An Illustrated Guide to Performing
Table of Contents
Iliac crest (posterior and anterior)
This paper describes a common medical procedure and is intended for medical personnel. Only trained, experiences, and credentialed individuals are permitted to perform the bone marrow aspiration and biopsy. The opinions expressed are entirely those of the authors and do not represent their respective institutions.
The bone marrow aspiration and biopsy are usually regarded by the public and physicians as a brutal, extremely painful procedure which is difficult to master. However, with knowledge and some experience, successful marrow examinations can be repeatedly performed with minimal discomfort to the patient. This paper reflects the collective knowledge and experience of a hematopathologist (RSR), hematologist/oncologist/pathologist (TFH) and pathology residents (DR, RF) in this area. This paper was adapted from a lecture series developed for residents by TFH.
Peripheral blood examination and other routine laboratory assays do not always provide enough information for diagnosis of hematologic disease. In some patients direct microscopic examination of the bone marrow is required for confirmation of a suspected clinical diagnosis or monitoring the course of therapy. Occasional patients require bone marrow for special studies, such as cytogenetic analysis, flow cytometry, or microbiological analysis.
Fig. 1. Clinical indications for a bone marrow evaluation. Data from 286 bone marrow procedures performed at the Medical college of Virginia between January and June, 1998.
A bone marrow examination is performed in nearly every patient with a suspected hematologic malignancy, whether because of a physical finding (lymphadenopathy, splenomegaly, etc.) or because of the presence of abnormal cells in the peripheral blood. Bone marrow examination is also part of the staging process for newly-diagnosed patients with a malignant lymphoma or for patients with solid tumors undergoing evaluation for bone marrow transplantation. Patients who are post-chemotherapy or bone marrow transplantation may require a bone marrow evaluation if their peripheral blood counts do not recover as expected. Some research treatment protocols may also require a bone marrow study at certain post-treatment intervals. Unexplained thrombocytopenia or neutropenia may require marrow examination to determine whether peripheral destruction or defective marrow production is involved. Anemic patients are seldom subject to bone marrow examinations unless the cause is not apparent after a variety of other laboratory assays have been performed, or if the disease does not respond to appropriate therapy. Bone marrow examination may also be performed in patients with unexplained fever ("fever of unknown origin") to obtain material for microbiologic culture and to rule out the presence of malignancy, granulomatous disease, or other conditions.
A successful bone marrow evaluation requires knowledge of the patient and the reason(s) the study was requested. The following information should be obtained when the laboratory is first contacted to schedule the marrow study:
Current and previous laboratory data should be reviewed, and a peripheral blood smear examined, to validate the request for a bone marrow study. For example, has the evaluation of an anemic patient included serum iron studies and a serum ferritin assay? If the request seems inappropriate, the requesting physician should be contacted to justify the request. Many hospitals require a consultation from the Hematology/Oncology Service prior to requesting a marrow examination. If the marrow is requested as part of a research protocol, a copy of the protocol, or a detailed list of required specimens, preparation instructions, and mailing instructions should be obtained. If premedication may be needed, arrangements should be made to have a "prn" order placed on the chart.
Since bone marrow procedures are usually performed in the clinic or at the bedside, appropriate supplies and equipment must be carried to the site. A compartmentalized plastic or wooden tray is usually used for this propose, or the equipment may be carried in a wheeled cart with a flat work surface for preparing the marrow slides. Adequate routine supplies to perform several bone marrow examinations should be carried in the tray, as well as any special tubes, preservative solutions, etc. At the Medical College of Virginia, our bone marrow tray includes the following items:
Fig 2. Commercially available bone marrow procedure kit containing supplies and eauipment for a bone marrow aspirate and biopsy.
The patients chart should be reviewed upon arriving at the location of the marrow procedure to verify the information previously provided to the laboratory. Do not assume that this information is complete or correct. The following facts should be verified:
Once the chart review is completed, the nurse caring for the patient should be notified of the procedure and necessary assistance requested.
The identification of the patient must be absolutely confirmed, preferably by verifying the hospital number from a wrist band or identification card. If such is not available, the patient should be asked to state their name and asked whether they were expecting to have a marrow performed. The marrow team should be introduced to the patient. The procedure must be explained to the patient, all questions answered to the satisfaction of the patient, and written consent obtained. The following is a typical description of a posterior iliac crest procedure provided to the patient.
" We have been asked by your doctor to obtain a sample of your bone marrow to look at under the microscope and perform certain other tests on. This is necessary to diagnose (or treat) your (low blood counts, leukemia, etc.). This procedure takes about 20 to 30 minutes to perform and will be done here in your room. Most of the time is used to get everything ready and wash the skin. We will place you on your side, wash the skin over from the back and upper part of your hip bone (point to the area on yourself), numb the skin and bone thoroughly in this area, and obtain the marrow with a couple types of needles. It may be somewhat uncomfortable at times, but actually hurts only for about 5 seconds ... I'll tell you ahead of time so you can hold your breath. To allow a clot to form, we will place a pressure bandage over the marrow site at the end of the procedure ask you to lie on your back for at least 30 minutes after the procedure. Most patients complain of a slightly sore back afterward but have no other problems. However, you need to be aware that there is a slight risk, about one in five thousand, of developing bleeding or infection from placing needles into the body. If you feel nervous about the procedure, we can give you some medicine to calm you down, but it will make you sleepy for several hours afterward. Since the soap we use to wash your skin contains iodine, I need to know whether you have an allergy to iodine. I also need to know whether you are allergic to lidocaine, the medicine that we use for numbing the skin and bone. Are you allergic to either of these substances? The bandage can come off in the morning, and it will pull of easier if you take a shower of bath first and get it wet. No other care of the biopsy site is required. Do you have any questions? Will you consent in writing to the marrow procedure?"
All questions should be answered completely. The patient should then be given the opportunity to sign the written consent form. If the patient seems anxious or reluctant, the procedure should be discussed further with the patient, and sedation offered, even if not requested to this point. Sedation should be especially considered if marrow procurement must be repeated later. In extreme cases, the procedure should be delayed until the proper type of anesthesia can be arranged.
Hematopoietically active bone marrow is distributed throughout the skeleton in children, but is restricted to the axial bones of adults. Of the potential sites to obtain the bone marrow, the posterior iliac crest is optimal for reasons of safety and ease of performance. Alternative sites should be considered if the posterior iliac crest is diseased or inaccessible because of morbid obesity or inability to position the patient correctly. These alternative sites include the tibia (infants only), anterior iliac crest (children and adults), and sternum (adults only, aspirate only). Sternal marrow examination should be considered only if other sites are unacceptable, and is completely contraindicated in patients with diseases associated with bone resorption, including multiple myeloma (Foucar, 1995).
There is continuing debate about adequate marrow sampling for various purposes. Most studies of multiple marrow sites have revealed marrow cellular content, cellular composition, and pathologic lesions to be rather uniformly distributed through the bone marrow. Therefore, most hematopathologists today consider an adequate sample from a single site acceptable in most patients. At the Medical College of Virginia, we try to obtain an aspirate specimen and two biopsy cores from a single site, with additional biopsy cores in patients where "focal" lesions are suspected, such as lymphoma, granulomata, and metastatic carcinoma. If radiographic studies suggest unilateral disease, sampling from that side is favored. We obtain a bilateral sample only if required by a treatment protocol.
Fig 3. Diagram of posterior pelvic bone, illustrating the location of the right posterior iliac crest (arrow).
The best sequence to obtain marrow specimens is also controversial. The biopsy may be altered by needle artifact if the aspirate is obtained first, while the aspirate specimen may clot if the biopsy is performed first and releases "tissue juices" into the area. In this regard, Foucar (1995) feels that the sequence is unimportant, as long as different areas along the posterior iliac crest are sampled.
The patient is positioned as follows, depending on the location of the procedure:
|"Im going to chose the area to obtain the marrow. You will feel me pushing with my fingers. Let me know whether any spot feels sore"
A continuing conversation should be began with the patient and continued throughout the entire procedure. This is necessary to inform the patient about anticipated discomfort from the procedure, to assess the patients feeling of pain, and to obtain early warning of complications such as a vasovagal reaction.
Nonsterile latex "examination" gloves and a plastic procedure gown or other protective clothing should be worn. The patients back should be carefully palpated to identify anatomical landmarks and the appropriate anatomic site for marrow procurement. To identify the chosen site after the area is cleaned with povidone-iodine soap, it can be highlighted with an indelible pen or by making a shallow impression in the skin with the tip of a plastic ear speculum. One of the following locations is chosen.
"Im going to wash your skin with iodine-soap ... it will feel cold and wet"
The skin of surrounding the procedure site should be cleaned as follows:
|"Im going to put on sterile gloves and then place a sterile drape over the washed area. Try to lie still. Are you relaxing?"
Since most patients are adapting well to the experience by this time, this is a good point to reassess the need for sedation. Although the vast majority of patients require no other pharmacologic intervention than local anesthesia, occasional patients may require conscious sedation to permit proper marrow procurement. Drugs commonly used for the bone marrow procedure are listed in Table I.
Anxious patients who have an intravenous line (IV) in place can be given diazepam ("Valium") by the assisting nurse or physician. This should be slowly hand-pushed (1 mg/min) into a rapidly running IV until the patients speech is slurred (keep the patient talking!). This may require 5-20 mg of diazepam over 5-10 minutes. The patient usually falls asleep and snores, but can be aroused. This sedation lasts 20 min to 2 hours and usually produces desirable amnesia for the procedure. Be sure to have Ambu-Bag nearby, just in case! ... But it wouldnt be needed.
"Im going get the numbing medicine ready. Have you ever had numbing medicine or local anesthetics before? They are used for dental work, biopsies, sewing up wounds, and other procedures"
Once a sterile site has been achieved, a local anesthetic is utilized to "numb" the skin and periosteum over the chosen area of the posterior iliac crest. Lidocaine or a similar local anesthetic can be used, providing the patient has no history of an allergic reaction to this medication (BE SURE TO ASK!). During this process, local anesthetic is first infiltrated into the skin and subcutaneous tissue to anesthetize an area approximately 1 cm. in diameter.
25-100 mg IM
50-100 mg PO
IM, IV, PO
0.044 mg/kg IM, IV
2-5 mg PO
* Dosages vary with weight, age, etc. and should be adjusted to the individual patient and desired level of sedation.
** Midazolam may cause severe respiratory depression and should only be used in situations where heavy sedation is required. Consult PDR for current dosing recommendations.
"Im going to start numbing the skin now. You will feel a little needlestick on your back"
After the skin is numb, lidocaine is infiltrated directly over the periosteum to numb an area approximately 2-3 cm in diameter. Discomfort can be avoided during the remainder of the procedure if adequate time is taken to assure good anesthesia. Local anesthesia is administered as follows:
- Adverse reactions to lidocaine can occur. The adverse reactions are primarily of a neurologic, cardiovascular, and allergic nature. The maximum recommended dose of lidocaine with epinephrine for healthy adults is approximately 7 mg/kg or 500 mg total dose (50 mL 1% lidocaine). If anaphylaxis occurs, know where the "crash cart" is! Other local anesthetics can be used in patients who have a known hypersensitivity to lidocaine. These include chloroprocaine (Nesacaine, Astra Pharmaceutical) and bupivacaine hydrochloride (Sensorcaine, Astra Pharmaceuticals). Another alternative in allergic patients is administer methylprednisone (40 mg) and benadryl (50 mg) intravenously immediately prior to the procedure using lidocaine, followed by oral prednisone (1 mg/kg) in two divided doses over 24 hours (Saul Yanovich, M.D., personal communication).
Fig 4. Subcutaneous infiltration of 1% buffered lidocaine, using a 26 gauge needle.
Fig 5. Infiltration of 1% lidocaine into the periosteum of the posterior iliac spine, using a 10 mL syringe with a 3 1/2 in. spinal needle.
Obtaining marrow specimens is relatively easy to perform if adequate care has been take to locate the periosteum and infiltrate an adequate area with a local anesthetic. We routinely obtain the bone marrow aspirate specimen first.
"Im going to let the numbing medicine work some more while we get the collection tubes for the marrow ready. Are you feeling OK?"
Marrow aspiration from the posterior or anterior iliac crest is performed as follows:
Fig 6. Bone marrow aspiration. A 16 gauge Illinois sternal/Iliac aspiration needle has been placed into the marrow cavity. The obturator is being removed.
"There will be a sharp sensation that lasts about 3 seconds, then it will go right away. So don't move now, 1. 2 .. 3"
Fig 7. Bone marrow aspiration. The obturator of the Illinois sternal/Iliac aspiration needle has been removed and a 10 mL syringe attached to the hub. Suction is being applied to the syringe, with successful aspiration of marrow.
Fig 8. Preparing aspiration smears. A experienced medical technologist is preparing smears from small drops of the bone marrow aspirate placed on glass microscope slides.
|"The first part of the procedure is finished. Im going to slowly remove this needle. We will start the biopsy in a minute. Just relax|
Marrow aspiration from the sternum is usually performed only when the posterior and anterior iliac crests are severely diseases or inaccessible as a result of massive obesity. In addition to the rare, but very serious complication complication of entering the mediastinum during the procedure, the sternum is an unsuitable site for biopsy procurement. If a sternal aspiration is necessary, the following procedure is used.
The bone marrow biopsy is obtained through the same skin incision site used for the marrow aspiration, but the needle is angled differently from the aspirate needle in order to sample a different area. Due to the larger caliber of the bone marrow biopsy needle, more force is usually required than with the aspirate needle. In addition, some patients complain of an uncomfortable dull ("pressure") sensation as the needle is advanced, which is not relieved by local anesthetic. Bone marrow biopsies are obtained from the PIC or AIC,
"I'm inserting a different type of needle to obtain a biopsy specimen. The area should be numb, but let me know if you feel any sharp pain"
Fig 9. Completed smears prepared from a bone marrow aspiration.
"Im starting to take a biopsy. You will probably feel some pressure. Tell me if it turns sharp"
|Fig. 10. Inserting a 4", 11 gauge, contoured Jamshidi bone marrow biopsy/aspiration needle into the posterior iliac crest for biopsy procurement|"Ive finished advancing the needle. Now Im going to turn the needle several times to break off the small piece of bone. You might feel a little pain"
Fig 11. Determining length of biopsy core in needle by carefully reinsurting obturator. Ideally, the core length should be 2 cm or greater.
Fig 12. Delivery of biopsy core unto a glass microscope slide. The core has been forced through the hub of the needle using a small blunt obturator.
Fig 13. Preparing touch preparations from the biopsy core. The medical technologist is gently touching a clear glass microscope slide to the biopsy core resting on another glass slide. Cells on the surface of the core stick to the clean slide, which is later stained by the Wright-Giemsa technique. Cytologic detail of the cells can be visualized and complements the aspirate and biopsy.
"Ive finished getting the biopsy. Now I will remove the drape, clean the area off with some alcohol swabs, and place a bandage over the site. Please continue to lie on your side for a few more minutes"
After procurement of the marrow specimens, bleeding must be stopped, the procedure site must be cleaned up, needles properly disposed of in a Sharps container, and the site bandaged. A procedure note must be placed on the patientIs chart.
"I've finished the procedure. I would like you to roll over on your back and remain in that position for at least thirty minutes. You can pull the bandage off tomorrow morning. Since the tape is very sticky, it will pull off easier if you get it wet first. An ice pack will help if your back feels tender. I dont believe you will have any problems from the procedure, but get in touch with your doctor here in the unlikely event you notice severe pain, swelling or bleeding from the area. I greatly appreciated your cooperation"
Fig 14. Disposal of used equipment in a Sharps container.
I personally performed a ____________ (right, left, bilateral) bone marrow aspiration and biopsy at the request of Dr. ______________ for the evaluation of ___________________ (acute leukemia, lymphocytosis, pancytopenia, etc.). The risks and benefits of the procedure were explained to the patient and written consent was obtained. The procedure was performed under sterile conditions, using 1% lidocaine for local anesthesia. The procedure was well tolerated by the patient and no complications were encountered. Although minimal bleeding was encountered during the procedure, the patient was instructed to lie supine for at least 30 minutes to minimize the risk of later bleeding or hematoma formation. Extra marrow aliquots were obtained for special studies.
Fig 15. Bandaging the procedure site. A folded gauze square is placed over the site, and this is covered by two six inch lengths of elastic tape.
If a resident assisted or performed the procedure, the introduction reads:
Dr. ______________ performed a ____________ (right, left, bilateral) bone marrow aspiration and biopsy with my assistance and under my direct supervision.
After returning to the laboratory, have one or two aspirate smears immediately stained by the Wright-Giemsa technique and examine microscopically. Inform the attending physician of the result by telephone, and place a message in the chart if necessary.
The bone marrow examination includes the following studies:
The posterior superior iliac spine (posterior iliac crest) is the preferred source of diagnostic bone marrow in adults and children > 2 years of age. The posterior iliac crest is located three to five cm. from the midline and five to seven cm caudal to the level of the superior margin of the iliac crest. Biopsies are safely obtained from this site, and the procedure can be obtained out of vision of the patient. Complications (infection, retroperitoneal hemorrhage) are exceedingly rare, and fatalities have not been reported. In children < 2 years, bone marrow is usually obtained from the medial aspect of the proximal tibia. After consent has been obtained from the patient (or guardian) and a mild sedative has been administered (if necessary), the patient is placed in a supine or lateral recumbent position, the biopsy site is located, and the overlying skin is surgically prepared and draped. Disposable, sterilized trays with all necessary components to perform a bone marrow aspirate and biopsy are commercially available and currently preferred for bone marrow examination. The skin, subcutaneous tissue, and periosteum are infiltrated with lidocaine or other local anesthetic with a small gauge needle, and after waiting several minutes, a small incision is made in the skin with a sharp scalpel. A No. 18 Illinois or other suitable aspiration marrow needle is inserted into the bone, a syringe is attached to the hub, and approximately one ml. of marrow is removed by aspiration. The patient experiences a sharp pain upon aspiration if the needle is correctly placed in the marrow cavity. The marrow is gently compressed between two cover slips which are then spread apart and dried for later staining and microscopic examination.
The bone marrow needle biopsy is usually obtained after the marrow aspiration. A Jamshidi needle with the stylus in place is inserted perpendicularly through the biopsy site into the outer cortex of the bone. The needle is then turned 30o cephalad and 30o laterally and pushed with a rotary motion through the bone between the cortical tables. A decrease in resistance after 1-2 cm of advance signifies entrance into the cancellous portion of the bone. The obturator is then removed and the needle is slowly advanced with a clockwise-counterclockwise motion. The needle is then withdrawn slightly, redirected at a slightly different angle, rotated several times, and slowly withdrawn while turning. The biopsy core is pushed out of the needle with a probe inserted into the cutting end. Touch imprints are made from the biopsy core by gently touching with a glass microscope slide, and the core is then placed into 10% formalin or another fixative. Sections of the marrow are cut and stained following brief decalcification. Local pressure is applied to the biopsy site for approximately five minutes or until the bleeding has stopped, a pressure dressing is then applied, and the patient is instructed to lie on his or her back for at least one hour. The biopsy site may remain tender for several days, although many patients have no residual pain or discomfort.
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