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Radiopaedia Blog

Part 4 of a 5-part series on the advantages of a freehand technique over a needle-guide system for ultrasound-guided biopsies. If you haven't read the rest of this post, please start at part 1


When planning the procedure, you need to visualize the geometry of the transducer and needle in your head and take care to view the true plane of the transducer. You must make sure that when you insert the needle, that it is in the plane of the transducer and that as you manipulate both the transducer and needle that you coordination the planes. The human eye is also remarkably good at estimating angles and you will be surprised how close you are to the proper angle when you start doing these. Yes, these are skills you may need to hone, but ones that help for other procedures and ones that virtually anyone who does procedures using needle guides can master…. really. 


First, positioning the patient and yourself is crucial, although many do not adequately account for their own positioning as well as they do the patient’s positioning. You need to be able to brace your scanning arm and sometimes the arm with which you are doing the biopsy, so you may need to elevate the table or move the patient. So, once the patient and you are properly positioned, you should brace yourself with your hand, arm and/or elbow resting on something immobile. I bring the lesion into optimal view, but before I actually insert the needle, I try to place my eyes directly within the plane of biopsy itself. If you are looking AT the plane rather than WITHIN the plane, you may not appreciate a subtle deflection of the needle from the viewing plane.

Finally — insert the needle

Once you see the lesion and you are properly braced, nothing is going to move (at least very much). If you are seeing the lesion and you know that you are inserting the needle in the plane of viewing, then you know that when you insert the needle, that it will be in the plane of viewing or very close. Here is the key that is nearly impossible for novices to accomplish psychologically: You should be looking at the needle and transducer as you insert, NOT the screen. Once you take your eyes off the needle and plane and turn your head (or even just your eyes) to look at the screen, you lose your eye-hand coordination and are likely to inadvertently incorrectly angle the needle or transducer. I have even sometimes stood in front of the screen or held my hand over it so the resident cannot see it as she/he inserts the needle. 

If you are looking at the needle while you insert it, it will be close to the right place. So, upon initial insertion, I don’t usually go all the way down to the lesion unless it is large and the orientation wouldn’t be a problem. I want to get it through the surface of the organ and within range of being able to see it. One other point, though, particularly for novices, is that you shouldn’t incrementally edge the needle into the patient millimeter by millimeter because you are scared to hurt something. If you have planned properly, you know that your route is safe and you will cause the patient considerably less discomfort if you insert swiftly through the sensitive peritoneum, liver capsule or other tissue plane rather than stretch and tent those surfaces as you insert slowly.


Once the needle is inserted, you can find it with subtle readjustments of the transducer and quickly figure out how to reposition, if necessary. You just need to appreciate that the screen and real geometry are nearly the same so that you intuitively know which way you need to re-angle the needle. So, yes, you may need to withdraw the tip to a more superficial position and reinsert. There are many different types of needles that you may use, so I won’t discuss actually acquiring or saving the specimens. Using the freehand technique is independent of these factors.

In the final 5th part of this series, I will discuss why the freehand technique is often less traumatic than using the needle guide and is cheaper and faster.

In this series: 

Lincoln L. Berland, MD is Professor Emeritus of the Abdominal Imaging Section of University of Alabama at Birmingham. 

Twitter: @linkberland

NB: Opinions expressed are those of the author alone, and are not those of his employer nor of 


Part 3 of a 5-part series on the advantages of a freehand technique over a needle-guide system for ultrasound-guided biopsies. If you haven't read the rest of this post, please start at part 1

In part 1 and part 2 of this series, I discussed issues related to planning, scanning, prepping and local anesthesia. In this part, I will first describe more about locating your ideal sites (not a single site). As I mentioned, I always mark the spot of insertion and find at least one point for viewing. This planning stage is usually the longest part of the procedure, other than the consent and timeout. The longer you plan, the faster the actual procedure goes.

Preferred subcostal approach

Generally, for liver lesion biopsies and some abdominal mass biopsies, if the lesion is high in the abdomen, I prefer inserting the needle subcostally, rather then intercostally, although I don’t adhere to that rigidly if it simply isn’t possible. Since you are penetrating the diaphragm/potential pleural space for an intercostal approach, you may be concerned about seeding the pleura with tumor or infection. In these cases, you want to at least attempt to plan a subcostal approach.

So, particularly with superficial lesions high in the liver, the best subcostal approach may require a very steep angle, sometimes with the needle almost parallel to the surface of the abdomen. It is often impossible to use a guide to achieve this because the footprint of the transducer plus the guide is too long, the guide does not allow such an angle and the lesion may not be visible for the position you have selected for insertion. Additionally, with a steep angle, often a fair amount of pressure is necessary and the sharp edges of the guide may be uncomfortable as they dig into the patient. Your position may also be awkward. Any of this sounding familiar to you guide-users?

More needle length available

One other issue that guide-users may not appreciate is that because of the required step-off of the needle portal to the skin, you cannot insert the needle hub all the way to the skin as you can freehand. This may require you to select a longer needle, which is more awkward to use.

Watch from anywhere

Freehand, you can position the needle optimally and then place the transducer intercostally, subxiphoid or elsewhere - wherever you can see the lesion and needle. You are no longer limited when picking your insertion point to accommodate for the fixed geometry of the guide. You can actually do biopsies that you might otherwise abandon because you can’t figure out how to do them with the needle guide. I have been invited in to help salvage these types of difficult procedures and simply have removed the guide. I have been able to acquire the tissue within a few minutes while the first radiologist had struggled for over 1/2 hour trying to use the guide with a difficult angle

See the lesion and needle better

Also, if when you start the procedure, and you are using the guide, you may find that you cannot see the lesion as well as you did when you marked the spot. There is a reason for this. If you use the guide, you likely will have a plastic sheath and gel inside the sheath. There may be a few gas bubbles trapped in the gel. The presence of the sheath and the gel actually degrades your visualization of the lesion and needle. Without the guide, sheath and gel, your visualization should be comparable to when you localized the lesion when you started.

In part 4 of this series, I will discuss the final stages of planning and actually performing the biopsy.

In this series: 

Lincoln L. Berland, MD is Professor Emeritus of the Abdominal Imaging Section of University of Alabama at Birmingham. 

Twitter: @linkberland

NB: Opinions expressed are those of the author alone, and are not those of his employer nor of 


I have recently submitted an editorial to the AJNR on my opinion that we should not be using disk-osteophyte-complex (DOC) term because it is a cop-out in not using the gradient echo T2W image to distinguish disk from osteophyte (disk bright, osteophyte dark). My surgeons say knowing whether the cervical disease is a disk versus an osteophyte is very important to them (diskectomy for disk versus posterior decompression for big osteophyte etc). Can I hear from other voices as to why DOC has become a default term for all DJD pathology in the cervical spine?


David M. Yousem is Director of Neuroradiology and a Professor of Radiology at the Johns Hopkins Hospital School of Medicine 

Twitter: @dyousem1

NB: Opinions expressed are those of the author alone, and are not those of his employer nor of 


Part 2 of a 5-part series on the advantages of a freehand technique over a needle-guide system for ultrasound-guided biopsies. If you haven't read the rest of this post, please start at part 1

Planning and scanning

When using the needle guide, many users identify only one spot to scan and then insert the needle through the guide portal to the side of the transducer. Therefore, they may not have adequately examined the actual route through which the needle will pass to see if it will encounter any structures unsafe to puncture. The needle is fixed at a fairly shallow angle to the transducer and may be harder to see. I will discuss this more in Part 3.

To optimize the freehand technique, you should look for TWO spots. One should be over the direct route of the needle (somewhere outside where the transducer will be while you are guiding the needle) and this should be marked before prepping the skin. The other point will be the position you will be using to view while inserting the needle. You don’t need to mark this because it might change, but you at least need to know that there is at least one good viewing point.

For freehand biopsies, unlike using the needle guide, there is no limitation to where you view, other than you need to be able to be within the plane of the needle. Of course, the closer your transducer is to perpendicular to your needle, the more easily visible it should be because of basic principles of ultrasound reflection. So, a position farther away from the needle may actually give you a better chance of finding it quickly and seeing more of it.


While we like to think that our procedures are “sterile,” they are better termed “clean.” I don’t want anyone to suggest that I am being capricious about spreading nosocomial infections, because I religiously follow hand washing protocols. However, I believe the perception that we need true sterility suggests a glorification that what we are doing is just short of a surgical procedure. Actually, we use a needle not really much larger than one used to draw blood, for which a lab tech may only use a quick alcohol swab swipe. I use a needle that does not even require a scalpel nick. If you prep your transducer and skin thoroughly with betadine and use sterile gloves, you should not induce an infection. I am not aware that I have ever done that.


Adequate local anesthesia is one of the most important aspects to optimizing the patient’s experience. So, I focus strongly on this part of the procedure. I am fascinated by the consistency (incorrectly, I believe) with which residents perform local anesthesia for ultrasound-guided biopsies whether the guide is used or not. This even includes thyroid FNAs. If someone else has instructed them before I observe their first procedure, they typically inject the lidocaine by taking the transducer in their left hand and placing it on the skin. They then take the lidocaine syringe in their right hand and insert it vertically into the skin as though they were placing the needle through an invisible guide portal! It is always awkward to use the syringe at that angle with one hand and then reliably achieve anesthesia at the skin. Clearly, this is a technique “learned” from doing deep biopsies with the guide. So, when using the guide many also attempt to achieve local anesthesia (often less effectively) through the needle portal rather than doing it as I describe below.

Instead, I inject in two stages. At the first stage, I hold the syringe in both hands (with no transducer) and insert the needle subcutaneously tangential to the skin. I then inject and raise a wheal. With the vertical (needle-guide-like technique), it is difficult to verify that you are truly numbing the skin and superficial tissues. I have observed a number of instances where the needle-guide approach to local anesthesia has led to unnecessary pain while doing the biopsy to the point where patients have asked to terminate the procedure. I instruct the resident that the first step should be to numb the skin, because it will be less painful when you inject the deeper tissues, I also point out that you don’t need a transducer to see the skin, which is often a liberating concept for them. They can then fully control the needle, the location of and the volume of lidocaine injected. Note that I believe that you should do it this way even if you DO use the needle guide.

Then, after a moment to allow anesthesia to take effect while I continue setting up the tray, I begin a second stage. I use the transducer to locate the proposed needle track and achieve deeper local anesthesia. Since I am trying to get deep to the skin, I take the transducer in my left hand and pick up the syringe with my right hand with my thumb on the plunger, insert and watch with ultrasound. As soon as I get to the depth I want, I can inject to cover the entire tract I will be traversing.

In part 3 of this series, I will discuss more about planning the procedure to design the best approach and about the added flexibility you have with a freehand approach.

In this series: 

Lincoln L. Berland, MD is Professor Emeritus of the Abdominal Imaging Section of University of Alabama at Birmingham. 

Twitter: @linkberland

NB: Opinions expressed are those of the author alone, and are not those of his employer nor of 


In many cases it’s just best to adequately describe your findings, but every radiologist knows about the myriad of classification and grading systems out there. often comes to the rescue if you come across an obscure classification and even for often used ones if you just can’t remember its details or considerations. 

However, it’s also good to know if a classification is still being used or when it was last updated. And on a historical note it’s just nice to find out how it developed and who came up with it.

Over the last months a team of our editors (Piotr Gołofit, Varun Babu, Praveen Jha, Matthew Morgan, Frank Gaillard, Jeremy Jones and yours truly) worked together on “Operation Bookworm” to provide just that information for almost 170 classifications and gradings at, also giving these articles a small facelift where needed. That’s about a third of our articles on classifications and gradings.

Some examples:

We believe that these additions are very relevant to everyday clinical practice and welcome everyone to help keeping them up to date and add this information in the remaining articles. 

This project is a great example of ongoing critical appraisal of existing content at, illustrating the dynamic and cooperative nature of a community based encyclopedia that everyone can use and contribute to for free and forever.

We hope you enjoy it!

Tim Luijkx is a Radiopaedia senior editor, and radiology registrar at the Meander Medical Center in Amersfoort, the Netherlands

Twitter: @TimLuijkx

NB: Opinions expressed are those of the author alone, and are not those of his employer nor of 


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