Percutaneous Needle Biopsy of Skeletal Muscle: Technic and Application Jacob H. Goldberger, MD, Providence, Rhode Island William L. Henry, Jr, BS, Providence, Rhode Island Henry T. Randall, MD, FACS, Providence, Rhode Island
Percutaneous needle biopsy of skeletal muscle can be used as a direct method for studying metabolic functions in living human subjects. Skeletal muscle is relatively uniform in its cellular composition in specific anatomic sites and constitutes the largest cellular compartment in the human body. It reflects alteration in metabolism and changes resulting from pathologic processes. Furthermore, skeletal muscle analysis reflects metabolic changes more accurately than does indirect evidence from analysis of blood or even metabolic balance studies. This valuable diagnostic and research technic is simple, relatively atraumatic, and can be carried out on the ward or in the outpatient department. With the aid of an electrobalance, smallsamples of muscle can be used, nermittinn reneated bionsies. Percut&eous biopsiesbf muscle have been carried out pre- and postoperatively to study changes in body comnosition and in intracellular amino acid concentration in seven morbidly obese patients undergoing jejunoileal bypass.
A
6
C
D 8.
I
,, ,,,
Figure 1. Components of the Bergstrom needle (Stille, Sweden): A, sty/et; B, hollow cylinder knife; C, hollow biopsy needle; D, the assembled needle.
Technic The purpose and possible risk and complications of the procedure were explained to all patients. A prepared consent form explaining the nature and purpose of the procedure was then voluntarily signed by each. A careful history of bleeding was obtained from each patient and hematocrit, platelet count, and prothrombin activity evaluated. The biopsy was taken from the lateral aspect of the quadriceps femoris muscle, approximately 15 cm above the patella. The procedure was best performed
From the Division of Surgical Research, Department of Surgery, Rhode Island Hospital, and the Division of Bio-Medical Sciences, Brown University, Providence, Rhode Island. This work was supported in part by the Holden Fund, Detroit, Michigan. Reprint requests should be addressed to Jacob H. Goldberger, MD, Department of Surgery, Rhode Island Hospital, 593 Eddy Street, Providence, Rhode Island 02902.
410
Figure 2. Biopsy needle is pushed through subcutaneous fat, and the operator’s hand pushes muscle against the needle point as it penetrates the muscle.
The American Journal of Surgery
Percutaneous Muscle Biopsy
Figure 3. The site and depth of needle insertion through the quadriceps femoris muscle.
with the operator standing opposite the site from which the biopsy was taken. The skin was washed with antiseptic so:ution, the thigh was draped, and local anesthesia was int‘iltrated into the skin only. A small 0.5 cm vertical skin incision was made, and a Bergstrom percutaneous biopsy needle (Figure 1) was introduced through the incision and pushed through the subcutaneous fat. (Figures 2 and 3.) By using gentle pressure of the free hand on the lateral as sect of the knee and asking the patient to hyperextend the leg, the deep fascia could be felt at the tip of the needle. The needle was rapidly pushed through the fascia into the muscle mass. The cylinder was rapidly pulled back a few centimeters, allowing muscle to bulge into the window of the needle. The cylinder was then pushed down again, cutting the muscle specimen, and the needle was withdrawn. The specimen-cutting maneuver can be repeated up to three times before withdrawing the needle. Sampling
Figure 4. Muscle cylinder.
fragment
is removed
from the needle
should take only a few seconds. Withdrawal of the needle was followed by direct pressure over the incision for 5 minutes to assure homeostasis. The edges of the small skin wound were then approximated with sterile adhesive and covered with a Band-Aid@. The muscle fragments were rapidly removed from the needle (Figure 4), and with fibrous strands removed, weighed on an electrobalance with an accuracy within 0.001 mg. With this weighing technic, which permits continuous recording, weight can be extrapolated to the initial weight of the muscle (time O), thus accounting for weight loss due to evaporation. The electrobalance and other analytical equipment can be brought to the bedside on a portable cart. (Figure 5.) The weight of tissue obtained ranged from 30 to 60 mg. The piece of muscle was then cut into multiple fragments in preparation for analysis for water. fat, and electrolyte content. A fragment was homogenized in preparation for amino acid determination.
Figure 5. Portable cart containing analyiic instruments for measurement of muscle weight. A, electrobalance (Cahn RTL, Cahn Instruments, Division of Ventnar Corporation, Paramount, CA); 6, electrobalance, 6’ power source (Cairn RG); C, paper recorder ( Perkin-Elmer 56, Hitachi Ltd, Tokyo, Japan).
Volume 136, September 1976
411
Goldberger, Henry, and Randall
Complications. Most patients complained of intense aching pain lasting several seconds after the needle penetrated through the fascia. Once the needle was removed from the wound, the‘patients were free of discomfort and were able to ambulate immediately after the procedure. Three patients complained of mild aching and stiffness of the thigh which subsided after 24 hours, and within three or four days the patients had no residual discomfort. There were no hematomas or evidence of infection, and all wounds healed with a minimal visible scar.
Comments Percutaneous skeletal muscle biopsy has been used extensively in Sweden by Bergstrom and co-workers [1,2] in the study of muscle metabolism and electrolytes in exercise and disease states. The technic and its application in diagnosis and research has been reviewed by Edwards [3], but relatively few publications have appeared in the American literature describing this technic. Of interest is the use of the technic in the study of changes in human body composition, particularly since injectable isotopes such as potassium 42 (42K) and hydronium (HsO) have become unavailable for clinical use. Percuta-
412
neous muscle biopsy can also be applied in the study of malnutrition and the efficiency of nutritional support of catabolic surgical patients.
Summary and Conclusions A rapid and atraumatic technic of obtaining small muscle specimens (30 to 60 mg) percutaneously from seven obese patients undergoing jejunoileal bypass is described. This is a valuable method of directly determining metabolic alteration on a cellular level in patients after major surgical stress. Complications are rare. Minimal preparation of the patient is required and biopsy can be carried out in the outpatient clinic as well as on the hospital ward.
References 1. Bergstrhm J: Muscle electrolytes in man. Stand J C/in Invest [Sup~l 741 66: 7, 1962. 2. Vinnars E, BergstrBm J, Furst P: Influence of the postoperative state on the intracellular free amino acids in human muscle tissue. Ann Surg 182: 665, 1975. 3. Edwards RHT: Percutaneous needle biopsy of skeletal muscle in diagnosis and research. Lancef 1: 593, 1971.
The American Journal of Surgery
Percutaneous needle biopsy of skeletal muscle can be used as a direct method for studying metabolic functions in living human subjects. Skeletal muscle is relatively uniform in its cellular composition in specific anatomic sites and constitutes the largest cellular compartment in the human body. It reflects alteration in metabolism and changes resulting from pathologic processes. Furthermore, skeletal muscle analysis reflects metabolic changes more accurately than does indirect evidence from analysis of blood or even metabolic balance studies. This valuable diagnostic and research technic is simple, relatively atraumatic, and can be carried out on the ward or in the outpatient department. With the aid of an electrobalance, smallsamples of muscle can be used, nermittinn reneated bionsies. Percut&eous biopsiesbf muscle have been carried out pre- and postoperatively to study changes in body comnosition and in intracellular amino acid concentration in seven morbidly obese patients undergoing jejunoileal bypass.
A
6
C
D 8.
I
,, ,,,
Figure 1. Components of the Bergstrom needle (Stille, Sweden): A, sty/et; B, hollow cylinder knife; C, hollow biopsy needle; D, the assembled needle.
Technic The purpose and possible risk and complications of the procedure were explained to all patients. A prepared consent form explaining the nature and purpose of the procedure was then voluntarily signed by each. A careful history of bleeding was obtained from each patient and hematocrit, platelet count, and prothrombin activity evaluated. The biopsy was taken from the lateral aspect of the quadriceps femoris muscle, approximately 15 cm above the patella. The procedure was best performed
From the Division of Surgical Research, Department of Surgery, Rhode Island Hospital, and the Division of Bio-Medical Sciences, Brown University, Providence, Rhode Island. This work was supported in part by the Holden Fund, Detroit, Michigan. Reprint requests should be addressed to Jacob H. Goldberger, MD, Department of Surgery, Rhode Island Hospital, 593 Eddy Street, Providence, Rhode Island 02902.
410
Figure 2. Biopsy needle is pushed through subcutaneous fat, and the operator’s hand pushes muscle against the needle point as it penetrates the muscle.
The American Journal of Surgery
Percutaneous Muscle Biopsy
Figure 3. The site and depth of needle insertion through the quadriceps femoris muscle.
with the operator standing opposite the site from which the biopsy was taken. The skin was washed with antiseptic so:ution, the thigh was draped, and local anesthesia was int‘iltrated into the skin only. A small 0.5 cm vertical skin incision was made, and a Bergstrom percutaneous biopsy needle (Figure 1) was introduced through the incision and pushed through the subcutaneous fat. (Figures 2 and 3.) By using gentle pressure of the free hand on the lateral as sect of the knee and asking the patient to hyperextend the leg, the deep fascia could be felt at the tip of the needle. The needle was rapidly pushed through the fascia into the muscle mass. The cylinder was rapidly pulled back a few centimeters, allowing muscle to bulge into the window of the needle. The cylinder was then pushed down again, cutting the muscle specimen, and the needle was withdrawn. The specimen-cutting maneuver can be repeated up to three times before withdrawing the needle. Sampling
Figure 4. Muscle cylinder.
fragment
is removed
from the needle
should take only a few seconds. Withdrawal of the needle was followed by direct pressure over the incision for 5 minutes to assure homeostasis. The edges of the small skin wound were then approximated with sterile adhesive and covered with a Band-Aid@. The muscle fragments were rapidly removed from the needle (Figure 4), and with fibrous strands removed, weighed on an electrobalance with an accuracy within 0.001 mg. With this weighing technic, which permits continuous recording, weight can be extrapolated to the initial weight of the muscle (time O), thus accounting for weight loss due to evaporation. The electrobalance and other analytical equipment can be brought to the bedside on a portable cart. (Figure 5.) The weight of tissue obtained ranged from 30 to 60 mg. The piece of muscle was then cut into multiple fragments in preparation for analysis for water. fat, and electrolyte content. A fragment was homogenized in preparation for amino acid determination.
Figure 5. Portable cart containing analyiic instruments for measurement of muscle weight. A, electrobalance (Cahn RTL, Cahn Instruments, Division of Ventnar Corporation, Paramount, CA); 6, electrobalance, 6’ power source (Cairn RG); C, paper recorder ( Perkin-Elmer 56, Hitachi Ltd, Tokyo, Japan).
Volume 136, September 1976
411
Goldberger, Henry, and Randall
Complications. Most patients complained of intense aching pain lasting several seconds after the needle penetrated through the fascia. Once the needle was removed from the wound, the‘patients were free of discomfort and were able to ambulate immediately after the procedure. Three patients complained of mild aching and stiffness of the thigh which subsided after 24 hours, and within three or four days the patients had no residual discomfort. There were no hematomas or evidence of infection, and all wounds healed with a minimal visible scar.
Comments Percutaneous skeletal muscle biopsy has been used extensively in Sweden by Bergstrom and co-workers [1,2] in the study of muscle metabolism and electrolytes in exercise and disease states. The technic and its application in diagnosis and research has been reviewed by Edwards [3], but relatively few publications have appeared in the American literature describing this technic. Of interest is the use of the technic in the study of changes in human body composition, particularly since injectable isotopes such as potassium 42 (42K) and hydronium (HsO) have become unavailable for clinical use. Percuta-
412
neous muscle biopsy can also be applied in the study of malnutrition and the efficiency of nutritional support of catabolic surgical patients.
Summary and Conclusions A rapid and atraumatic technic of obtaining small muscle specimens (30 to 60 mg) percutaneously from seven obese patients undergoing jejunoileal bypass is described. This is a valuable method of directly determining metabolic alteration on a cellular level in patients after major surgical stress. Complications are rare. Minimal preparation of the patient is required and biopsy can be carried out in the outpatient clinic as well as on the hospital ward.
References 1. Bergstrhm J: Muscle electrolytes in man. Stand J C/in Invest [Sup~l 741 66: 7, 1962. 2. Vinnars E, BergstrBm J, Furst P: Influence of the postoperative state on the intracellular free amino acids in human muscle tissue. Ann Surg 182: 665, 1975. 3. Edwards RHT: Percutaneous needle biopsy of skeletal muscle in diagnosis and research. Lancef 1: 593, 1971.
The American Journal of Surgery
