Image-Guided Percutaneous Spinal Biopsy: CT or C-Arm Guidance?

Abstract

Image-guided percutaneous spinal biopsy is a minimally invasive procedure for histopathological confirmation and/or microbiological assessment of spinal lesions. When considering image-guided percutaneous spinal biopsy, both computed tomography (CT) and C-arm guidance have their advantages and specific applications. CT provides high-resolution cross-sectional images, allowing for precise localization of lesions and thus, effective for biopsy of spinal lesions in complex anatomical locations (e.g., cervical and upper dorsal spine). However, patients may receive higher doses of radiation than those with C-arm. C-arm guidance offers continuous imaging, which can enhance needle placement accuracy and is typically associated with lower radiation exposure than CT. However, C-arm provides less detailed images compared with CT, especially for certain lesions, and can be more challenging for accessing certain spinal areas, especially in the presence of anatomical variations. The choice between CT and C-arm guidance often depends on the specific clinical scenario, the location of the lesion, and the preferences of the clinician. For lesions that are easily accessible (lumbar, lower dorsal spine) and require real-time monitoring, C-arm may be preferred. For deeper or more complex lesions, CT guidance often provides better visualization and accuracy. Ultimately, the decision should be tailored to each patient's needs and the expertise of the clinician. This review article aims to compare the use of CT and C-arm guidance in percutaneous spinal biopsy, focusing on their technical aspects, diagnostic accuracy, and safety profiles.

Keywords

CT-guided spinal biopsy - C-arm guided spinal biopsy - vertebral biopsy - transpedicular vertebral biopsy

Introduction

The technological advancements in magnetic resonance imaging (MRI) have increased our understanding of the nature of spinal lesions; still, biopsy is needed in most cases for histopathological confirmation and/ or microbiological assessment.[1] Historically, spinal biopsies were performed via open surgery, which involved increased morbidity, a higher risk of complications, extended hospital stays, and a greater likelihood of tumor spillage or contamination of adjacent tissues. In contrast, percutaneous spine biopsy offers advantages such as being minimally invasive with lower infection risk and “wound-related complications,” and it can usually be done on an outpatient basis with local anesthesia. Complication rates for percutaneous biopsy are much lower (1–3%) compared with open biopsy (16%).[1] [2] Common approaches for spinal biopsy include computed tomography (CT) and C-arm guidance, which enable precise needle placement. In this review article, we compare two different imaging guidance methods based on patient-related and technical factors.

Preprocedural Planning and Preparation

The planning for an image-guided spinal biopsy involves several critical steps to ensure the procedure's safety and efficacy. This includes assessing the patient's medical history, including their coagulation profile and any prior spinal procedures or surgeries; reviewing previous spinal imaging to identify the target lesion and nearby anatomy; and obtaining informed consent from the patient after explaining the procedure, risks, and benefits. Additionally, determining the optimal approach and trajectory for the biopsy needle based on the lesion's location and adjacent critical structures is essential.

Image-guided spinal biopsy is generally safe when performed by an experienced interventional radiologist; however, certain contraindications and considerations must be taken into account to ensure patient safety and minimize risks. Absolute contraindications include patient refusal or inability to provide informed consent, unstable vital signs or severe coexisting medical conditions that pose a high risk during the procedure, severe coagulopathy or bleeding disorders, and local skin infection at the biopsy site. Relative contraindications include lesions located near critical structures such as major blood vessels, the spinal cord, or nerve roots, pregnancy, and allergy to contrast media (if contrast-enhanced imaging is needed). Although major complications from the percutaneous biopsy are rare, they can include bleeding, infection, neurological compromise, pleural puncture, and lung injury, tumor seeding, technical failure, and the risk of sinus tract or fistula formation secondary to infection.[2] [3]

Imaging Review and Site Selection

Reviewing all pertinent imaging is essential in prebiopsy planning to optimize biopsy success. Lesion enhancement observed on both MRI and CT scans assists in identifying viable tissue for targeting. The increasing use of positron emission tomography in assessing and staging spinal lesions, especially malignancies, aids in pinpointing hypermetabolic areas that correlate with viable or hypercellular tissue, thus enhancing diagnostic accuracy ([Fig. 1]). CT angiography may be required if there is a risk of vascular injury during the biopsy procedure, particularly during cervical spine biopsies. In cases involving multiple lesions, selecting the safest and most accessible lesion while balancing procedural risk with diagnostic yield is critical.

Fig. 1 (A, B) A 34-year-old male with multiple avid lesions on positron emission tomography (PET); (A) lesion in the left sacral ala was chosen for biopsy (arrow); and (B) computed tomography (CT)-guided biopsy of the left sacral was performed which revealed lymphomatous infiltrate on histopathological evaluation.

The biopsy target is typically the hypermetabolic, enhancing, or most diffusion-restricting part of the lesion to increase the likelihood of obtaining a diagnostic specimen. Necrotic and cystic areas within the lesion are generally avoided. In cases where the lesion contains both soft tissue and bony components, sampling both may be necessary to acquire the complete histological spectrum. The type of lesion significantly affects diagnostic yield, with metastatic lesions yielding more than primary neoplasms and primary malignancies yielding more than benign lesions. Lesions characterized by osteolysis or a mix of osteolytic and sclerotic features typically have higher diagnostic yields than purely sclerotic lesions. Lesions associated with lower diagnostic yield include lesions having fibrous and collagenous matrix, nonneoplastic inflammatory lesions, and lesions having cystic spaces for example aneurysmal bone cysts and hemangiomas. The size of the lesion also affects diagnostic yield; lesions smaller than 2 cm. are associated with lower yield.[4] [5]

The needle trajectory should avoid crossing critical neurovascular structures, for example, exiting nerve roots, dural sac, and spinal cord, and must not pass through infected areas to prevent the unintended spread or seeding of infection.[5]

Patient Positioning

Achieving the desired trajectory for a biopsy requires careful consideration of optimal patient positioning. Patient comfort is paramount to ensure they can remain still and cooperative during the procedure, especially if it is performed under local anesthesia or conscious sedation. It is crucial to assess whether the patient can comfortably maintain a specific position for an extended period.

For thoracic, lumbar, and sacral spinal biopsies, patients are positioned prone. For cervical spine biopsies, the patient may be positioned prone, supine, or in lateral decubitus depending on the specific level being targeted. The choice of position is determined by the accessibility of the lesion and ensuring the patient's comfort and safety throughout the procedure.

Needle Selection and Technical Factors

Different types of needles used in biopsy procedures can be categorized into three main groups: “aspiration needles,” “core (cutting) needles,” and “trephine needles.” The choice of needle depends on factors such as the nature of the lesion (whether osseous or soft tissue) and its location.[6] [7] In fine-needle aspiration cytology, the interventionist typically uses a small needle bore (22–27 gauge) to obtain cytologic samples, which are mainly used to detect malignant cells or diagnose infections. As the sample size obtained by this method is typically small, this process suffers from lower diagnostic yield. Moreover, pathologists cannot comment on tissue architecture or histologic grade making it a less preferred method for diagnosing most musculoskeletal neoplasms.[7]

Core (cutting) needles are commonly used for lesions with accessible soft-tissue components. Samples obtained with this method generally preserve the tissue architecture and allow grading of musculoskeletal neoplasms. In cases where there is no accessible soft-tissue component and the bone cortex needs to be punctured to access the pathologic tissue, trephine needles come into the role. These needles are typically larger gauge needles and have a “serrated or saw-tooth” cutting edge. Larger bore needles are associated with an increased complication risk.

Utilizing a coaxial technique for biopsy allows multiple core samples to be obtained from one access point while minimizing damage to surrounding structures and enhancing patient comfort. The coaxial access needle can be used to control bleeding during the procedure by replacing the stylet between passes to ensure hemostasis and injecting autologous clots/gel foam or slurry.[7]

With the increasing demand for comprehensive testing of specimens, such as flow cytometry, immunohistochemistry, and chromosomal analysis, larger tissue volumes are now preferred. Therefore, core or trephine biopsy techniques are routinely employed to ensure adequate sample collection. Crush artifact refers to specimen damage during the biopsy procedure, which can be minimized by using a larger gauge needle to reduce tissue trauma.[7] In our institution, the minimum needle caliber used for soft tissue biopsies utilizing a core biopsy needle is 16 gauge, while 11 gauge is used for bone biopsies utilizing a trephine needle, or 13-gauge trephine needle for thinner pedicles and in pediatric patients. This ensures sufficient tissue sampling while balancing the risk of complications associated with larger needle sizes.

CT or C-Arm Guidance

CT-guided biopsy has become the preferred method for spinal biopsies due to its high safety and accuracy rates exceeding 90%, with complication rates typically ranging from 0 to 2%.[8] However, traditional CT imaging has drawbacks such as increased radiation exposure, longer procedural times, and limited real-time guidance capabilities, particularly in achieving a wide range of needle approach angles compared with C-arm. Axial imaging of the curved spine can pose challenges in achieving optimal needle trajectories toward lesions. Features like real or virtual gantry tilt can help address some of these limitations, but certain situations may still require craniocaudal tilt or out-of-plane imaging, complicating the procedure.[2]

C-arm guidance, when performed by experienced operators, offers advantages such as reduced radiation exposure and shorter procedural durations. However, it has limitations in visualizing soft-tissue structures and can be challenging in the complex anatomy of critical areas like the cervical and upper thoracic spine. It has proven efficacy in lower thoracic and lumbar biopsies. The development of CT-C-arm/C-arm cone-beam CT with flat panel detector combines the cross-sectional imaging capabilities of CT with real-time C-arm, enabling faster procedures and improved needle control during intervention. It allows a complete volumetric data set acquisition covering a large anatomic region of interest from which submillimeter isotropic reconstructions can be created. CT fluoroscopy also combines the advantages of cross-sectional imaging of CT and real-time tracking of fluoroscopy. Despite these benefits, CT-C-arm and CT fluoroscopy involve significantly higher radiation exposure than traditional C-arm. To mitigate this risk, thorough preoperative planning, adoption of low-dose protocols, and careful monitoring of radiation exposure are essential measures.

Lumbar Spine

The transpedicular approach is commonly used for lumbar vertebral biopsy, whether under CT or C-arm guidance, and is applicable across the spine where feasible to reduce risks associated with bleeding and unintended seeding ([Fig. 2]). However, the posterior-central aspect of the vertebral body can represent a “potential blind spot” with transpedicular approach, particularly under C-arm. C-arm is as effective as CT for performing transpedicular lumbar vertebral biopsy, and patient preparation remains consistent regardless of the imaging method used. Under CT guidance, the patient is positioned prone, and the area of interest is cleaned and sterilized. Initial scout images are acquired, followed by cross-sectional images covering the specific area of interest to minimize radiation exposure. The interventional radiologist reviews these images carefully to plan the entry site and needle trajectory, avoiding critical structures while precisely targeting the lesion within the vertebral body ([Fig. 3]). Multiple images are captured during needle advancement to confirm accurate positioning relative to the target lesion.[9]

Fig. 2 Schematic diagram demonstrates transpedicular (red arrow) and extrapedicular (blue arrow) approaches of lumbar vertebral biopsy.

Fig. 3 (A, B) A 24-year-old female with suspicion of infective spondylodiscitis; (A) changes of spondylodiscitis L4 vertebral body (arrow); (B) transpedicular lumbar biopsy with a trephine biopsy needle having a coaxial system was performed.

Under C-arm guidance, the target pedicle is identified using true anteroposterior (AP) and lateral views. The C-arm is rotated to bring the medial cortex of the target to the middle third of the vertebral body (barrel view). The vertebrae adopt a “Scottish dog” configuration, for end-on needle placement (ipsilateral oblique by 15–20 degrees). An optimal entry point is chosen, typically the center of the pedicle (Barrel view), and the needle is advanced under real-time guidance on lateral view. It is crucial to ensure the needle does not breach the medial border of the pedicle. Once the needle reaches the posterior border of the vertebral body on the lateral view, an AP image is obtained to confirm proper positioning within the pedicle. After that, the needle can be safely advanced with a cephalocaudal inclination to reach the target area within the vertebral body on lateral view ([Fig. 4]). After reaching the desired location, multiple tissue samples are collected from various angles or depths to ensure diagnostic adequacy. It is important to choose the trephine needle diameter relative to the pedicular size to avoid iatrogenic fracture during insertion.[7]

Fig. 4 (A, B) A 29-year-old male with chronic back pain and fever underwent a C-arm-guided L3 vertebral biopsy. (A) Left anterior oblique (patient prone) C-arm image of the lumbar spine demonstrates biopsy needle in end-on position over the left pedicle. (B) Lateral C-arm image of the lumbar spine demonstrates transpedicular vertebral biopsy using a trephine needle with a coaxial system.

When the transpedicular approach becomes difficult and nonfeasible due to circumstances like thin lumbar pedicles, or an open wound or scar in the posterior cutaneous or subcutaneous plane, a posterolateral extrapedicular approach can be used. In this technique, the needle trajectory is directed through the psoas muscle, or posteromedial to the psoas outside pedicle to access the vertebral body ([Fig. 5]). Care must be taken to avoid misdirection of the needle posteromedial toward the neural foramen and anteromedially toward the aorta/iliac arteries. However, this approach carries potential risks, including injury to the aberrant spinal artery or radicular artery, as well as an increased risk of retroperitoneal hematoma or pseudoaneurysm formation. It is important to note that this approach is not suitable for use under C-arm guidance.[9]

Fig. 5 Axial prone computed tomography (CT) image of D11 vertebrae having right pedicular erosion demonstrates the posterolateral approach of vertebral biopsy.

Dorsal Spine

For biopsy of lesions located in the dorsal spine, CT guidance is preferred over C-arm guidance, particularly in the upper dorsal spine, due to the proximity of critical structures such as the lungs, pleura, and aorta, which present significant challenges for selecting a biopsy approach. In the dorsal spine, needles can be approached through various methods, including transpedicular, transforaminal, or costotransverse approaches ([Fig. 6]).[10] The costotransverse approach is favored in the dorsal spine, with the inferior costotransverse approach used in the upper dorsal spine and the superior costotransverse approach employed in the mid and lower dorsal spine ([Fig. 7]). In this approach, the interventionist uses costotransverse space, a potential space between ribs and transverse process of the dorsal vertebra. This approach minimizes the risk of injury to the pleura and nerve roots; however, due to fixation of the needle in the space makes it difficult to change the needle trajectory, thus limiting the area available to sample.[9] This approach can become difficult to use in cases of costovertebral joint arthrosis.

Fig. 6 Schematic diagram demonstrates transpedicular (red arrow) and costotransverse (blue arrow) approaches of dorsal vertebral biopsy.

Fig. 7 (A, B) Axial prone computed tomography (CT) images of D4 vertebrae (A) and D10 vertebrae (B) demonstrate inferior costotransverse and superior costotransverse approaches of vertebral biopsy, respectively.

The lower dorsal vertebrae can be approached safely under C-arm guidance by experienced hands through transpedicular approach, provided the pedicular width is sufficient for the biopsy needle to pass safely without breaching to medial cortex of the pedicle ([Fig. 8]). However, in narrow pedicle, costotransverse approach can be employed. On the oblique C-arm view, the needle is targeted to the costotransverse joint lateral to the pedicle. Once the needle is fixed into the costotransverse space, and at the posterior vertebral margin on the lateral view, the fluoroscope is rotated to the AP view, to check the needle at the superolateral/lateral margin of the pedicle. The medial cortex of the pedicle should not be breached. The needle is then inserted into the vertebral body and tracked on the lateral view. After reaching the desired location, a biopsy is taken ([Fig. 9]).

Fig. 8 (A, B) C-arm images of the dorsolumbar spine demonstrate a biopsy needle in an end-on position over the left pedicle of D12 vertebrae on left anterior oblique projection (A), and a transpedicular approach of vertebral biopsy using a trephine needle on lateral projection (B).

Fig. 9 (A, B) C-arm images of the dorsal spine demonstrate a biopsy needle at the costotransverse joint of D7 vertebrae on left anterior oblique projection (A), and the costotransverse approach of vertebral biopsy using trephine needle on lateral projection (B).

For the lower dorsal spine, CT and C-arm both are considered safe. However, for upper dorsal vertebrae, CT is preferable to C-arm for vertebral biopsy.

Sacrum

For nearly all sacral lesions, a straightforward posterior or posterolateral approach using CT or C-arm is considered feasible and should be utilized whenever possible ([Fig. 10]). It is important to avoid transrectal and transabdominal approaches due to the significant risk of biopsy tract contamination and potential tumor seeding.

Fig. 10 Lateral C-arm image of sacrum demonstrates biopsy of S2 vertebrae.

Cervical Spine

For biopsies of lesions located in the cervical spine, it is recommended to use CT guidance rather than C-arm guidance to ensure precision and accuracy. Given the proximity of vital structures such as the carotid artery, vertebral artery, jugular vein, trachea, and esophagus, these procedures should always be performed by experienced professionals under CT guidance to minimize the risk of serious complications. Various approaches can be employed depending on the specific location of the lesion within the cervical spine, with the patient positioned supine, in lateral decubitus, or prone position. A small amount of nonionic intravenous iodinated contrast should be injected to highlight key vascular structures (carotid artery, jugular vein, vertebral artery) and prevent accidental vessel injury.

In the anterolateral/lateral approach, the biopsy needle is advanced anterior to the sternocleidomastoid muscle and posteromedial to carotid sheath and the trachea ([Fig. 11]). The right side is preferred to prevent injury to the esophagus. Through this approach, the interventionist can target the anterior aspect of the vertebral bodies, intervertebral discs, and transverse processes. In the posterolateral approach, the needle trajectory is through the sternocleidomastoid muscle and just posterior to the carotid sheath to target lesions involving lateral masses, pedicles, transverse processes, and lamina. Caution must be exercised as the vertebral artery is particularly vulnerable due to its passage through the transverse foramen ([Fig. 12]). The posterior approach can be used to target posterior element lesions by advancing the needle through the paraspinal muscles with caution to avoid penetrating spinal canal and dural lining.

Fig. 11 Schematic diagram demonstrating anterolateral/lateral (red arrow) approach of cervical vertebral biopsy.

Fig. 12 (A, B) Axial computed tomography (CT) image of the cervical spine demonstrates the right lateral approach of C5 vertebral body biopsy (A) and posterolateral approach of C2 posterior element biopsy (B).

The transoral approach can be used for lesions located in the C1 and C2 vertebrae. The needle is typically advanced through the posterior pharynx, retropharyngeal space, and prevertebral musculature to reach the bone avoiding critical neurovascular structures. Each of these approaches has specific considerations and potential risks, highlighting the importance of precise planning and execution under CT guidance to ensure the safety and efficacy of cervical spine biopsies.[9] [11]

In a systematic review and meta-analysis by Michalopoulos et al, CT-guided biopsies for spinal lesions demonstrated a “high diagnostic yield of 91%” and “diagnostic accuracy of 86%,” with a “low complication rate of 1%.” The diagnostic yield was consistent across different lesion locations, lesion types (lytic, sclerotic, mixed), and needle types (wide- and thin-bore).[8] Similarly, Daniels and Chazen reported comparable findings in their study.[12]

Zakaria Mohamad et al compared C-arm and CT-guided transpedicular biopsy for spinal lesions and found no statistically significant difference in accuracy (p = 0.731) and adequacy (p = 0.492) between the two methods.[13] Diffre et al evaluated disco-vertebral biopsy under C-arm versus CT guidance in patients with pyogenic vertebral osteomyelitis with negative blood cultures. They reported a higher yield (69.4%) under C-arm guidance compared with CT guidance (33.3%).[14]

Lee et al conducted a prospective randomized trial comparing C-arm and CT-guided biopsy techniques and found similar accuracy, procedure time, complication rate, and pain score between both groups.[15] Oka et al also reported no difference in diagnostic accuracy between C-arm and CT-guided biopsies.[16]

Mireles-Cano et al demonstrated an effectiveness of 83% for diagnosing vertebral destruction syndrome using transpedicular percutaneous biopsy guided by C-arm.[17] Overall, these studies highlight the efficacy and safety of both CT-guided and C-arm-guided biopsy techniques for diagnosing spinal lesions, with comparable diagnostic outcomes and complication rates.

Special Considerations

In cases of spondylodiscitis, a biopsy should be obtained from the endplate as well as the disc ([Fig. 13]). It is recommended to withhold antimicrobial therapy for up to 2 weeks to maximize microbiological yield, although this recommendation is based on limited literature. Targeting paraspinal fluid collections or soft tissue abnormalities for sampling, acquiring multiple core samples if possible, and using larger gauge needles can improve yield.[18] [19] The microbiological yield of repeat CT-guided biopsy for suspected infectious spondylodiscitis is generally low, with higher yield observed in younger patients not exposed to prebiopsy antibiotics.[20] Paravertebral soft-tissue changes, even in the absence of a paravertebral abscess, may be considered a viable target for biopsy in cases of spondylodiscitis.[21] Factors affecting microbiologic yield in CT-guided spine biopsies include the time from the initial referral of spinal symptoms to the procedure, with earlier biopsies in the acute phase of infection associated with increased yield. Needle size (11–13G vs. 16–18G) and site of biopsy (disc vs. bone vs. disc plus endplate) do not significantly affect yield. However, thin or degenerated intervertebral discs on MRI are negative factors for positive cultures.[22] Biopsies performed with handheld drill require less conscious sedation compared with manual biopsies and yield longer bone core specimens for histopathologic evaluation.[23] [24] For cystic osseous lesions, the conventional approach using a trephine or tru-cut biopsy needle often fails to provide sufficient samples, necessitating aspiration biopsy instead. To perform a successful aspiration biopsy, it is essential to extract the lesion's contents and scrape its walls. This process involves maintaining consistent negative pressure on the syringe, which can be challenging during bone biopsies where one hand must exert significant pressure on the plunger while the other manipulates the needle within the lesion. In such cases, a practical new method called the “needle cap technique” can be utilized, enabling the operator to work with both hands for better control and manipulation of the biopsy needle.[25]

Fig. 13 (A, B) Sagittal reconstructed computed tomography (CT) (A) and lateral C-arm (B) images of the lumbosacral spine of two different patients demonstrate endplate-disc complex biopsy through a transpedicular approach.

Postbiopsy Consideration and Handling of Samples

After completing the biopsy, the needle is withdrawn, and pressure is applied to the biopsy site to control bleeding, followed by the application of a sterile dressing. The patient is monitored briefly in the recovery area to ensure stability and detect any immediate postprocedure complications. Following a dorsal spine biopsy, a postprocedure CT scan of the lungs may be necessary if pneumothorax is suspected. The duration of postbiopsy observation varies depending on the procedure's invasiveness and whether sedation was used.

Institutions have varying protocols for handling specimens based on suspected diagnoses; it is crucial to communicate with the pathologist to ensure proper processing postcollection. Typically, specimens are placed in separate sterile containers with normal saline and formalin. Both saline and formalin containers are sent regardless of imaging findings to rule out atypical infection in suspected malignancies and potential malignancy in suspected infections.

Despite adequate preparation and technique, approximately 8 to 10% of biopsies yield nondiagnostic or insufficient samples.[18] After a negative result, one may consider repeating the percutaneous biopsy, attempting an open biopsy, targeting a different site, or opting to monitor the lesion with serial imaging. A multidisciplinary tumor board's input is essential for decision-making. For heterogeneous lesions or suspected infections, a repeat biopsy is often performed. In one study, a second needle biopsy provided a diagnosis in 60% of spondylodiscitis cases that initially had negative results. Generally, biopsy attempts are limited to three or four times due to low diagnostic yield beyond this threshold.[19]

Conclusion

In conclusion, image-guided percutaneous spinal biopsy, utilizing CT or C-arm guidance, is a highly effective and minimally invasive procedure for diagnosing spinal lesions. A comparative analysis between the two modalities is summarized in [Table 1]. Both imaging techniques offer distinct advantages depending on the location and complexity of the lesion. CT guidance excels in its accuracy and ability to visualize soft tissue, making it ideal for anatomically challenging regions such as the cervical and upper thoracic spine. On the other hand, C-arm guidance offers reduced radiation exposure and shorter procedural times, particularly in the lumbar and lower thoracic regions. When a lesion with both osseous as well as soft tissue components needs to be sampled, CT scores over C-arm. The choice between these two techniques is often guided by patient-specific factors, such as lesion location, proximity to critical structures, procedural risk, as well as the expertise of an intervention radiologist in using the particular modality. Regardless of the imaging modality, proper preprocedural planning, site selection, and needle technique are crucial for maximizing diagnostic yield while minimizing complications.

Table 1 A comparative analysis of CT- versus C-arm-guided spinal biopsy

	CT	C-arm
Plane of acquisition	Axial	End-on view, profile view, oblique view
Contrast resolution	High	Low
Real time monitoring	Limited	Yes
Radiation exposure	More	Less
Procedure time	More	Less
Lumbar spine biopsy	Both CT and C-arm are equally effective
Dorsal spine biopsy	CT is preferable than C-arm, particularly for upper dorsal spine
Cervical spine biopsy	CT is recommended
Sacral biopsy	Both CT and C-arm are equally effective

Abbreviation: CT, computed tomography.

Conflict of Interest

None declared.

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Artikel online veröffentlicht:
04. Juni 2025