0:00

So let's look at a video of ir guided for

0:03

table biopsy.

0:05

So we have a 44 year old male with history of Ivy drug

0:08

use hepatitis C not presenting to the emergency room

0:11

with two days of worsening back pain and chills. So the patient was admitted

0:14

two months prior actually for similar pain that was diagnosed at

0:17

that time with thoracic spinal osteomyelitis slasheditis.

0:20

So he had no

0:23

end to desectomy with Fusion at that time. But since then has

0:26

had some aching back pain with cycles of fever and chills. So

0:29

when he presidents the emergency room what we

0:32

see is a temperature of 102 degrees Fahrenheit physical examination

0:35

was noted for limited range of trunk mobility

0:38

and pain to palpation over Tha slash

0:41

T9 vertebra. So the white count on this

0:44

patient actually is particularly elevated 12,000 the

0:47

urethral site that a meditation rate the

0:50

ESR was actually elevated 39 as was the

0:53

sea reactive protein at 16.4.

0:56

Surgical biopsy specimen from the patient's prior Mission

0:59

actually demonstrated the bacteria. That was

1:02

particularly concerning.

1:04

But the team was a little unclear if this might

1:07

be a contaminant versus cause of the spinal

1:10

infection. So what do we do in this particular

1:13

setting Imaging actually was then employed an

1:16

MRI specifically of the thoracic spine

1:19

with and without contrast was then ordered so in the

1:22

reading room, what do we see?

1:27

So on this T2 enhanced image we see

1:30

evidence of discitis and

1:33

osteomyelitis as evidenced by Maru edema

1:36

at the level of T8 and T9. We see

1:39

near complete loss of this space

1:42

height secondary to obliteration of the end plate

1:45

and the disc and these are findings highly suspicious

1:48

for the skydeus austinitis in the setting

1:51

what's even more concerning is that there's some hansing inflammatory tissue

1:54

within the ventral epidural space that is

1:57

consistent with the flag one the inferior and

2:00

plate of T9, but there was not thought to be a drainable collection

2:03

Regional to this site.

2:05

So infectious disease specialists are

2:08

consulted and because of this recurrent awesome

2:11

myelitis slash the skydis and what they recommend is

2:14

a bone biopsy in order to guide antibiotic

2:17

selection, then the patient is sent for CT guided

2:20

procedure.

2:22

So, how do we approach this here? We see the Scout topograph to

2:25

the left of this patient. We see the hardware spinal

2:28

fixation Hardware in this

2:31

region just below the scouted region

2:34

prior to starting the procedure. One of

2:37

the things that we want to do is plan the biopsy route and so let's take

2:40

a look. So this is that initial slice that's looked

2:43

at on the Scout tomograph and a radio

2:46

pick marker has been placed as in the previous case. We

2:49

see the cranial card ad longitudinally

2:52

oriented radio pick lines, the third

2:55

medial radio pick marker is selected. And

2:58

what we do is we draw a line right from that

3:01

particular site to the area in

3:04

question. So the three separate

3:07

numbers we discussed before are again discuss now, we have

3:10

the depth of the lesion from that

3:13

great position.

3:15

The third medial marker to the intended

3:18

site in question. Once we then have

3:21

identified those two things the grid position the

3:24

depth of the lesion from the surface of the skin to

3:27

the lesion in question. We then identify what

3:30

slice in this case I 224 which

3:34

is that index CT slice, which the lesion is best

3:37

visualized. So what we do next

3:39

of the lesion depth we have that grid marking

3:42

and we have the actual CT slice.

3:45

So now we want to mark that on the patient's skin.

3:57

So we've marked it on the patient's skin nice Bullseye

4:00

for us to begin preparing to

4:03

perform our targeted tissue sampling

4:06

procedure.

4:09

Like before we want to make sure that we clean the skin

4:12

chlorhexidine cross hatching technique.

4:16

Once the skin is nicely cleaned. We

4:19

then proceed with our four towel

4:22

Border tomorrow after the skin has been

4:25

marked and protected one of the things that's also

4:28

done is once you clean the skin what should actually happen

4:31

as you clean it to the point where the skin marking is

4:34

actually blurred and so you use the

4:37

back portion of the sterile marker at this particular point and

4:40

just indent at that particular site to ensure

4:43

that that intersection of those marks is

4:46

seen which is the exact point that you want to begin your

4:49

access from

4:51

Sterile border is obtained.

4:59

And once that's in place we drape the patient.

5:02

In order to complete our sterile feel

5:05

preparation.

5:11

One part of the procedure is ensuring that the patients get the

5:14

local anesthesia. They deserve whether that be one percent

5:17

lidocaine slash ilocaine whether that be 2%

5:20

We want to make sure that we're using local anesthetic

5:23

at the skin and then deeper to the

5:26

site in question. And then now let's review our table.

5:29

So this is a little different than the previous

5:32

table where we use a side cutting needle and

5:35

we have a needle that's actually a bone biopsy

5:38

needle 11 engage or 13 gauge. We

5:41

have our sterile Mallet that's given to

5:44

us in a sterile container from the central processing

5:47

unit in the hospital, which is the same site that sterilizes

5:50

surgical equipment. We have our blunt style

5:53

land we have second plant or a bevel stylet

5:56

that is more directional and then within the

5:59

biopsy needle sense. Usually it's a diamond tipped biopsy needle

6:02

and then of course, we have our local anesthetic ready to

6:05

go.

6:06

As before the biopsy track

6:09

is anesthetized and the lidocaine needle is left in place to guide

6:12

the biopsy needle through the same puncture site.

6:15

And we position that so that it's right in plane with our

6:18

laser guide from the CT.

6:21

We then want to take control of the CT fluoroscopy

6:24

control in a sterile manner.

6:29

So as would have mentioned the needle is in place.

6:32

We see our laser marker guide from the CT on

6:35

the area that we would have marked on the needle

6:38

from The Hub to the shop marking showing that

6:41

we are nicely in plain in order to begin our procedure

6:44

and lo and behold we perform me CT fluoroscopy

6:47

at this particular level. And what do we see? We see

6:50

our needle the shaft in the patient rightly in

6:53

plain almost in a Costco transverse orientation

6:56

where we see the middle border

6:59

of the rib the transverse process in that

7:02

region of that cost to transverse joint. Are

7:05

we on track seems to be

7:08

So now the Radiology prepares the biopsy needle by marking the appropriate

7:11

depth on the needle. So if we would have obtained the depth from

7:14

the skin to the side in question, we then

7:17

want to take that same number and Mark that distance.

7:21

From the needle tip to where

7:24

that terminates on the shaft and what can be done is by

7:27

using a little marker external to the patient so we

7:30

know exactly when we've obtained that distance in

7:33

question.

7:34

And on this particular needle each of the

7:37

gradations the markings represent a centimeter so

7:40

we can even eyeball it from here if we knew what

7:43

the number is and know if the radiologist was on track, perhaps we

7:46

could even see it from the other side of the room.

7:48

So now with the radiologist does is takes the initial

7:51

lidocaine needle as a guide the biopsy needle is

7:54

introduced the protected biopsy track. The lidocy needle

7:57

is then removed.

8:00

So that little top suggests that Boone has

8:03

been hit and what we then do is then remove the lidocaine

8:06

needle which was our sounding needle to ensure

8:09

that we were in position.

8:10

So the patient is placed back in the CT

8:13

scanner. And what do we see? We see the laser marker from

8:16

the CT scan directly corresponding with the

8:19

Hub of the bone biopsy needle. This is the

8:22

shaft showing that we are on the intended course.

8:26

so once again

8:27

We perform the CT scan at that level

8:30

CG fluoroscopy. In this case. We see the needle external

8:33

to the patient the needle through the soft tissues power

8:36

spinal muscles and then into the area in question.

8:40

We then perform advancement of the needle

8:43

to the intended site. We're going

8:46

to watch that red marker on the shaft

8:49

the needle as the operator hammers the

8:52

needle in place Advanced that red marker

8:55

to the skin side.

9:00

So once that needle is Advanced

9:03

a bit check CT fluoroscopy to ensure

9:06

that we are advancing as suggested and

9:09

we're simultaneously visualizing that on our

9:12

CT scan.

9:14

Once we are at the point where we've broken into bone the

9:17

blunt style that's often removed. So usually that

9:20

is at the point where we entered into a place where

9:23

we safe to then continue the advancement

9:26

of the outer biopsy needle, which is actually what

9:29

captures the tissue so initially, we have

9:32

the outer biopsy needle and we have the inner

9:35

stylet, which is actually either the diamond tipped

9:38

or the bevel The Edge which is directional once we're

9:41

in appropriate position. We remove the sharp inner

9:44

Starlet and then we continue to advance with the outer needle

9:47

to the site in question.

9:50

Or holding on the needle to ensure that we don't dislodge it.

9:54

As we remove the inner skylight.

9:58

and then once we're in Striking Distance

10:01

We then Advance just the needle by itself so

10:04

that the tissue can be captured in

10:07

the bore of the needle.

10:09

stabilizing the needle with our hand

10:13

advancing until we get flush with that red

10:16

marker to the skin.

10:20

Once that's in place we have that red marker

10:23

by the skin.

10:24

The radiologist confirms that we are actually on target with the

10:27

needle tip.

10:28

Which we are.

10:30

And then what can then be done is applying a

10:33

syringe to the back portion of the Hub and

10:36

then aspirating on removal to

10:39

ensure that that tissue that's interrupt or

10:42

partially trapped in the needle

10:45

itself actually stays in the hub so that it can

10:48

then be harvested and removed from the body.

10:52

Oftentimes that's locked in place.

10:56

And then using two hands, we then sort

10:59

of Jimmy the biopsy needle out of

11:02

the bone.

11:03

through the track

11:05

ensuring that we do the safely.

11:08

Once the biopsy needle has been successfully and

11:11

safely removed. We can then deposit the contents of

11:14

that property needle in the sterile

11:17

container.

11:19

We can take whatever was in that syringe and

11:22

flush it in.

11:24

That's sterile area.

11:27

The next thing we do which is the most important portion is

11:30

now we want to capture that tissue. That

11:33

was actually the bone that we targeted that's

11:36

now trapped in the bone biopsy needle.

11:39

So now we want to replace the blunt style it

11:42

and we want to gently advance that out of the

11:45

biopsy needle so that we can capture that

11:48

tissue there. We see

11:51

the bone emanating from the tissue.

11:54

And then we drop it like so into that sterile

11:57

saline solution.

12:00

harvesting and submission to our on-site

12:03

nurse or our cytopathology team

12:08

As per usual we then apply manual pressure in

12:11

order to achieve hemastasis at our site and

12:14

then we seal the area off with a clean

12:17

sterile bandage.

12:20

So in conclusion, the patient's aspirin in this particular setting as

12:23

well as the core Rapture we're actually sent for one culture including

12:26

fungal and anaerobic evaluation and

12:29

about two weeks post procedure. There

12:32

was no observe growth in any of the tested organisms

12:35

per the Infectious Disease recommendations. The patient

12:38

was given a course of Ivy penicillin just as

12:41

empiric antibiotic coverage for that previously noted

12:44

bacteria in question on the culture results from its

12:47

prior admission.