential painful procedures, early or late side effects as well as global evaluation by the patients.
Bone biopsy was judged as non painful by almost 70% of patients; some discomfort was present in 25 % in the following days. The procedure was described as similar as or less painful than bone marrow aspiration, venipuncture or tooth extraction. About 90% of the patients estimated that it was a quite bearable diagnostic procedure. Side effects were not serious. About 7% remembered of vasovagal episode, 47% of local bruising in the following days. There was no report of hematoma or infection. In experienced hands and adapted trephine, transiliac bone biopsy is a safe procedure that brings invaluable information in bone disorders.

pain during bone biopsy tolerability bone biopsy

Bone biopsy is an invaluable diagnostic tool in patients suffering from metabolic bone diseases, when performed in experienced hands and should not be considered as an obsolete procedure, replaced by imaging techniques. Our study also demonstrates, as previously shown by others, that the procedure is safe and bearable to patients. It is likely that improvements in the quality of the trephine material, the use of a thorough analgesic premedication and large amounts of anaesthetic fluid are key factors in the success of the performing bone biopsy.

Handling and use of bone biopsy in the laboratory

After fixation, bone biopsies are processed in the bone pathology laboratory. Bones are infiltrated with methylmethacrylate-based mediums and polymerized. Blocks are then sectioned on specially designed heavy duty microtomes equipped with tungsten carbide knives. Sections (usually 7µm in thickness) are stained with several histological techniques:

  • Goldner’s trichrome is favored for identification osteoid and mineralized matrix (1),

  • osteoclasts can be identified by enzymatic detection of their tartrate resistant acid phosphatase content (TRAcP) (2),

  • Bone marrow cells can be identified by toluidine blue, hematoxyline –eosin.

  • sections for the analysis of tetracycline labelling are left unstained (3).

  • Several histochemical reactions can be used if necessary (iron (4), lead, aluminum…)

  • for a detailed paper on the histological techniques see this paper

The histomorphometric analysis is done either with integration microscopic oculars or with image analyzers. Histomorphometry provides “static parameters” including cortical thickness and porosity, trabecular bone volume, trabecular characteristics (thickness, number and separation). Bone mineralization is studied on osteoid parameters and “histodynamic parameters” are obtained with fluorescent microscopy of the tetracycline labels. Recently, microarchitectural descriptors of trabecular bone architecture have been proposed by some laboratories and appear very useful in the analysis of osteoporosis. The development of microcomputed tomographs has also permitted a direct 3D analysis of the bone core before the more classical histological processing (see our webpage).

Leica Quantimet Q550 (left)                                                         and Skyscan 1172 microcomputed tomograph (right)

 

 

References

1.         Frost HM 1976 A method of analysis of trabecular bone dynamics. In: Meunier PJ (ed.) Bone Histomorphometry - 2 nd Int. Workshop. Armour Montagu Lab., Levallois-Perret, pp 445-476.

2.         Altman K, Blenkinsopp PT 1994 Use of the bone biopsy trephine to obtain iliac crest cancellous bone. J Oral Maxillofac Surg 52:522-3.

3.         Faugere MC, Malluche HH 1983 Comparison of different bone-biopsy techniques for qualitative and quantitative diagnosis of metabolic bone diseases. J Bone Joint Surg Am 65:1314-8.

4.         Helleberg-Rasmussen I, Sondergaard-Petersen H 1975 Bone-marrow biopsy with the bordier trephine. Scand J Haematol 14:123-8.

5.         Lalor B, Freemont A, Carlile S 1986 An improved transilial crest bone biopsy drill for quantitative histomorphometry. Bone 7:273-6.

6.         Minns RJ, Sher L 1983 An iliac crest bone biopsy trephine. Injury 14:370.

7.         Sacker LS, Nordin BE 1953 A simple bone biopsy needle. Lancet 266:347.

8.         Schuyt C, Meulemans A, van Eek WH 1979 A bone-fixing trephine for large-diameter iliac biopsies in dogs. Calcif Tissue Int 29:71-3.

9.         Smith R, Byers P 1967 Trephine for full-thickness iliac-crest biopsy. Brit Med J 1:682-3.

10.       Williams JA, Nicholson GI 1963 A modified bone-biopsy drill for outpatient use. Lancet 1:1408.

11.       Meunier P, Vauzelle JL, Vignon G 1968 La lecture quantitative de la biopsie osseuse. Moyen de diagnostic et d'etude des osteoses decalcifiantes diffuses. Rhumatologie 20:301-12.

12.       Chappard D, Alexandre C, Bousquet G, Riffat G 1983 Nouvelles modifications du trocart de Bordier pour la biopsie osseuse. Rev Rhum Mal Osteoartic 50:307-8.

13.       Trueba D, Sawaya BP, Mawad H, Malluche HH 2003 Bone biopsy: indications, techniques, and complications. Semin Dial 16:341-5.

14. Audran M., Maury E., Bouvard B., Legrand E., Baslé M.F., Chappard D. Is trans-iliac bone biopsy a painful procedure? Clin Nephrol 77, 97-104, 2012.

 

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