External Intercostal Muscle Biopsy Lawrence . Stern, MD;
Raphael Gruener, PhD;
Robert M. Anderson, MD
External intercostal muscle biopsies performed on 36 patients with neuromuscular disease, 13 patients un¬ dergoing thoracotomy for other diseases, and 3 healthy volunteers. The procedure is safe, of diagnostic value, and uniquely useful as a research tool, as it allows cor¬ relation of results of histochemical, ul¬
reports have not, however, detailed the method of performing intercostal biopsy and treating the tissue. The purpose of this communication is to describe the surgical aspects of the biopsy, preparation of specimens, and our clinical experience.
nerves (usually the fifth to ninth) gave consistently satisfactory anes¬ thesia. Lidocaine (1.5%) or bupivacaine (Marcaine) (0.25%) were the local anesthet¬ ics employed (each usually with 1:200,000 epinephrine). With the patient in the right lateral decubitus position, a 4.5-cm incision was made through the superficial thoracic
trastructural, physiological, pharmaco¬
SUBJECTS AND METHODS
fascia. The latissimus dorsi and the under¬ lying serratus anterior were divided in the direction of the fibers, exposing the sixth intercostal space. A 2 x 3-cm parallelogram of external intercostal muscle, weighing about 3.5 gm, was removed, with a rim of periosteum left attached to either end of the specimen to insure that intact muscle fibers were obtained. The latissimus dorsi, serratus anterior, fasciai layers, and skin were then reapproximated, using inter¬ rupted 4-0 silk.
•
were
logical, and biochemical studies on the same specimens. (Arch Neurol 32:779-780, 1975)
biopsy External intercostal muscle unique has been shown to be of usefulness in the study of human neuromuscular disease.112 Providing intact fibers, it allows direct corre¬ lation of results of morphological, physiological, pharmacological, and biochemical studies on the same
specimens. Recently,
we
presented
evidence that the same histochemical and ultrastructural changes known to occur in limb muscle that had under¬ gone biopsy also occur in intercostal muscle in the muscular dystrophies and motor neuron disease.11 Previous Accepted for publication April 8, 1975. From the departments of neurology, physiol¬ ogy, and surgery, University of Arizona College of Medicine, Tucson. Reprint requests to Department of Neurology, University of Arizona Medical Center, Tucson, AZ 85724 (Dr. Stern).
Thirty-six patients were recruited from being observed at the Univer¬ sity of Arizona Clinic for Neuromuscular Disorders. The diagnostic categories in¬ cluded various forms of muscular dys¬ trophy and spinal muscular atrophy, motor neuron disease, paramyotonia congenita, and the myopathies associated with acro¬ megaly and hyperthyroidism. Of these, seven had previously had diagnostic limb muscle biopsies elsewhere and two patients had both limb and intercostal biopsies here. Biopsies were also obtained from 13 adult patients without neuromuscular dis¬ ease, who were undergoing thoracotomy for other diseases, and from 3 healthy adult volunteers. Control subjects were all among those
under 60 years of age. Informed consent was obtained after the nature of the proce¬ dure had been fully explained. A chest roentgenogram and pulmonary function studies were performed on all subjects prior to biopsy. As a precaution, patients were kept in the hospital for one night after the biopsy. Except in the tho¬ racotomy cases, specimens were obtained from the left sixth intercostal space in the
midaxillary line, using paravertebral nerve block anesthesia. Blockage of four or five
Downloaded From: http://archneur.jamanetwork.com/ by a University of Calgary User on 05/27/2015
intercostal
on removal, specimens mounted, slightly stretched, on a
Immediately
were
plastic holder to avoid contractures. The holder was placed in a Dewar flask filled with continuously oxygenated (95% 0.. + 5% CO,), cold (20 C) balanced salt solution (BSS) and taken to the laboratory. The BSS had the following composition: NaCI 135 mM, NaHCO:1 15 mM, KC1 5 mM, MgCl l mM, Trie-Cl-6 mM, CaCl 2 mM, Na2HP04 5 mM, and glucose 11 mM. The pH of this solution was 7.15 ±0.05. A dissecting microscope was used to divide the specimens into fascicles containing intact fibers free of superficial connective and adipose tissue for histo¬ chemical, ultrastructural, physiological, and pharmacological studies. This proce¬ =
=
=
=
=
=
dure
was
=
carried out under continuous
su-
perfusion with cold, oxygenated BSS and usually took 45 to 90 minutes. Details and results of specific studies have either been812 or will be reported separately. COMMENT
All 52 of the biopsy specimens were used for histochemical and electron microscopic studies. Electrophysio¬
logical measurements, using
conven¬
tional double microelectrode tech¬ niques, were made on 48 specimens, and pharmacological studies on 33 specimens, although all were suitable
for such measurements. The nine patients who had both limb and intercostal biopsies showed similar morphological changes in both muscles, though the limb muscle changes were more severe. All pa¬ tients tolerated the procedure well. They reported little discomfort, and the surgery was accompanied by min¬ imal blood loss, in no case requiring replacement. The wounds healed as fast or faster than most limb muscle biopsies and there were no wound in¬ fections. Most of the patients who
had had both limb and intercostal biopsies reported the latter to be less painful, both during and after the procedure. In only one of the 52 biopsies was there a complication: partial pneumothorax in a 77-year-old man with motor neuron disease. It was treated successfully and his dis¬ charge from the hospital was delayed
by just
one
day.
This study was supported in part by grants from the Muscular Dystrophy Association, NINDS grant NS 10417, and the Edward and Florence Watz Neuromuscular Research Fund.
References 1. Creese R, Dillon JB, Marshall J, et al: The effect of neuromuscular blocking agents on iso¬ lated human intercostal muscle. J Pharmacol Exp Ther 110:485-494, 1957. 2. Dillon J, Fields J, Gumas T, et al: An iso¬
lated human voluntary muscle preparation. Proc Soc Exp Biol Med 90:409, 1955. 3. Elmqvist D, Hofmann WW, Kugelberg J, et al: An electrophysiological investigation of neuromuscular transmission in myasthenia gravis. J Physiol (London) 174:417-434, 1964. 4. Ludin HP: Microelectrode study of dys¬ trophic human skeletal muscle. Eur Neurol 3:116-121, 1969. 5. Santa T, Engel AG, Lambert EH: Histometric study of neuromuscular junction ultra-
structure: I.
82, 1972.
Myasthenia gravis. Neurology 22:71-
6. Santa T, Engel AG, Lambert EH: Histometric study of neuromuscular junction ultra¬ structure: II. Myasthenie syndrome. Neurology 22:370-376, 1972. 7. Hofmann WW, Birnberger KL, Harlacher A, et al: Normal and dystrophic human muscle in vitro: An argument against denervation. Exp Neurol 39:249-260, 1973. 8. Stern LZ, Payne CM, Hannapel LK: Acro¬ megaly: Histochemical and electron microscopic changes in deltoid and intercostal muscle. Neu¬ rology 24:589-593, 1974. 9. Gruener R, Stern LZ, Payne CM, et al: Hyperthyroid myopathy: Intracellular electrophys-
Downloaded From: http://archneur.jamanetwork.com/ by a University of Calgary User on 05/27/2015
iological measurements in biopsied human inter¬ costal muscle. J Neurol Sci 24:351-359, 1975. 10. Payne CM, Stern LZ, Curless RG, et al: Ul¬ trastructural fiber typing in normal and diseased human muscle. J Neurol Sci, 25:99-108, 1975. 11. Stern LZ, Gruener R: Intercostal muscle in human neuromuscular disease: Histo¬ chemical and electron microscope studies. J Neu¬ rol Neurosurg Psychiatry, to be published.
biopsy
12. Gruener R, Stern LZ: Intercostal muscle biopsy in human neuromuscular disease: Physio¬ logical studies. Third International Congress on Muscle Diseases, abstracted, Excerpta Medica, 334:115, 1974.
Raphael Gruener, PhD;
Robert M. Anderson, MD
External intercostal muscle biopsies performed on 36 patients with neuromuscular disease, 13 patients un¬ dergoing thoracotomy for other diseases, and 3 healthy volunteers. The procedure is safe, of diagnostic value, and uniquely useful as a research tool, as it allows cor¬ relation of results of histochemical, ul¬
reports have not, however, detailed the method of performing intercostal biopsy and treating the tissue. The purpose of this communication is to describe the surgical aspects of the biopsy, preparation of specimens, and our clinical experience.
nerves (usually the fifth to ninth) gave consistently satisfactory anes¬ thesia. Lidocaine (1.5%) or bupivacaine (Marcaine) (0.25%) were the local anesthet¬ ics employed (each usually with 1:200,000 epinephrine). With the patient in the right lateral decubitus position, a 4.5-cm incision was made through the superficial thoracic
trastructural, physiological, pharmaco¬
SUBJECTS AND METHODS
fascia. The latissimus dorsi and the under¬ lying serratus anterior were divided in the direction of the fibers, exposing the sixth intercostal space. A 2 x 3-cm parallelogram of external intercostal muscle, weighing about 3.5 gm, was removed, with a rim of periosteum left attached to either end of the specimen to insure that intact muscle fibers were obtained. The latissimus dorsi, serratus anterior, fasciai layers, and skin were then reapproximated, using inter¬ rupted 4-0 silk.
•
were
logical, and biochemical studies on the same specimens. (Arch Neurol 32:779-780, 1975)
biopsy External intercostal muscle unique has been shown to be of usefulness in the study of human neuromuscular disease.112 Providing intact fibers, it allows direct corre¬ lation of results of morphological, physiological, pharmacological, and biochemical studies on the same
specimens. Recently,
we
presented
evidence that the same histochemical and ultrastructural changes known to occur in limb muscle that had under¬ gone biopsy also occur in intercostal muscle in the muscular dystrophies and motor neuron disease.11 Previous Accepted for publication April 8, 1975. From the departments of neurology, physiol¬ ogy, and surgery, University of Arizona College of Medicine, Tucson. Reprint requests to Department of Neurology, University of Arizona Medical Center, Tucson, AZ 85724 (Dr. Stern).
Thirty-six patients were recruited from being observed at the Univer¬ sity of Arizona Clinic for Neuromuscular Disorders. The diagnostic categories in¬ cluded various forms of muscular dys¬ trophy and spinal muscular atrophy, motor neuron disease, paramyotonia congenita, and the myopathies associated with acro¬ megaly and hyperthyroidism. Of these, seven had previously had diagnostic limb muscle biopsies elsewhere and two patients had both limb and intercostal biopsies here. Biopsies were also obtained from 13 adult patients without neuromuscular dis¬ ease, who were undergoing thoracotomy for other diseases, and from 3 healthy adult volunteers. Control subjects were all among those
under 60 years of age. Informed consent was obtained after the nature of the proce¬ dure had been fully explained. A chest roentgenogram and pulmonary function studies were performed on all subjects prior to biopsy. As a precaution, patients were kept in the hospital for one night after the biopsy. Except in the tho¬ racotomy cases, specimens were obtained from the left sixth intercostal space in the
midaxillary line, using paravertebral nerve block anesthesia. Blockage of four or five
Downloaded From: http://archneur.jamanetwork.com/ by a University of Calgary User on 05/27/2015
intercostal
on removal, specimens mounted, slightly stretched, on a
Immediately
were
plastic holder to avoid contractures. The holder was placed in a Dewar flask filled with continuously oxygenated (95% 0.. + 5% CO,), cold (20 C) balanced salt solution (BSS) and taken to the laboratory. The BSS had the following composition: NaCI 135 mM, NaHCO:1 15 mM, KC1 5 mM, MgCl l mM, Trie-Cl-6 mM, CaCl 2 mM, Na2HP04 5 mM, and glucose 11 mM. The pH of this solution was 7.15 ±0.05. A dissecting microscope was used to divide the specimens into fascicles containing intact fibers free of superficial connective and adipose tissue for histo¬ chemical, ultrastructural, physiological, and pharmacological studies. This proce¬ =
=
=
=
=
=
dure
was
=
carried out under continuous
su-
perfusion with cold, oxygenated BSS and usually took 45 to 90 minutes. Details and results of specific studies have either been812 or will be reported separately. COMMENT
All 52 of the biopsy specimens were used for histochemical and electron microscopic studies. Electrophysio¬
logical measurements, using
conven¬
tional double microelectrode tech¬ niques, were made on 48 specimens, and pharmacological studies on 33 specimens, although all were suitable
for such measurements. The nine patients who had both limb and intercostal biopsies showed similar morphological changes in both muscles, though the limb muscle changes were more severe. All pa¬ tients tolerated the procedure well. They reported little discomfort, and the surgery was accompanied by min¬ imal blood loss, in no case requiring replacement. The wounds healed as fast or faster than most limb muscle biopsies and there were no wound in¬ fections. Most of the patients who
had had both limb and intercostal biopsies reported the latter to be less painful, both during and after the procedure. In only one of the 52 biopsies was there a complication: partial pneumothorax in a 77-year-old man with motor neuron disease. It was treated successfully and his dis¬ charge from the hospital was delayed
by just
one
day.
This study was supported in part by grants from the Muscular Dystrophy Association, NINDS grant NS 10417, and the Edward and Florence Watz Neuromuscular Research Fund.
References 1. Creese R, Dillon JB, Marshall J, et al: The effect of neuromuscular blocking agents on iso¬ lated human intercostal muscle. J Pharmacol Exp Ther 110:485-494, 1957. 2. Dillon J, Fields J, Gumas T, et al: An iso¬
lated human voluntary muscle preparation. Proc Soc Exp Biol Med 90:409, 1955. 3. Elmqvist D, Hofmann WW, Kugelberg J, et al: An electrophysiological investigation of neuromuscular transmission in myasthenia gravis. J Physiol (London) 174:417-434, 1964. 4. Ludin HP: Microelectrode study of dys¬ trophic human skeletal muscle. Eur Neurol 3:116-121, 1969. 5. Santa T, Engel AG, Lambert EH: Histometric study of neuromuscular junction ultra-
structure: I.
82, 1972.
Myasthenia gravis. Neurology 22:71-
6. Santa T, Engel AG, Lambert EH: Histometric study of neuromuscular junction ultra¬ structure: II. Myasthenie syndrome. Neurology 22:370-376, 1972. 7. Hofmann WW, Birnberger KL, Harlacher A, et al: Normal and dystrophic human muscle in vitro: An argument against denervation. Exp Neurol 39:249-260, 1973. 8. Stern LZ, Payne CM, Hannapel LK: Acro¬ megaly: Histochemical and electron microscopic changes in deltoid and intercostal muscle. Neu¬ rology 24:589-593, 1974. 9. Gruener R, Stern LZ, Payne CM, et al: Hyperthyroid myopathy: Intracellular electrophys-
Downloaded From: http://archneur.jamanetwork.com/ by a University of Calgary User on 05/27/2015
iological measurements in biopsied human inter¬ costal muscle. J Neurol Sci 24:351-359, 1975. 10. Payne CM, Stern LZ, Curless RG, et al: Ul¬ trastructural fiber typing in normal and diseased human muscle. J Neurol Sci, 25:99-108, 1975. 11. Stern LZ, Gruener R: Intercostal muscle in human neuromuscular disease: Histo¬ chemical and electron microscope studies. J Neu¬ rol Neurosurg Psychiatry, to be published.
biopsy
12. Gruener R, Stern LZ: Intercostal muscle biopsy in human neuromuscular disease: Physio¬ logical studies. Third International Congress on Muscle Diseases, abstracted, Excerpta Medica, 334:115, 1974.
