Chapters Transcript Video Case Studies: Powered Bone Biopsy System (Clavicle, Fibula Head, and Scapula) Duration: 16:10 minutes Case Studies: Powered Bone Biopsy System (Clavicle, Fibula Head, and Scapula); So my first case is that of a 64 year old male who had a very complex medical history including hepatitis C cirrhosis. He was in liver liver failure from that. He also had hi palliative cellular carcinoma. Was in chronic renal disease, also had additional prostate carcinoma and he was undergoing liver transplant evaluation. He was currently admitted at the time that I saw him uh to the hospital for rib pain after sustaining a fall, the bone scan during this admission showed a focal area of uptake along the medial aspect of the clavicle that was concerning for metastatic disease. Um particularly because he remember he has two cancers prostate carcinoma and hepatocellular carcinoma. And thus, he was indicated for an image guided uh left clavicle bone biopsy to try to figure out uh number one, is this a malignant lesion from a metastatic lesion? And number two, if it is, is it from his prostate carcinoma or is it from uh his hepatocellular carcinoma or is it from some other uh cancer as well? So, here was the initial bone scan and you can see see there the area of uptake shown by the blue arrow at the medial aspect of the left clavicle, we see two other foi of uptake along the left sided ribs. There, those turned out to be rib fractures which were sustained from his fall and which were the area of his pain. But it was this area of uptake along the medial aspect of the clavicle that was concerning. Here's the ct chest again showing uh the area um in of concern that corresponds to the area of uptake uh shown by the blue circle. There. You see it's a somewhat mixed lytic sclerotic lesion um has somewhat of a sclerotic border here, no expansion, no pathologic fracture. Um But it's somewhat of an ill defined non-specific lesion at this point. And then here you can see the uh the biopsy, the bone biopsy using a power drill device here. And you can see the trajectory chosen for this approach was quite uh oblique here. And that was purposely done because remember we have some vital very critical structures here in the media stum, the trachea, we have the um uh large blood vessels. Uh We have the apex of the lung under here which is nearby. So we want to come from a kind of an oblique approach as as possible. Also notice here that the we're dealing with a very tight space at the base of the neck here. So when you have the bone drill in this location, we have to um uh put it in a certain orientation that uh we, we have to get into this tight space basically. And so this is as far oblique as we could come. And you can see the needle here, there is some expected streak artifact, but you can see the lesion um around the needle there. This turned out to be lamellar bone with interstitial fibrosis. So, a fibro osseous lesion was how it was actually ended up being signed out as and it was negative for carcinoma. So this uh patient luckily was able to stay on the transplant list. Potential complexities with this particular case were number one, this is a very um sick patient. He was in the intensive care unit. Anytime we're doing a bone biopsy on an intensive care unit patient, it comes with its own inherent complexities and difficulties. His complex medical history with liver failure made him at risk for increased bleeding. I believe his platelets were on the order of 10 to 15 at the time of the biopsy. Um he was uh at risk for infection due to his immunocompromised state, of course, and I didn't mention before but uh right before they sent him down for the biopsy, they called him and said, oh, by the way, he has an intractable cough that we cannot suppress. Um So that also made it a little bit more, a lot more difficult causing lots of respiratory motion um during the biopsy as he continued to cough. Um as I mentioned before, we were dealing with the location of this lesion at the medial aspect of the left clavicle. Um So it's a tight biopsy space at the base of the neck. And of course, the nearby critical structures um also made it very complex and difficult with the lung there, the trachea, the brachial plexus somewhat nearby. Um which is why we chose that lateral to medial approach rather than a medial to lateral approach. And then of course, those subclavian vessels and nerves and all the vessels in the mediastinum. OK. So let's move on to our next case. And at the end, I'm gonna tie all these together with some further uh highlights. So the next case is that of a 27 year old male who had a recent lacrosse injury, uh where he hyperextended his knee and felt a pop. His initial MRI demonstrated a complete tear of his anterior cruciate ligament. But on that, MRI, it was noted that he had an incidental expansile lesion in the proximal fibula. So here is the MRI, the image on your left, the sagittal image showing the complete tear of the anterior cruciate ligament. And on the coronal image on the image on your right, the blue arrow pointing to that lesion that was picked up somewhat expansile lesion here um with a somewhat hyper intense uh heterogeneous uh internal center and a relatively narrow zone of transition which you can better appreciate on the radiographs that you see on the right there um a very narrow zone of transition, a sclerotic rim expansile lesion, not much of a matrix there. We don't see really any uh calcifications or ossification within the lesion itself, but it looks like it's expansile and um and it has a very nice sclerotic rim. And then just another SAG image, a PD image also showing you the lesion or the, the mass there, a low signal rim corresponding to the sclerotic rim and it is expansile. So we chose to use a powered bone uh uh needle biopsy device. And you can see here the posterior approach with the introducer needle here and then you can see here the biopsy needle going through the coaxial introducer needle. And you see our uh our biopsy device here within the lesion there at the posterior aspect of the proximal fibula. Um the uh structures here that we needed to avoid were the common perineal nerve which you can't really see well in this image, but it has already passed around the fibular head. Remember that comes very superficial around the fibular head and of course, you will have a little bit more proximately, the the popliteal vessels that are gonna continue distally and branch off including the nerves in the in the distal popliteal fossa. The final diagnosis here turned out to be fibrous dysplasia. So the potential complexities in this case that we had to be uh cognizant of or the fact that it's a lyric a lytic lesion which can often make it make it difficult to obtain an intact core biopsy. Um The relatively small rounded bone at the fibular head um can also make it difficult because we could slip off the bone when the, when bones are rounded, obviously. So we want need something that's gonna give us nice control and purchase into that rounded bone. And then, as I mentioned before, the most critical structure in that area was the common perineal nerve which we had to avoid um and make sure that we didn't slip off and hit that common perineal nerve. OK. Let me go through the last case and then I'll tie them all together with a couple last slides. After that, this case is that of a 39 year old female who uh had shoulder pain for about a year, but it had been worsening recently. Uh with limited range of motion. She had actually seen many physicians before she came to our institution and referred, was referred to us for further work up and was referred to us actually to get an image guided uh uh biopsy. So here are the initial radiographs. Um You can see here the blue arrows pointing to the lesion which is a, a dense mass, uh relatively calcified, I would say, um it's very large, it's overlying the scapula coming underneath the corro likely in the subscapular recess area and extending in here into the axillary recess sort of outlining that. So we see another focus out laterally here. So you get the sense that this could be an intra-articular mass. And then here are some other images from the, from an initial MRI showing similar findings, the mass relatively low signal or predominantly a low signal mass with intervening areas of hyperintense T two signal. And again, it sort of follows the intra-articular portion, expanding the capsule here coming underneath. Uh you can't see it too well in this. But the aid and into the axillary recess seen better on the image on your right, probably the mass is also composed of these um kind of oddly shaped low signal structures. Um And you can see them kind of infiltrating. But I think the MR images in combination with the X ray images uh show that this is probably a synovial based intra-articular mass. So here's the CT uh from the same mass obviously. And you can see here again, this uh relatively calcified large mass, we can see that it's caused some chronic bony remodeling along the humeral neck here. So we know it's been around for a long time. Um And we can see it's a predominantly intra-articular mass, probably obviously extending outside but predominantly intra-articular. But note here, the red arrows which are gonna be important when we plan our biopsy because these are pointing to the sub clavia brachial vessels that are really coming right over the area where we're gonna probably want a biopsy. So the approach, we want to take an anterior approach here to get into the, the major portion of the mass. But um you know, you could potentially go posteriorly here, but the majority of it is anteriorly. So we wanna have something that's gonna give us a lot of confidence and control and getting in there so that we don't damage any vessels um in that uh in that area. So here is our approach, you can see the uh the introducer needle um and the uh biopsy needle, which is coaxial through that. And the biopsy tip here extending into the mass. You can see um we've avoided the vessels, which this is on a bone window, so you don't see them as well. But the red is pointing to those major vessels that we're avoiding right here. Um And we're directly into the mass in that location. This turned out to be synovial chondroma tosis, which is a benign entity. Now, the potential complexities in this case were number one, we identified early on as I tried to show you that this was a synovial based intra-articular mass. Now, common teaching is that you, you don't wanna ever violate the sy the intra-articular portion when you're doing biopsies. But because this was located inside of the joint, we had to go through the joint, but we do need to be cognizant of that and try to limit our like passes that we do through the joint and sort of limit potential, any potential spread through a. So we want to be quite careful that this was an intra-articular mass and sometimes intra-articular masses can be somewhat mobile. Um So we need to be uh sort of careful that we want something with good control. And then, of course, in this particular case, there were some nearby critical structures that I showed you that were draping over the area, um particularly the subclavian vessels and nerves. Ok. So let's just finish up here and try to tie all these together with some uh clinical considerations regarding device selection. And I'll use these three places to sort of highlight uh some of these clinical considerations. So the first consideration that I usually have is noise. All most all I would say the majority of our uh bone biopsies are done with moderate sedation. So these patients are sedated, but they're awake, you can talk to them, you know, depending on how deep you get the sedation. Um But you know, we try to, you know, limit the amount of sedation. So they're not too sedated, get like a nice happy medium, but usually they're awake and able to, to uh kind of talk to you. Um And so they can hear things they can hear. As doctor Doshi had mentioned earlier, they can hear the drill that can be quite frightening to them. They could jump and move if they're not aware that it could be occurring and sometimes afterward, they could say, oh, I heard all this, you know, construction noise going on in the biopsy, what's going on here. So you wanna be uh noise is a big factor when you're dealing with, you know, powered bone drill systems. And the quieter operation of this system is quite beneficial um as it does have a quieter operation than first generation power driven devices. And this is particularly important with, with the first case that I showed you. And the last case that I showed you because those are being done in the upper extremities and in the neck area, we're closer to the ears and the head and neck area. So patients are gonna hear the drill more when you're dealing in that area, particularly that first case because I had that, that um biopsy power biopsy device right at the base of the neck, right close to the patient's ear. So that was quite important to have something, you know, much quieter uh for that particular case. And for all cases in general control and better purchase is always something that we need to consider because we want to be able to control what we're doing in a, in a, in a nice fashion so that we have confidence and we're not gonna slip off any structures and damage any other structures. And that and that becomes important when we need to get purchase on to the bone, when we're dealing with a rounded bone or a bone that's near a AAA critical structure. And the features that help with this are the variable speed technique because we can control the speed of the drill. So when we hold it uh very lightly or onto the trigger, we're gonna have a slow speed as we get purchased into the bone. And then as we hold it down further, we can get uh uh more power as it drills faster. And then there's the threaded needle introducer threads on the end of the needle that can also help with getting better control and better purchase. This feature was particularly helpful with all the cases, but particularly in these cases, the medial clavicle case um where it was again near critical structures. Um And we're dealing with a curved bone in that area, the small rounded bone in the fibula that I showed you. Also, these, these features are very important, the variable speed um and the threaded needle portion. Um because again, as I mentioned before, a rounded bone, it's very easy to slip off of it. And then for the last case, the intra-articular mass, as I mentioned before, these can be mobile if you're dealing with a mobile mass, um you want to be able to get really good confident control and purchase as you get into the mass so that the mass doesn't just push away from you before you actually get into it. And lastly, the lightweight ergonomic features of uh uh bone drill system is quite, quite important. Um That's important with any bone biopsy that we're doing in these examples that I showed you, it was particularly important for that medial clavicle case because as I mentioned before, we're up in that tight space. And when I, when, when I had a compact drill system, I could turn the drill almost 90 degrees to get into that uh next space and come perpendicular to the curved portion of the medial clavicle, which was quite important for the safety of the procedure and the success of the procedure. Thank you very much. Published November 1, 2024 Created by
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