title: Utility of routine biopsy at vertebroplasty in the management of vertebral compression fractures: a tertiary center experience.
abstract: OBJECTIVE
  The authors assess the utility of routine biopsy at vertebroplasty for vertebral compression fracture (VCF) as a tool in the early detection of malignancy in presumed benign VCF.
  
  
  METHODS
  A prospective observational study was conducted on a cohort of consecutive patients undergoing vertebroplasty over a 5-year period between April 2006 and March 2011 at the Royal London Hospital. Polymethylmethacrylate cement injection was used in every procedure. Intraoperative vertebral body biopsy was performed routinely at every level of VCF. Pain visual analog scale (VAS) scores, Oswestry Disability Index (ODI) scores, analgesic usage, and complications were recorded preoperatively and at 1 day, 1 week, 1 month, 6 months, and 1 year postoperatively.
  
  
  RESULTS
  A total of 202 levels were augmented in 147 patients. The most common levels augmented were T-12 (17%), L-1 (18%), and L-4 (10%). Analysis of 184 routine vertebral biopsies in 135 patients revealed that in 86 patients with presumed osteoporosis and no prior cancer diagnosis, 4 (4.7%) had a malignant VCF. In 20 known cancer patients presumed to be in remission, 2 (10%) had a malignant VCF. Routine vertebral biopsy returned an overall cancer diagnosis rate of 5.5% (6 of 109) when combining the 2 groups (patients with no prior history of cancer or cancer thought to be in remission). In these 6 patients, history, examination, laboratory tests, and preprocedure imaging all failed to suggest malignancy diagnosed at routine biopsy. Significant reductions in pain VAS and ODI scores were evident at Day 1 and were sustained at up to 1 year postoperatively (p < 0.001). They were not dependent on the level of fracture (T3-10, T11-L2, or L3-S1) (p > 0.05), number of levels treated (single level, 2 levels, or > 2 levels) (p > 0.05), or etiology of VCF (p > 0.05). The complication rate was 6% (9 of 147). There were 5 deaths, none of which were directly related to surgery.
  
  
  CONCLUSIONS
  Routine vertebral biopsy performed at vertebroplasty may demonstrate cancer-related VCFs in unsuspected patients with no previous cancer diagnosis or active malignancy in patients previously thought to be in remission. This early diagnosis of cancer or relapsed disease will play an important role in expediting patients' subsequent cancer management. In cases of multiple-level VCF, the authors advocate biopsy at each level to maximize the diagnostic yield from the specimens and to avoid missing a malignancy at a single level.
authors.affiliation: Department of Neurosurgery, Royal London Hospital, London ; and.
authors.forename: Soumya
authors.initials: S
authors.lastname: Mukherjee
authors.forename: Bhaskar
authors.initials: B
authors.lastname: Thakur
authors.forename: Dolin
authors.initials: D
authors.lastname: Bhagawati
authors.forename: Dimpu
authors.initials: D
authors.lastname: Bhagawati
authors.forename: Samira
authors.initials: S
authors.lastname: Akmal
authors.forename: Vasileios
authors.initials: V
authors.lastname: Arzoglou
authors.forename: John
authors.initials: J
authors.lastname: Yeh
authors.forename: Habib
authors.initials: H
authors.lastname: Ellamushi
mesh_terms: D000293:Adolescent; D000368:Aged; D000369:Aged, 80 and over; D001706:Biopsy; D001843:Bone Cements / Q000627:therapeutic use; D004185:Disability Evaluation; D005260:Female; D050815:Fractures, Compression / Q000209:etiology / Q000473:pathology* / Q000601:surgery; D006801:Humans; D008297:Male; D008875:Middle Aged; D010147:Pain Measurement; D019904:Polymethyl Methacrylate / Q000627:therapeutic use; D011446:Prospective Studies; D016103:Spinal Fractures / Q000209:etiology / Q000473:pathology* / Q000601:surgery; D013125:Spinal Neoplasms / Q000150:complications*; D062606:Tertiary Care Centers; D016896:Treatment Outcome; D054854:Vertebroplasty
chemical_list: D001843:Bone Cements; D019904:Polymethyl Methacrylate
keywords: EPR = electronic patient records; LDH = lactate dehydrogenase; ODI = Oswestry Disability Index; VAS = visual analog scale; VCF = vertebral compression fracture; malignancy; oncology; osteoporosis; vertebral body biopsy; vertebral compression fracture; vertebroplasty