Background/Objectives: Differentiating atypical lipomatous tumours (ALT) from lipomas remains challenging, as both share similar clinical and radiological features but require different forms of management. We previously proposed a clinical–radiological score integrating routine parameters to improve preoperative discrimination. This study aimed to externally validate the score in an independent cohort and refine it for enhanced robustness. Methods: We retrospectively analysed 119 patients with lipomatous tumours treated between 2022 and 2024 at an external university hospital. Diagnostic performance of the original models was assessed using receiver operating characteristic analysis. Data were then combined with the initial development cohort (n = 106) to recalibrate the models and define new cut-offs. Results: In the external validation cohort, predictive accuracy decreased compared to the derivation cohort, especially in extremity tumours assessed without contrast (AUC 0.830 vs. 0.942). Across four recalibrated models in the combined dataset (n = 225), diagnostic accuracy remained high (AUCs 0.918–0.954). Models combining clinical and imaging parameters consistently outperformed single-parameter approaches, with contrast enhancement providing the greatest incremental value. Accuracy was lower in trunk-localised tumours, highlighting the need for molecular confirmation in selected subgroups. Conclusions: The re-modelled score demonstrated robust diagnostic accuracy and practicality for routine use, offering a resource-efficient tool to support preoperative risk stratification. While molecular testing remains essential in high-risk cases, the refined score may reduce unnecessary testing and facilitate tailored diagnostic strategies. To support clinical adoption, the score is available as a web application that automatically selects the appropriate model and presents results in a colour-coded format.

Background: The rising incidence of vertebral body fractures, vertebral infections and metastatic disease increases the need for diagnostic modalities with high specificity. Biopsy remains essential, yet comparative data on CT-guided versus intraoperative percutaneous fluoroscopy-guided biopsy are limited. Methods: This retrospective study compared two cohorts biopsied for spinal lesions between April 2015 and April 2024: CT-guided biopsy (n = 62), and intraoperative percutaneous biopsy (n = 154). Groups were analyzed for demographic and clinical characteristics, and diagnostic yield was defined by the conclusiveness of the primary biopsy; statistical comparisons were performed using Fisher’s exact test. Results: CT-guided biopsy yielded conclusive results in 46 of 62 cases (74.2%), whereas intraoperative, fluoroscopy-guided biopsy was conclusive in 41 of 154 cases (26.6%), representing a statistically significant difference (p < 0.001). In analogy, propensity score matching (1:1) resulted in similar significant (p < 0.001) results (CT-guided group vs. intraoperative, fluoroscopy-guided group: 86.7% vs. 35.6%) Conclusions: CT-guided biopsy demonstrated a substantially higher rate of conclusive results compared with intraoperative biopsy in this cohort. Further studies with larger and more balanced cohorts are needed to strengthen clinical recommendations.