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ORIGINAL ARTICLE Table of Contents   
Year : 2002  |  Volume : 36  |  Issue : 1  |  Page : 46-48
Role of fine needle aspiration cytology in vertebral body lesions


Departments of Orthopaedics and Pathology, Government Medical College, Patiala, India

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   Abstract 

To evaluate the role of FNAC in the diagnosis of vertebral body lesions, FNAC under image intensifier control was carried out on 25 cases in which the diagnosis was not clear on X-rays/ CT scan examination. Comparison was made between the provisional, cytological and the final diagnosis. The study confirmed the usefulness of FNAC in all regions of spine from C 6 to L 5 with accuracy of over 75%. The procedure was quick, inexpensive and could be performed as an outdoor procedure with minimal complications.

Keywords: Vertebral body tumours-FNAC

How to cite this article:
Aggarwal R, Bandlish U, Mahajan S, Gupta N, Rambani R. Role of fine needle aspiration cytology in vertebral body lesions. Indian J Orthop 2002;36:46-8

How to cite this URL:
Aggarwal R, Bandlish U, Mahajan S, Gupta N, Rambani R. Role of fine needle aspiration cytology in vertebral body lesions. Indian J Orthop [serial online] 2002 [cited 2014 Oct 1];36:46-8. Available from: http://www.ijoonline.com/text.asp?2002/36/1/46/35929

   Introduction Top


The diagnosis of an osseous lesion anywhere in the body requires a combined clinical, radiological and histopathological proof. In some cases e.g. Giant cell tumor or Osteogenic sarcoma, the clinical and radiological features are very typical and suggestive of the diagnosis, while in other cases, the radiological and clinical evaluation may be inconclusive. In both instances, a detailed cytological or histopathological study of the lesion is essential to confirm the diagnosis and to institute proper treatment. It is for this reason that biopsy is required.

Biopsy of an osseous lesion can be done by following methods: open or closed biopsy which could be a core biopsy using thick needle or fine needle aspiration cytology. The needle biopsy for the diagnosis of bone tumors was first attempted by Martin and Ellis. [1] Since then several important works have been published using 18 gauge or thicker needles. [2],[3],[4]


   Material and Methods Top


Twenty-five patients with vertebral body lesions were selected for the study in which the diagnosis was not clear on X-rays/ CT scan examination or the patients were poorly responding to the treatment being given to them. Children were excluded from the study as FNAC was done under local anesthesia. Detailed history and examination of each patient was noted. The patients were selected after detailed workup.

Fine needle aspiration from the affected vertebral body was done taking full aseptic precautions using pre-sterilized lumbar puncture needle no. 21 or 22 under image intensifier control. Most of the time the vertebra that was diseased was soft and could be easily penetrated. In those cases where it was not possible to penetrate, aspiration was done from paravertebral soft tissue. In sclerotic lesions a thicker needle may be used particularly if CT/MRI shows no paravertebral soft tissue mass. The procedure was different at different levels.

For D 2 to D 9 Thoracic Vertebrae

Patient was made to lie on the table. The spinous process of the vertebra to be aspirated was marked after identification. Area cleaned and under local anesthesia LP needle was inserted 4 cm from the midline at an angle of 35 degrees from the horizontal. Fluoroscopy was carried out to check the position of needle in the vertebral body. When the position was confirmed to be in the affected vertebrae, 10 ml sterilized syringe was attached to the LP needle and aspiration was obtained. The needle may have to be manipulated above or below the rib. Smears were made on plain glass slides and air-dried-for MGG (comprises of May & Grunwald's + Giemsa stain) staining. Some of the smears were fixed in ether alcohol mixture for H&E (Haemotoxylin and Eosin) staining.

For D10 to L 5 Vertebrae

The same technique as described above was used except that LP needle was placed at a point 6 5 cm away from the midline [Figure 1]

For Cervical Vertebrae

The cervical vertebrae can be easily approached through anterior triangle by retracting the neurovascular bundle posterolaterally [Figure 2].

The reports of the cytological examination were collected and analyzed after correlation with clinical finding and other investigations. The cytological picture was compared with the subsequent histopathological examination wherever possible.


   Observations Top


There were 16 males and 9 females with an average age of 57.4 and 41.4 years respectively (range 16 to 75 years). The aspiration was performed in dorsal spine in 12 cases, lumbar spine in 12 cases and cervical spine in one case. In the 25 aspirations performed MGG stain was used in 14 patients and H&E staining in 11 patients.

All cases tolerated the procedure well. No complication was noted in any of the patients. The overall accuracy was 76.2%. Four patients were lost to follow up and were excluded in calculating the accuracy rate. Nine patients had Caries spine, out of which 6 patients were either not on antitubercular treatment or <3 months on treatment at the time of FNAC. Three patients were poorly responding to treatment and FNAC was done to rule out malignancy. [Table 1] compares provisional diagnosis with the cytological diagnosis. Out of the total 21 cases considered in this study, there were 11 true positives, 5 true negatives and 5 false negatives. There was no false positive case in the entire series.


   Discussion Top


Vertebral column is the most common site for the metastasis and infectious lesions. Spinal tuberculosis is the most common form of extra pulmonary tuberculosis. Since the roentgenographic appearance of vertebral tuberculosis can be similar to that of pyogenic infection, histiocytosis x, fungal infection and neoplasm, histological confirmation is mandatory before an appropriate treatment is begun.

The disadvantages of open biopsy are well known. Mondal and Mishra [5] performed FNAC of spine under CT control in 112 lesions and found 54.3 % cases with metastasis and 21.4% cases with tuberculosis. The incidence of diseases affecting the spine in the present study is similar to Kishore et al [6] where a core biopsy needle was used.

Previously we were apprehensive of thicker needles in the thoracic spine because of fear of injury to the aorta and lungs but by using a thinner gauge needle this risk is minimized and even if the vessel gets punctured the size is too small to cause any clinical problem. Although it is difficult to puncture a normal vertebra with a narrow gauge needle but in most of the cases the vertebra in question is diseased and soft and can be penetrated without much difficulty. In some of the cases where the lesion is sclerotic the FNAC can be taken from paravertebral mass if the vertebra cannot be penetrated.

Various complications of core biopsy or FNAC from spine have been reported [7],[8] namely increase in neurological deficit, CSF leak, haematoma at the site of FNAC, local infection, fall in blood pressure, neurogenic shock. However in the present study, none of these complications were observed in any of the patients.

Fine needle aspiration cytology is a procedure highly underestimated. The procedure is quick and inexpensive and could be performed as an outdoor procedure. The procedure has almost no complications and over 75% positive results. This technique should be used more often than not in the cases where diagnosis is in doubt and there are financial constraints and where no further surgery is indicated after cytological confirmation. In some of the cases the FNAC can give definite diagnosis but by no means it can replace the usefulness and accuracy of the open biopsy. The study is just an example of using the FNAC in diagnosing spinal lesions where diagnosis is in doubt prior to open biopsy.

 
   References Top

1.Martin HE, Ellis EB. Biopsy by needle puncture and aspiration. Ann Surg 1930; 92:169.  Back to cited text no. 1    
2.Snyder RE, Coley BL. Further studies on the diagnosis of bone tumors by aspiration biopsy. Surg Gynecol Obstet 1945; 80: 517.  Back to cited text no. 2    
3.Hadju SI, Melamed MR. Needle biopsy of primary malignant bone tumors. Surg GynecolObstet 1971; 133:829.  Back to cited text no. 3    
4.Schajowicz F, Derqui JC. Puncture biopsy in lesions of the locomotor system. Review of results in 4050 cases including 941 vertebral punctures. Cancer 1968; 21 : 531-48.  Back to cited text no. 4    
5.Mondal A, Mishra DK. CT guided needle aspiration cytology (FNAC) of 112 vertebral lesions. Indian J Pathol Microbiol 1994; 37:255 -61.  Back to cited text no. 5    
6.Kishore LT, Gayatri K, Rao AS, Prasad BN. Percutaneous biopsy of vertebrae-preliminary report of 100 cases. Indian J Radiol Imag 1992; 2:133-38.  Back to cited text no. 6    
7.Moore TM, Meyers MH, Patzakis MJ, Terry R, Harvey JP. Closed biopsy of musculoskeletal system. J Bone Joint Surg [Am] 1979; 61-A: 375-79.  Back to cited text no. 7    
8.Fyfe IS, Henry APJ, Mulholland RC. Closed vertebral biopsy. J Bone Joint Surg [Br] 1983; 65-B: 140-43.  Back to cited text no. 8    

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Correspondence Address:
R Aggarwal
I-E New Lal Bagh Colony, Patiala
India
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    Abstract
    Introduction
    Material and Methods
    Observations
    Discussion
    References
    Article Figures
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