Bone Biopsy:Bone Biopsy:Review of Indications, Review of Indications,

Procedure & Clinical UtilityProcedure & Clinical Utility

November 18, 2011November 18, 2011David David VaziriVaziri, MD, MD

Trephination of BoneTrephination of BoneFrom Latin From Latin trypantrypan, , meaning to boremeaning to boreThe act of obtaining a The act of obtaining a cylindrically shaped core cylindrically shaped core of bone that can be used of bone that can be used for tests and bone for tests and bone studies, cutting holes in studies, cutting holes in bones or for cutting out a bones or for cutting out a round piece of the cornea round piece of the cornea for eye surgery.for eye surgery.–– http://http://en.wikipedia.org/wiki/en.wikipedia.org/wiki/

TrephineTrephine

Bone Biopsy: IntroductionBone Biopsy: Introduction

Trephination of boneTrephination of boneDiagnostic tool to assess static and Diagnostic tool to assess static and dynamic parametersdynamic parametersAssess effects of new medicationsAssess effects of new medications““Gold StandardGold Standard”” in evaluation of Metabolic in evaluation of Metabolic bone disordersbone disorders

Bone Biopsy: IndicationsBone Biopsy: IndicationsOsteoporosisOsteoporosisOsteomalaciaOsteomalaciaHyperparathyroidismHyperparathyroidismRenal Renal OsteodystrophyOsteodystrophy--Chronic Kidney DiseaseChronic Kidney Disease–– Predominant HyperparathyroidismPredominant Hyperparathyroidism–– Low turnover diseaseLow turnover disease

OsteomalaciaOsteomalaciaAdynamicAdynamic bone diseasebone disease

–– Mixed Uremic Mixed Uremic OsteodystrophyOsteodystrophyBone painBone painFracturesFractures

Bone BiopsyBone Biopsy

Skilled PhysicianSkilled PhysicianAdequate sampleAdequate sampleProper instrumentsProper instrumentsLabeling with bone markersLabeling with bone markers

Bone biopsy: LabelingBone biopsy: Labeling

Bone turnoverBone turnover–– Rate of bone formation and mineralizationRate of bone formation and mineralization–– Double labeling Double labeling

Tetracycline Tetracycline -- Days 1 & 2Days 1 & 2DeclomycinDeclomycin -- Days 12Days 12--1414Bone harvest Bone harvest -- Day 20Day 20

Double LabelingDouble Labeling

Tetracycline doubleTetracycline double--labeling at the bonelabeling at the bone--osteoidosteoidinterface. Two regular distinct labels. The outer golden interface. Two regular distinct labels. The outer golden yellow label represents administration of yellow label represents administration of declomycindeclomycin; ; the inner greenish layer represents administration of the inner greenish layer represents administration of tetracycline.tetracycline.

Bone Biopsy: ProcedureBone Biopsy: Procedure

OR / OfficeOR / OfficeGeneral or Local General or Local AnesthesiaAnesthesiaDonor Site Donor Site –– Iliac Iliac CrestCrest–– Anterior vs. PosteriorAnterior vs. Posterior–– Vertical vs. HorizontalVertical vs. Horizontal

Bone Biopsy: ProcedureBone Biopsy: Procedure

InstrumentationInstrumentation–– Manual vs. Electric Manual vs. Electric

DrillDrill

Specimens x 2Specimens x 2–– 55--8 mm 8 mm diamterdiamter–– 1.51.5--2.5mm length2.5mm length

Storage in 100% Storage in 100% Ethyl AlcoholEthyl Alcohol

Bone Biopsy: ConstraintsBone Biopsy: ConstraintsPainful, InvasivePainful, InvasiveCostlyCostlyLimited number of centers to analyzeLimited number of centers to analyzeDelay in Delay in interpretationinterpretationLimited understanding of resultsLimited understanding of results

Bone Biopsy: ComplicationsBone Biopsy: Complications

InfectionInfectionHematomaHematomaNeuropathyNeuropathyHip FractureHip FractureOsteomyelitisOsteomyelitis

Bone Biopsy: PitfallsBone Biopsy: Pitfalls

Poor SpecimenPoor SpecimenPatient Body Patient Body HabitusHabitusInappropriate Specimen HandlingInappropriate Specimen Handling

Bone Biopsy: Clinical UtilityBone Biopsy: Clinical Utility

OsteopeniaOsteopenia. . TrabeculaeTrabeculae cut perpendicularly to their long axis. cut perpendicularly to their long axis. Reduced connectivity between Reduced connectivity between tradculaetradculae..

OsteopeniaOsteopenia

Low Turnover Low Turnover OsteopeniaOsteopeniaAbsence of Absence of osteoblastsosteoblasts, , osteoblaseosteoblase, , osteoidosteoid and and resorptionresorptionzoneszones

High Turnover High Turnover OsteopeniaOsteopeniaHigh fraction of High fraction of trabeculartrabecular surface surface covered by covered by osteoidosteoid and presence and presence of numerous of numerous osteoblastsosteoblasts covering covering the the osteoidosteoid seam.seam.

Bone Biopsy: Clinical UtilityBone Biopsy: Clinical Utility

OsteomalaciaOsteomalaciaExcessive accumulation of Excessive accumulation of osteoidosteoid and and

increased width of increased width of steoidsteoid seams.seams.

Bone Biopsy: Clinical UtilityBone Biopsy: Clinical Utility

HyperparathyroidHyperparathyroid bone diseasebone diseaseAppearance of woven Appearance of woven osteoidosteoid. .

HyperparathyroidHyperparathyroid bone diseasebone diseaseIncrease in number of Increase in number of osteoclastsosteoclastsand increased extent of and increased extent of trabeculartrabecularsurface exhibiting surface exhibiting resorptionresorptionlacunae. Increased density of lacunae. Increased density of osteocytesosteocytes. Marrow fibrosis.. Marrow fibrosis.

Bone Biopsy: Clinical UtilityBone Biopsy: Clinical Utility

Renal Renal OsteodystrophyOsteodystrophyPredominant Predominant hyperparathyroidhyperparathyroid bone disease. High bone disease. High fraction of fraction of trabeculartrabecular surface covered by surface covered by osteoidosteoid seams. seams. High High osteoidosteoid--osteoblastosteoblast interface. High boneinterface. High bone--osteoclastosteoclastinterface with appearance of tunneling interface with appearance of tunneling resorptionresorption. . Marrow fibrosis.Marrow fibrosis.

SummarySummary

Bone biopsy with Bone biopsy with morphometricmorphometric analysis is the analysis is the best method to assess metabolic bone disorders best method to assess metabolic bone disorders and to guide clinical management. and to guide clinical management. The procedure is safe and tolerated well by The procedure is safe and tolerated well by patients.patients.Research to develop nonResearch to develop non--invasive serum or invasive serum or bone markers have not proven to be specific or bone markers have not proven to be specific or sensitive enough at this point in time. sensitive enough at this point in time.

Thank You!Thank You!Happy Thanksgiving!Happy Thanksgiving!