Skip to main content

Review article: the current status of CT-guided needle biopsy of the spine


CT-guided percutaneous needle biopsy of the spine is a well-described technique for determining the nature of indeterminate vertebral lesions or establishing a diagnosis of spinal infection, the high diagnostic accuracy and the safety of the procedure having been extensively documented. The purpose of the current article is to review the literature to date on CT-guided spinal biopsy. Specifically, indications for spinal biopsy, techniques for optimising yield, detail of the approaches for various spinal levels which is dependent upon both the region within the spinal column and lesion location within the vertebra (body vs. neural arch), determinants of biopsy outcome and complications are covered. It is hoped that the review will be of particular benefit to junior radiologists who are required to perform this procedure.

This is a preview of subscription content, access via your institution.

We’re sorry, something doesn't seem to be working properly.

Please try refreshing the page. If that doesn't work, please contact support so we can address the problem.

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7
Fig. 8
Fig. 9
Fig. 10
Fig. 11
Fig. 12
Fig. 13
Fig. 14
Fig. 15
Fig. 16
Fig. 17
Fig. 18
Fig. 19


  1. 1.

    Ortiz AO, Zoarski GH. Image-guided percutaneous spine biopsy. Image-Guided Spine Interv. Berlin: Springer-Verlag; 2006. p. 69–93.

    Google Scholar 

  2. 2.

    Tehranzadeh J, Tao C, Browning CA. Percutaneous needle biopsy of the spine. Acta Radiol. 2007;48:860–8.

    CAS  PubMed  Google Scholar 

  3. 3.

    Gupta S. Biopsy of the spine. Percutaneous image-guided biopsy. New York: Springer; 2014. p. 313–33.

    Google Scholar 

  4. 4.

    Adapon BD, Legada BD, Lim EVA, Silao JV, Dalmacio-Cruz A. CT-guided closed biopsy of the spine. J Comput Assist Tomogr. 1981;5:73–8.

    CAS  PubMed  Google Scholar 

  5. 5.

    Ozsarlak O, De Schepper AM, Wang X, De Raeve H. CT-guided percutaneous needle biopsy in spine lesions. JBR-BTR. 2003;86:294–6.

    CAS  PubMed  Google Scholar 

  6. 6.

    Peh W. CT-guided percutaneous biopsy of spinal lesions. Biomed Imaging Interv J. 2006;2:e25.

    PubMed  PubMed Central  Google Scholar 

  7. 7.

    Rajeswaran G, Malik Q, Saifuddin A. Image-guided percutaneous spinal biopsy. Skelet Radiol. 2013;42:3–18.

    Google Scholar 

  8. 8.

    Heyer CM, Al-Hadari A, Mueller K-M, Stachon A, Nicolas V. Effectiveness of CT-guided percutaneous biopsies of the spine: an analysis of 202 examinations. Acad Radiol. 2008;15:901–11.

    PubMed  Google Scholar 

  9. 9.

    Rimondi E, Staals EL, Errani C, Bianchi G, Casadei R, Alberghini M, et al. Percutaneous CT-guided biopsy of the spine: results of 430 biopsies. Eur Spine J. 2008;17:975–81.

    PubMed  PubMed Central  Google Scholar 

  10. 10.

    Hua W-B, Wu Q, Zhang B, Yang S-H, Shao Z-W, Xu W-H, et al. Initial CT-guided percutaneous biopsy of vertebral lesions: evaluation of its diagnostic accuracy and clinical value. J Huazhong Univ Sci Technol Med Sci. 2015;35:569–73.

    Google Scholar 

  11. 11.

    Mauch JT, Carr CM, Cloft H, Diehn FE. Review of the imaging features of benign osteoporotic and malignant vertebral compression fractures. AJNR Am J Neuroradiol. 2018;39:1584–92.

    CAS  PubMed  PubMed Central  Google Scholar 

  12. 12.

    Leong S, Kok HK, Delaney H, Feeney J, Lyburn I, Munk P, et al. The radiologic diagnosis and treatment of typical and atypical bone hemangiomas: current status. Can Assoc Radiol J. 2016;67:2–11.

    PubMed  Google Scholar 

  13. 13.

    Gaudino S, Martucci M, Colantonio R, Lozupone E, Visconti E, Leone A, et al. A systematic approach to vertebral hemangioma. Skelet Radiol. 2015;44:25–36.

    Google Scholar 

  14. 14.

    Wang B, Zhang L, Yang S, Han S, Jiang L, Wei F, et al. Atypical radiographic features of aggressive vertebral hemangiomas. J Bone Joint Surg Am. 2019;101:979–86.

    PubMed  Google Scholar 

  15. 15.

    Grivé E, Rovira A, Capellades J, Rivas A, Pedraza S. Radiologic findings in two cases of acute Schmörl’s nodes. AJNR Am J Neuroradiol. 1999;20:1717–21.

    PubMed  PubMed Central  Google Scholar 

  16. 16.

    Hauger O, Cotten A, Chateil JF, Borg O, Moinard M, Diard F. Giant cystic Schmorl’s nodes: imaging findings in six patients. AJR Am J Roentgenol. 2001;176:969–72.

    CAS  PubMed  Google Scholar 

  17. 17.

    Rajakulasingam R, Saifuddin A. Focal nodular marrow hyperplasia: imaging features of 53 cases. Br J Radiol. 2020;93(1112):20200206.

  18. 18.

    Leone A, Cassar-Pullicino VN, Casale R, Magarelli N, Semprini A, Colosimo C. The SAPHO syndrome revisited with an emphasis on spinal manifestations. Skelet Radiol. 2015;44:9–24.

    Google Scholar 

  19. 19.

    Jurik AG, Klicman RF, Simoni P, Robinson P, Teh J. SAPHO and CRMO: the value of imaging. Semin Musculoskelet Radiol. 2018;22:207–24.

    PubMed  Google Scholar 

  20. 20.

    Morales H. MR imaging findings of Paget’s disease of the spine. Clin Neuroradiol. 2015;25:225–32.

    CAS  PubMed  Google Scholar 

  21. 21.

    Suh CH, Yun SJ, Jin W, Park SY, Ryu C-W, Lee SH. Diagnostic performance of in-phase and opposed-phase chemical-shift imaging for differentiating benign and malignant vertebral marrow lesions: a meta-analysis. AJR Am J Roentgenol. 2018;211:W188–97.

    PubMed  Google Scholar 

  22. 22.

    van Vucht N, Santiago R, Lottmann B, Pressney I, Harder D, Sheikh A, et al. The Dixon technique for MRI of the bone marrow. Skelet Radiol. 2019;48:1861–74.

    Google Scholar 

  23. 23.

    Gallucci PM, D’Orazio F. Image guided interventions in spinal infections. Neuroimaging Clin N Am. 2015;25:281–94.

    PubMed  Google Scholar 

  24. 24.

    Rehm J, Veith S, Akbar M, Kauczor HU, Weber MA. CT-guided percutaneous spine biopsy in suspected infection or malignancy: a study of 214 patients. Rofo. 2016;188:1156–62.

    CAS  PubMed  Google Scholar 

  25. 25.

    McNamara AL, Dickerson EC, Gomez-Hassan DM, Cinti SK, Srinivasan A. Yield of image-guided needle biopsy for infectious discitis: a systematic review and meta-analysis. AJNR Am J Neuroradiol. 2017;38:2021–7.

    CAS  PubMed  Google Scholar 

  26. 26.

    Sertic M, Parkes L, Mattiassi S, Pritzker K, Gardam M, Murphy K. The efficacy of computed tomography-guided percutaneous spine biopsies in determining a causative organism in cases of suspected infection: a systematic review. Can Assoc Radiol J. 2019;70:96–103.

    PubMed  Google Scholar 

  27. 27.

    Garg V, Kosmas C, Young PC, Togaru UK, Robbin MR. Computed tomography-guided percutaneous biopsy for vertebral osteomyelitis: a department’s experience. Neurosurg Focus. 2014;37:E10.

    PubMed  Google Scholar 

  28. 28.

    Sehn JK, Gilula LA. Percutaneous needle biopsy in diagnosis and identification of causative organisms in cases of suspected vertebral osteomyelitis. Eur J Radiol. 2012;81:940–6.

    PubMed  Google Scholar 

  29. 29.

    Gasbarrini A, Boriani L, Salvadori C, Mobarec S, Kreshak J, Nanni C, et al. Biopsy for suspected spondylodiscitis. Eur Rev Med Pharmacol Sci. 2012;16(Suppl 2):26–34.

    PubMed  Google Scholar 

  30. 30.

    Heyer CM, Brus L-J, Peters SA, Lemburg SP. Efficacy of CT-guided biopsies of the spine in patients with spondylitis--an analysis of 164 procedures. Eur J Radiol. 2012;81:e244–9.

    PubMed  Google Scholar 

  31. 31.

    Lis E, Bilsky MH, Pisinski L, Boland P, Healey JH, O’malley B, et al. Percutaneous CT-guided biopsy of osseous lesion of the spine in patients with known or suspected malignancy. AJNR Am J Neuroradiol. 2004;25:1583–8.

    PubMed  Google Scholar 

  32. 32.

    Feroz I, Makhdoomi RH, Khursheed N, Shaheen F, Shah P. Utility of computed tomography-guided biopsy in evaluation of metastatic spinal lesions. Asian J Neurosurg. 2018;13:577–84.

    PubMed  PubMed Central  Google Scholar 

  33. 33.

    Iizuka Y, Iizuka H, Tsutsumi S, Nakagawa Y, Nakajima T, Sorimachi Y, et al. Diagnosis of a previously unidentified primary site in patients with spinal metastasis: diagnostic usefulness of laboratory analysis, CT scanning and CT-guided biopsy. Eur Spine J. 2009;18:1431–5.

    PubMed  PubMed Central  Google Scholar 

  34. 34.

    Foreman SC, Schwaiger BJ, Gempt J, Jungmann PM, Kehl V, Delbridge C, et al. MR and CT imaging to optimize CT-guided biopsies in suspected spondylodiscitis. World Neurosurg. 2017;99:726–734.e7.

    PubMed  Google Scholar 

  35. 35.

    Braun A, Germann T, Wünnemann F, Weber M-A, Schiltenwolf M, Akbar M, et al. Impact of MRI, CT, and clinical characteristics on microbial pathogen detection using CT-guided biopsy for suspected spondylodiscitis. J Clin Med. 2019;9(1):32.

  36. 36.

    Spira D, Germann T, Lehner B, Hemmer S, Akbar M, Jesser J, et al. CT-guided biopsy in suspected spondylodiscitis--the association of paravertebral inflammation with microbial pathogen detection. PLoS One. 2016;11:e0146399.

    PubMed  PubMed Central  Google Scholar 

  37. 37.

    Kihira S, Koo C, Mahmoudi K, Leong T, Mei X, Rigney B, et al. Combination of imaging features and clinical biomarkers predicts positive pathology and microbiology findings suggestive of spondylodiscitis in patients undergoing image-guided percutaneous biopsy. AJNR Am J Neuroradiol. 2020;41:1316–22.

    CAS  PubMed  Google Scholar 

  38. 38.

    Diffre C, Jousset C, Roux A-L, Duran C, Noussair L, Rottman M, et al. Predictive factors for positive disco-vertebral biopsy culture in pyogenic vertebral osteomyelitis, and impact of fluoroscopic versus scanographic guidance. BMC Infect Dis. 2020;20:512.

    PubMed  PubMed Central  Google Scholar 

  39. 39.

    Chang CY, Simeone FJ, Nelson SB, Taneja AK, Huang AJ. Is biopsying the paravertebral soft tissue as effective as biopsying the disk or vertebral endplate? 10-year retrospective review of CT-guided biopsy of diskitis-osteomyelitis. AJR Am J Roentgenol. 2015;205:123–9.

    PubMed  Google Scholar 

  40. 40.

    Joo E-J, Yeom J-S, Ha YE, Park SY, Lee C-S, Kim E-S, et al. Diagnostic yield of computed tomography-guided bone biopsy and clinical outcomes of tuberculous and pyogenic spondylitis. Korean J Intern Med. 2016;31:762–71.

    PubMed  PubMed Central  Google Scholar 

  41. 41.

    Strauss SB, Gordon SR, Burns J, Bello JA, Slasky SE. Differentiation between tuberculous and pyogenic spondylodiscitis: the role of the anterior meningovertebral ligament in patients with anterior epidural abscess. AJNR Am J Neuroradiol. 2020;41:364–8.

    CAS  PubMed  Google Scholar 

  42. 42.

    Kasalak Ö, Adams HJA, Jutte PC, Overbosch J, Dierckx RAJO, Wouthuyzen-Bakker M, et al. Culture yield of repeat percutaneous image-guided biopsy after a negative initial biopsy in suspected spondylodiscitis: a systematic review. Skelet Radiol. 2018;47:1327–35.

    Google Scholar 

  43. 43.

    Pupaibool J, Vasoo S, Erwin PJ, Murad MH, Berbari EF. The utility of image-guided percutaneous needle aspiration biopsy for the diagnosis of spontaneous vertebral osteomyelitis: a systematic review and meta-analysis. Spine J. 2015;15:122–31.

    PubMed  Google Scholar 

  44. 44.

    Dumont RA, Keen NN, Bloomer CW, Schwartz BS, Talbott J, Clark AJ, et al. Clinical utility of diffusion-weighted imaging in spinal infections. Clin Neuroradiol. 2019;29:515–22.

    PubMed  Google Scholar 

  45. 45.

    Husseini JS, Simeone FJ, Nelson SB, Chang CY. CT-guided discitis-osteomyelitis biopsies: needle gauge and microbiology results. Skelet Radiol. 2020;49:1431–9.

    Google Scholar 

  46. 46.

    Pozzi G, Albano D, Messina C, Angileri SA, Al-Mnayyis A, Galbusera F, et al. Solid bone tumors of the spine: diagnostic performance of apparent diffusion coefficient measured using diffusion-weighted MRI using histology as a reference standard. J Magn Reson Imaging. 2018;47:1034–42.

    PubMed  Google Scholar 

  47. 47.

    Suh CH, Yun SJ, Jin W, Lee SH, Park SY, Ryu C-W. ADC as a useful diagnostic tool for differentiating benign and malignant vertebral bone marrow lesions and compression fractures: a systematic review and meta-analysis. Eur Radiol. 2018;28:2890–902.

    PubMed  Google Scholar 

  48. 48.

    Loudini N, Glaudemans AWJM, Jutte PC, Yakar D, Kwee TC. The value of prebiopsy FDG-PET/CT in discriminating malignant from benign vertebral bone lesions in a predominantly oncologic population. Skelet Radiol. 2020;49:1387–95.

    Google Scholar 

  49. 49.

    Suh CH, Yun SJ. Diagnostic outcome of image-guided percutaneous core needle biopsy of sclerotic bone lesions: a meta-analysis. AJR Am J Roentgenol. 2019;212:625–31.

    PubMed  Google Scholar 

  50. 50.

    Bress A, Metzler S, Plastaras C, Nguyen C, Schuster JM, Pukenas B. “Scout no scan” technique reduces patient radiation exposure during CT-guided spine biopsy. AJR Am J Roentgenol. 2017;209:1158–61.

    PubMed  Google Scholar 

  51. 51.

    Burke MC, Garg A, Youngner JM, Deshmukh SD, Omar IM. Initial experience with dual-energy computed tomography-guided bone biopsies of bone lesions that are occult on monoenergetic CT. Skelet Radiol. 2019;48:605–13.

    Google Scholar 

  52. 52.

    Kang M, Gupta S, Khandelwal N, Shankar S, Gulati M, Suri S. CT-guided fine-needle aspiration biopsy of spinal lesions. Acta Radiol. 1999;40:474–8.

    CAS  PubMed  Google Scholar 

  53. 53.

    Garg V, Kosmas C, Josan ES, Partovi S, Bhojwani N, Fergus N, et al. Computed tomography-guided percutaneous biopsy for vertebral neoplasms: a department’s experience and hybrid biopsy technique to improve yield. Neurosurg Focus. 2016;41:E17.

    PubMed  Google Scholar 

  54. 54.

    Yaffe D, Greenberg G, Leitner J, Gipstein R, Shapiro M, Bachar GN. CT-guided percutaneous biopsy of thoracic and lumbar spine: a new coaxial technique. AJNR Am J Neuroradiol. 2003;24:2111–3.

    PubMed  Google Scholar 

  55. 55.

    Naresh-Babu J, Neelima G, Reshma-Begum SK. Increasing the specimen adequacy of transpedicular vertebral body biopsies. Role of intraoperative scrape cytology. Spine J. 2014;14:2320–5.

    CAS  PubMed  Google Scholar 

  56. 56.

    Singh DK, Kumar N, Nayak BK, Jaiswal B, Tomar S, Mittal MK, et al. Approach-based techniques of CT-guided percutaneous vertebral biopsy. Diagn Interv Radiol. 2020;26:143–6.

    PubMed  PubMed Central  Google Scholar 

  57. 57.

    Gupta S, Henningsen JA, Wallace MJ, Madoff DC, Morello FAJ, Ahrar K, et al. Percutaneous biopsy of head and neck lesions with CT guidance: various approaches and relevant anatomic and technical considerations. Radiographics. 2007;27:371–90.

    PubMed  Google Scholar 

  58. 58.

    Cox M, Pukenas B, Poplawski M, Bress A, Deely D, Flanders A. CT-guided cervical bone biopsy in 43 patients: diagnostic yield and safety at two large tertiary care hospitals. Acad Radiol. 2016;23:1372–5.

    PubMed  Google Scholar 

  59. 59.

    Wiesner EL, Hillen TJ, Long J, Jennings JW. Percutaneous CT-guided biopsies of the cervical spine: technique, histopathologic and microbiologic yield, and safety at a single academic institution. AJNR Am J Neuroradiol. 2018;39:981–5.

    CAS  PubMed  PubMed Central  Google Scholar 

  60. 60.

    Renfrew DL, Whitten CG, Wiese JA, el-Khoury GY, Harris KG. CT-guided percutaneous transpedicular biopsy of the spine. Radiology. 1991;180:574–6.

    CAS  PubMed  Google Scholar 

  61. 61.

    Jelinek JS, Kransdorf MJ, Gray R, Aboulafia AJ, Malawer MM. Percutaneous transpedicular biopsy of vertebral body lesions. Spine (Phila Pa 1976). 1996;21:2035–40.

    CAS  Google Scholar 

  62. 62.

    Poyanli O, Akan K, Unay K, Tangay C. CT-guided percutaneous transpedicular biopsy for the diagnosis of vertebral lesions. Acta Orthop Belg. 2008;74:503–6.

    PubMed  Google Scholar 

  63. 63.

    Brugieres P, Gaston A, Heran F, Voisin MC, Marsault C. Percutaneous biopsies of the thoracic spine under CT guidance: transcostovertebral approach. J Comput Assist Tomogr. 1990;14:446–8.

    CAS  PubMed  Google Scholar 

  64. 64.

    Kaltsikis I, Chourmouzi D, Drevelegas K, Potsi S, Moumtzouoglou A, Drevelegas A. Core needle biopsy of spinal lesions under CT guidance: review of 79 cases. J Neurol Surg A Cent Eur Neurosurg. 2012;73:199–203.

    PubMed  Google Scholar 

  65. 65.

    Sucu HK, Bezircioglu H, Ciçek C, Erşahin Y. Computerized tomography-guided percutaneous transforaminodiscal biopsy sampling of vertebral body lesions. J Neurosurg. 2003;99:51–5.

    PubMed  Google Scholar 

  66. 66.

    Hao DJ, Sun HH, He BR, Liu TJ, Jiang YH, Zhao QP. Accuracy of CT-guided biopsies in 158 patients with thoracic spinal lesions. Acta Radiol. 2011;52:1015–9.

    CAS  PubMed  Google Scholar 

  67. 67.

    Stringham DR, Hadjipavlou A, Dzioba RB, Lander P. Percutaneous transpedicular biopsy of the spine. Spine (Phila Pa 1976). 1994;19:1985–91.

    CAS  Google Scholar 

  68. 68.

    Garcés J, Hidalgo G. Lateral access for CT-guided percutaneous biopsy of the lumbar spine. AJR Am J Roentgenol. 2000;174:425–6.

    PubMed  Google Scholar 

  69. 69.

    Oñate Miranda M, Moser TP. A practical guide for planning pelvic bone percutaneous interventions (biopsy, tumour ablation and cementoplasty). Insights Imaging. 2018;9:275–85.

    PubMed  PubMed Central  Google Scholar 

  70. 70.

    Olscamp A, Rollins J, Tao SS, Ebraheim NA. Complications of CT-guided biopsy of the spine and sacrum. Orthopedics. 1997;20:1149–52.

    CAS  PubMed  Google Scholar 

  71. 71.

    Shaikh H, Thawani J, Pukenas B. Needle-in-needle technique for percutaneous retrieval of a fractured biopsy needle during CT-guided biopsy of the thoracic spine. Interv Neuroradiol. 2014;20:646–9.

    PubMed  PubMed Central  Google Scholar 

  72. 72.

    Kesler K, Shamrock A, Hendrickson N, Igram C. Complete spinal cord injury following computed tomography-guided biopsy of the thoracic spine: a case report. SAGE Open Med Case Rep. 2020;8:2050313X20927580.

    PubMed  PubMed Central  Google Scholar 

  73. 73.

    Kulkarni K, Matravers P, Mehta A, Mitchell A. Pseudoaneurysm following vertebral biopsy and treatment with percutaneous thrombin injection. Skelet Radiol. 2007;36:1195–8.

    Google Scholar 

  74. 74.

    Mifune Y, Yagi M, Iwasaki Y, Doita M. Pseudoaneurysm of lumbar artery following a vertebral biopsy: a case report. Case Rep Radiol. 2012;2012:127124.

  75. 75.

    Huang AJ, Halpern EF, Rosenthal DI. Incidence of delayed complications following percutaneous CT-guided biopsy of bone and soft tissue lesions of the spine and extremities: a 2-year prospective study and analysis of risk factors. Skelet Radiol. 2013;42:61–8.

    Google Scholar 

  76. 76.

    Kim BJ, Lee JW, Kim SJ, Lee GY, Kang HS. Diagnostic yield of fluoroscopy-guided biopsy for infectious spondylitis. AJNR Am J Neuroradiol. 2013;34:233–8.

    CAS  PubMed  Google Scholar 

  77. 77.

    Kamei Y, Nishida J, Mimata Y, Shiraishi H, Ehara S, Satoh T, et al. Core needle percutaneous transpedicular vertebral body biopsy. J Spinal Disord Tech. Lippincott Williams and Wilkins. 2015;28:E394–9.

    PubMed  Google Scholar 

  78. 78.

    Liang Y, Liu P, Bo JL, Lei WH, Nan HA, Gang ZX, et al. Value of CT-guided core needle biopsy in diagnosing spinal lesions: a comparison study. Orthop Surg. Sociedade Brasileira de Matematica Aplicada e Computacional. 2019;11:60–5.

    PubMed  PubMed Central  Google Scholar 

  79. 79.

    Gupta S, Takhtani D, Gulati M, Khandelwal N, Gupta D, Rajwanshi A, et al. Sonographically guided fine-needle aspiration biopsy of lytic lesions of the spine: technique and indications. J Clin Ultrasound. 1999;27:123–9.

    CAS  PubMed  Google Scholar 

  80. 80.

    Liu M, Sequeiros RB, Xu Y, He X, Zhu T, Li L, et al. MRI-guided percutaneous transpedicular biopsy of thoracic and lumbar spine using a 0.23t scanner with optical instrument tracking. J Magn Reson Imaging. 2015;42:1740–6.

    PubMed  Google Scholar 

Download references

Author information



Corresponding author

Correspondence to Syed Ehtasham Junaid.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Saifuddin, A., Palloni, V., du Preez, H. et al. Review article: the current status of CT-guided needle biopsy of the spine. Skeletal Radiol 50, 281–299 (2021).

Download citation


  • CT
  • Needle biopsy
  • Spine