An Illustrated Guide to Performing Bone Marrow Puncture (without picture)

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An Illustrated Guide to Performing the Bone Marrow Aspiration and Biopsy

Roger S. Riley, M.D., Ph.D.Dawn Rosenblum, M.D.Robert Forysthe, M.D.

Medical College of Virginia, Virginia Commonwealth UniversityRichmond, VA

Thomas F. Hogan, M.D.Robert C. Byrd Health Sciences Center of West Virginia University

Morgantown, WV Table of Contents

Clinical indicationsGetting ready

Patient informationSupplies and equipmentReviewing the medical

recordMeeting the patient

Bedside preparation General considerationsPositioning the patient

Notice! This paper describes a commonmedical procedure and is intendedfor medical personnel. Onlytrained, experiences, andcredentialed individuals are

permitted to perform the bonemarrow aspiration and biopsy. Theopinions expressed are entirelythose of the authors and do notrepresent their respectiveinstitutions.

http://www.pathology.vcu.edu/education/PathLab/pages/hematopath/bm.html#Anchor-Clinical-49575

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Local anesthesia Bone marrow aspiration

Iliac crest (posterior andanterior)Sternum

Bone marrow biopsyFinishing upSummary References and additional reading

The bone marrow aspiration and biopsy are usually regarded by the publicand physicians as a brutal, extremely painful procedure which is difficult tomaster. However, with knowledge and some experience, successful marrowexaminations can be repeatedly performed with minimal discomfort to thepatient. This paper reflects the collective knowledge and experience of ahematopathologist (RSR), hematologist/oncologist/pathologist (TFH) andpathology residents (DR, RF) in this area. This paper was adapted from alecture series developed for residents by TFH.

Clinical Indications Peripheral blood examination and other routine laboratory assays do notalways provide enough information for diagnosis of hematologic disease. Insome patients direct microscopic examination of the bone marrow is requiredfor confirmation of a suspected clinical diagnosis or monitoring the course of therapy. Occasional patients require bone marrow for special studies, such ascytogenetic analysis, flow cytometry, or microbiological analysis.

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Fig. 1.Clinicalindicationsfor a bonemarrow

evaluation.Data from286 bonemarrowproceduresperformedat theMedicalcollege of Virginiabetween

Januaryand June,1998.

A bone marrow examination is performed in nearly every patient with asuspected 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 partof the staging process for newly-diagnosed patients with a malignantlymphoma or for patients with solid tumors undergoing evaluation for bone

marrow transplantation. Patients who are post-chemotherapy or bone marrowtransplantation may require a bone marrow evaluation if their peripheral bloodcounts do not recover as expected. Some research treatment protocols mayalso require a bone marrow study at certain post-treatment intervals.Unexplained thrombocytopenia or neutropenia may require marrowexamination to determine whether peripheral destruction or defective marrowproduction is involved. Anemic patients are seldom subject to bone marrowexaminations unless the cause is not apparent after a variety of other laboratory assays have been performed, or if the disease does not respond toappropriate therapy. Bone marrow examination may also be performed in

patients with unexplained fever ("fever of unknown origin") to obtain materialfor microbiologic culture and to rule out the presence of malignancy,granulomatous disease, or other conditions.

Getting Ready



Obtaining Patient Medical Information A successful bone marrow evaluation requires knowledge of the patient andthe reason(s) the study was requested. The following information should be

obtained when the laboratory is first contacted to schedule the marrow study:

Patient name Patient age and sex Primary diagnosis Reason/indication for bone marrow examination Allergies (especially to povidone iodine and lidocaine) Recent chemotherapy, radiation therapy, bone marrow transplantation Medications (iron, B12/folate, G-CSF, aspirin, coumadin, heparin,

antibiotics, etc.)

Special studies requested (immunophenotypic analysis, cytogeneticanalysis, culture, etc.) Anticipated patient difficulties (obtaining written consent, need for

premedication, etc.) Patient location/requested time of marrow examination Name/pager #/telephone # of person requesting examination Name of attending physician

Current and previous laboratory data should be reviewed, and a peripheralblood smear examined, to validate the request for a bone marrow study. For

example, has the evaluation of an anemic patient included serum iron studiesand a serum ferritin assay? If the request seems inappropriate, the requestingphysician should be contacted to justify the request. Many hospitals require aconsultation from the Hematology/Oncology Service prior to requesting amarrow examination. If the marrow is requested as part of a researchprotocol, 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.

Supplies and Equipment Since bone marrow procedures are usually performed in the clinic or at thebedside, appropriate supplies and equipment must be carried to the site. Acompartmentalized 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 anyspecial tubes, preservative solutions, etc. At the Medical College of Virginia,our bone marrow tray includes the following items:

Obtaining written consent

Small clipboardBallpoint penPatient consent forms

Site preparation

Alcohol prep pads, 2 ply, largeBetadine (povidone iodine) swabsticks (packets of 3) Ear speculumsGauge sponges 3 x 4 in. (7.5 x 10 cm

Plastic isolation gownsIsopropyl alcohol swabsticks (packets of 3) Latex gloves, examination,non-sterileLatex gloves, sterileLidocaine HCL, injection, 1%, 10 mg/mL, 20 mL vials Needles, 22gauge, 11/2 in.Small fenestrated sheet, sterile, 30" x 30" with 1 1/2" x 2" fenestrationSodium bicarbonate solution, 8.4% (1 mEq/mL), 50 mL vialsSodium heparin, 100 USP Units/mL, 2 mL vialsSpinal needles, 3 1/2" (Quincke type point)Sub-Q needles, 26 gauge, 5/8 in.

Marrow procurement

Blank labelsBone marrow aspiration needle, 15 gauge, 4"Bone marrow biopsy needle, "J" type, 11 gauge, 6" (15 cm)Contoured Jamshidi bone marrow biopsy/aspiration needle - 11 gauge,4"Disposable plastic syringes, sterile,10 cc.Disposable plastic syringes, sterile U 20 cc.Disposable scalpel, 25 kGy (2.5 mrad)Illinois sternal/iliac aspiration needle, 16 gauge, adjustable length (3/16"to 1 7/8")

Other supplies



AZF fixative, 10 mL sealed, labeled containersBandage scissorsElastic tape (Elastikon, J&J)Green-top (sodium heparin) vacutainersMicroscope slides, 1" x 3", frosted

Plastic bags, zip-lockPurple-top vacutainersSafety flow lancetTranspore tape (3M)

Fig 2.Commerciallyavailable

bone marrowprocedure kitcontainingsupplies andeauipmentfor a bonemarrowaspirate andbiopsy.

Reviewing the Patients Medical Record

The patients chart should be reviewed upon arriving at the location of themarrow procedure to verify the information previously provided to thelaboratory. Do not assume that this information is complete or correct. Thefollowing facts should be verified:



Is the patient identification correct? Use hospital numbers, not names. Is the request for a marrow procedure justified? Can the patient give written consent for the procedure? If not, obtain the

name and telephone number of the person giving consent Does the patient have special medical problems which may complicate

the procedure? These may include disease or recent surgery involvingthe pelvic bone, bleeding, severe cardiac or pulmonary disease,unusual sensitivity to pain, adversity to medical procedures, allergies toiodine or lidocaine, extreme obesity, etc.

Once the chart review is completed, the nurse caring for the patient should benotified of the procedure and necessary assistance requested.

Meeting the Patient The identification of the patient must be absolutely confirmed, preferably byverifying the hospital number from a wrist band or identification card. If such isnot available, the patient should be asked to state their name and askedwhether they were expecting to have a marrow performed. The marrow teamshould be introduced to the patient. The procedure must be explained to thepatient, all questions answered to the satisfaction of the patient, and writtenconsent obtained. The following is a typical description of a posterior iliaccrest procedure provided to the patient.

" We have been asked by your doctor to obtain a sample of your bonemarrow to look at under the microscope and perform certain other testson. This is necessary to diagnose (or treat) your (low blood counts,leukemia, etc.). This procedure takes about 20 to 30 minutes to performand will be done here in your room. Most of the time is used to geteverything ready and wash the skin. We will place you on your side, washthe skin over from the back and upper part of your hip bone (point to thearea on yourself), numb the skin and bone thoroughly in this area, andobtain the marrow with a couple types of needles. It may be somewhatuncomfortable at times, but actually hurts only for about 5 seconds ... I'lltell 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 theprocedure ask you to lie on your back for at least 30 minutes after theprocedure. Most patients complain of a slightly sore back afterward buthave no other problems. However, you need to be aware that there is aslight risk, about one in five thousand, of developing bleeding or infectionfrom placing needles into the body. If you feel nervous about theprocedure, 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 towash your skin contains iodine, I need to know whether you have anallergy 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 allergicto 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. Noother care of the biopsy site is required. Do you have any questions? Willyou consent in writing to the marrow procedure?"

All questions should be answered completely. The patient should then begiven the opportunity to sign the written consent form. If the patient seemsanxious or reluctant, the procedure should be discussed further with thepatient, and sedation offered, even if not requested to this point. Sedationshould be especially considered if marrow procurement must be repeated

later. In extreme cases, the procedure should be delayed until the proper typeof anesthesia can be arranged.

Bedside Preparation General Considerations

Hematopoietically active bone marrow is distributed throughout the skeleton inchildren, 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 theposterior iliac crest is diseased or inaccessible because of morbid obesity or inability to position the patient correctly. These alternative sites include thetibia (infants only), anterior iliac crest (children and adults), and sternum(adults only, aspirate only). Sternal marrow examination should be consideredonly if other sites are unacceptable, and is completely contraindicated inpatients with diseases associated with bone resorption, including multiplemyeloma (Foucar, 1995).

There is continuing debate about adequate marrow sampling for variouspurposes. Most studies of multiple marrow sites have revealed marrowcellular content, cellular composition, and pathologic lesions to be rather uniformly distributed through the bone marrow. Therefore, mosthematopathologists today consider an adequate sample from a single siteacceptable in most patients. At the Medical College of Virginia, we try toobtain an aspirate specimen and two biopsy cores from a single site, with



additional biopsy cores in patients where "focal" lesions are suspected, suchas lymphoma, granulomata, and metastatic carcinoma. If radiographic studiessuggest unilateral disease, sampling from that side is favored. We obtain abilateral sample only if required by a treatment protocol.

Fig 3. Diagram of posterior pelvic bone, illustrating thelocation of the right posterior iliac crest (arrow).

The best sequence to obtain marrow specimens is also controversial. Thebiopsy may be altered by needle artifact if the aspirate is obtained first, whilethe aspirate specimen may clot if the biopsy is performed first and releases"tissue juices" into the area. In this regard, Foucar (1995) feels that thesequence is unimportant, as long as different areas along the posterior iliac

crest are sampled. Positioning the Patient

The patient is positioned as follows, depending on the location of theprocedure:

Posterior iliac crest (PIC) Lateral decubitus position, knees flexed, pillowunder head, eyes away

Anterior iliac crest (AIC) - Supine position, hips and knees flexed, eyesaway

Sternum Supine position, head and eyes away, light towel over face "tokeep things sterile" (and cover eyes)

"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 aboutanticipated discomfort from the procedure, to assess the patients feeling of pain, and to obtain early warning of complications such as a vasovagalreaction.

Nonsterile latex "examination" gloves and a plastic procedure gown or other protective clothing should be worn. The patients back should be carefullypalpated to identify anatomical landmarks and the appropriate anatomic sitefor marrow procurement. To identify the chosen site after the area is cleanedwith 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. PIC - Center of posterior superior iliac spine AIC - Center of prominence of anterior superior iliac spine, just under lip

of crest Sternum - Second intercostal space in midline

"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: Use three sterile, disposable swabs soaked with 10% povidone-iodine

solution (Betadine Solution, Purdue Frederick Company). For individuals allergic to iodine,

chlorhexidine gluconate, 4% (Betasept Surgical Scrub, PurdueFrederick Company) may be utilized.

With each of the three swabs, wash the skin in a circular motionbeginning with the marked site and working outward approximately four

inches. Remove the povidone-iodine in the center of the washed area with a

single swipe of a sterile isopropyl-soaked swab.

"Im going to put on sterile gloves and then place a sterile drape over thewashed area. Try to lie still. Are you relaxing?"



Since most patients are adapting well to the experience by this time, this is agood 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 marrowprocurement. 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 givendiazepam ("Valium") by the assisting nurse or physician. This should beslowly hand-pushed (1 mg/min) into a rapidly running IV until the patientsspeech 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, butcan be aroused. This sedation lasts 20 min to 2 hours and usually producesdesirable amnesia for the procedure. Be sure to have Ambu-Bag nearby, justin case! ... But it wouldnt be needed.

"I'm getting ready to cover your back with a sterile towel to keep the areaclean. The towel has some sticky tape on it to hold it in place. You will feelit stick to your skin"

Place a sterile drape with a fenestrated opening over the area to besampled. "Im going get the numbing medicine ready. Have you ever had numbingmedicine or local anesthetics before? They are used for dental work,biopsies, sewing up wounds, and other procedures"

Local Anesthesia 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 andsubcutaneous tissue to anesthetize an area approximately 1 cm. in diameter.

Agent Route Adult Dosage Vistaril (Hydroxyzene) IM, PO 25-100 mg IM

50-100 mg PO



Ativan (Lorazepam) IM, IV, PO 0.044 mg/kg IM, IV2-5 mg PO

Demerol (Merperidine) IM 50-100 mg Versel (Midazolam) IM, IV **

* Dosages vary with weight, age, etc. and should be adjusted to the individualpatient and desired level of sedation. ** Midazolam may cause severe respiratory depression and should only beused in situations where heavy sedation is required. Consult PDR for currentdosing recommendations.

"Im going to start numbing the skin now. You will feel a little needlestick onyour back"

After the skin is numb, lidocaine is infiltrated directly over the periosteum tonumb an area approximately 2-3 cm in diameter. Discomfort can be avoidedduring the remainder of the procedure if adequate time is taken to assuregood anesthesia. Local anesthesia is administered as follows:

Aspirate 2 mL of 1% sterile sodium bicarbonate solution (to reduce theburning effect of the acidic lidocaine solution) and 8 mL 1% lidocainehydrochloride (Xylocaine, Astra Pharmaceuticals) into a 10 mL syringe.

Slowly infiltrate the skin with the buffered lidocaine, raising a "dime-sized" intradermal wheal with 26-gauge needle.

Caution! - Adverse reactions to lidocaine can occur. The adversereactions are primarily of a neurologic, cardiovascular, and allergic nature.The maximum recommended dose of lidocaine with epinephrine for healthyadults 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 anestheticscan be used in patients who have a known hypersensitivity to lidocaine. Theseinclude chloroprocaine (Nesacaine, Astra Pharmaceutical) and bupivacaine

hydrochloride (Sensorcaine, Astra Pharmaceuticals). Another alternative inallergic patients is administer methylprednisone (40 mg) and benadryl (50 mg)intravenously immediately prior to the procedure using lidocaine, followed byoral prednisone (1 mg/kg) in two divided doses over 24 hours (Saul Yanovich,M.D., personal communication).



Fig 4.Subcutaneous infiltration of 1% bufferedlidocaine,

using a 26gaugeneedle.

Infiltrate the subcutaneous tissue and periosteum, using a 22-gaugeneedle (or spinal needle for overweight patients). This usually requires2-5 mL of buffered lidocaine. Assess the thickness of the subcutaneoustissue and the depth to the periosteum for later reference.

Determine the adequacy of local anesthesia after several minutes bygently tapping the periosteum with the sharp point of the numbingneedle. If sharp pain is stilled experienced, the injection of additionallidocaine is required. Unbuffered lidocaine is used for this purpose.

Gently probe the surrounding periosteum with the needle to makecertain no sensitive areas remain.



Fig 5.Infiltration of 1% lidocaineinto theperiosteum of

the posterior iliac spine,using a 10mL syringewith a 3 1/2in. spinalneedle.

Obtaining marrow specimens is relatively easy to perform if adequate carehas been take to locate the periosteum and infiltrate an adequate area with alocal anesthetic. We routinely obtain the bone marrow aspirate specimen first.

"Im going to let the numbing medicine work some more while we get thecollection tubes for the marrow ready. Are you feeling OK?"

Bone Marrow Aspiration Marrow Aspiration: AIC, PIC

Marrow aspiration from the posterior or anterior iliac crest is performed asfollows:

Fill the necessary number of 10 mL syringes with heparin solution or other anticoagulant as required. Regardless of the suspected diagnosisor purpose of the study, it is best to obtain at least one heparin-anticoagulated tube of marrow aspirate, "just in case" it is needed for special studies (i.e., microbiologic culture, immunophenotypic analysis,cytogenetic analysis, molecular biology studies, etc.).



Obtain the desired marrow aspirate needle from the assistant andinspect for signs of manufacturing defects.

Remove the plastic guard from the needle (if one is present). Loosen and remove the obturator to make certain that it can be

removed with ease. Insert obturator and relock. If the skin is tough, make a small incision with a sterile scalpel. Hold the needle with index finger near needle tip to control the depth of

penetration. Hold needle horizontally (for a patient lying on their side) or vertically (if

supine) to puncture the anesthetized skin. Advance the needle with steady pressure and a slight twisting motion to

the center of the posterior iliac prominence (PIC) or to the bone (AIC). Fig 6.Bonemarrowaspiration.

A 16gaugeIllinoissternal/Iliacaspirationneedlehas beenplacedinto themarrowcavity.Theobturator is beingremoved.

Angle the needle 15 degrees caudad (PIC) or cephalad (AIC). Rotate the needle back and forth (90o-180o) and carefully apply

pressure to advance the needle through the cortical bone. Theconsistency of the bone varys considerably from patient to patient, butmay have significance as follows: Soft ("Swiss cheese") consistency =



osteoporotic bone (elderly patient, multiple myeloma, renal failure, somepost-chemotherapy patients), firm ("pine board") consistency = Normalfor young athletic individuals, very hard ("oak board") consistency =possible hyperostosis.

Decreased resistance (Usually!) indicates penetration of cortex and

entry into the marrow cavity. Advance needle about 1 cm into the marrow cavity. Unlock and slowly remove the obturator. Some patients may notice pain

if the obturator is not removed carefully. Attach a 10 ml syringe to the aspirate needle.

"There will be a sharp sensation that lasts about 3 seconds, then it will goright away. So don't move now, 1. 2 .. 3"

Quickly (< 5 seconds) aspirate 1.0 mL marrow into the 10 mL syringe(more than this dilutes the specimen with peripheral blood). BEWARE!The sudden sharp pain may cause the patient to shout, move suddenly,or even try the strike you! Remain alert, try to maintain sterility, andcalm the patient quickly if this happens.

Quickly give the syringe to the technical assistant to prepare specimenslides.

Hold a finger over needle opening to prevent blood flow while thetechnician prepares slides and evaluates for the presence of spicules.



Fig 7.Bonemarrowaspiration.The

obturator of theIllinoissternal/Iliacaspirationneedle hasbeenremovedand a 10mL syringe

attachedto the hub.Suction isbeingapplied tothesyringe,withsuccessfulaspirationof marrow.

If spicules are present, extra marrow specimen(s) for special studiescan be obtained. Aspirate approximately 2 mL of marrow into a syringecontaining 1 mL of heparin solution.

If a "dry tap" (no fluid, no sharp pain) occurs, then reposition needle(depth, angle or location) and try again. As a "last resort" touchpreparations can be prepared from the core biopsy. Try the oppositeside if necessary.

Remove aspiration needle and apply pressure with a sterile sponge untilbleeding ceases.

Perform a bone marrow biopsy or place a folded piece of gauze over the site, apply a pressure bandage, and have patient lie supine for atleast 30 minutes (see "Finishing Up" below).



Fig 8.Preparingaspirationsmears. Aexperience

d medicaltechnologist ispreparingsmearsfrom smalldrops of thebonemarrowaspirateplaced on

glassmicroscopeslides.

"The first part of the procedure is finished. Im going to slowly remove thisneedle. We will start the biopsy in a minute. Just relax

Marrow Aspiration: Sternum Marrow aspiration from the sternum is usually performed only when theposterior and anterior iliac crests are severely diseases or inaccessible as aresult of massive obesity. In addition to the rare, but very serious complicationcomplication of entering the mediastinum during the procedure, the sternum isan unsuitable site for biopsy procurement. If a sternal aspiration is necessary,the following procedure is used.

Use "Illinois" needle with guard. Assess subcutaneous thickness during local anesthetic. Adjust guard to 5-10 mm depth. Hold needle perpendicular to skin; insert down to bone. Rotate needle and advance.



Decrease in resistance (usually!) indicates entry into marrow cavity. Avoid penetrating the posterior table of the sternum (if the needle enters

the mediastinum, you may see fluid bubbles as the patient breatheswhen the stylus is removed).

Aspirate marrow specimen as above. Bone Marrow Biopsy

The bone marrow biopsy is obtained through the same skin incision site usedfor the marrow aspiration, but the needle is angled differently from the aspirateneedle in order to sample a different area. Due to the larger caliber of thebone marrow biopsy needle, more force is usually required than with theaspirate 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, NEVER THE STERNUM!

"I'm inserting a different type of needle to obtain a biopsy specimen. Thearea should be numb, but let me know if you feel any sharp pain"

Obtain a biopsy needle and inspect for bent, loose, or almost-brokenparts.

Remove obturator and inspect. Reinsert obturator and lock with a twist. Use the numbing syringe and needle to determine of additional local

anesthesia is needed for the skin and periosteum. Hold biopsy needle with hub in palm, index finger tip on skin to control

needle penetration. Insert through skin incision site. Using steady pressure, advance biopsy needle to the bone.



Fig 9.Completed smearspreparedfrom a

bonemarrowaspiration.

"Im starting to take a biopsy. You will probably feel some pressure. Tellme if it turns sharp"

At bone, advance needle through cortex with forceful rotating movement-- decreased resistance (usually) indicates entry into marrow cavity.

Remove obturator when needle is firmly anchored in bone. Advance needle 1-2 cm more with continued "back and forth" rotation.

To determine the length of the biopsy specimen in the needle, theobturator can be carefully reinserted into the needle. An ideal biopsycore is 2 cm or greater in length.



Fig. 10.Inserting a 4",11 gauge,contouredJamshidi bone

marrowbiopsy/aspiration needle intothe posterior iliac crest for biopsyprocurement

"Ive finished advancing the needle. Now Im going to turn the needleseveral times to break off the small piece of bone. You might feel a littlepain"



Fig 11.Determininglength of biopsycore in needleby carefully

reinsurtingobturator.Ideally, the corelength shouldbe 2 cm or greater.

Break off the biopsy specimen from the surrounding bone by vigorouslyrotating the needle 360 degrees several times while applying slightpressure. Decreased resistance to rotation usually indicates detachmentof the core from the surrounding bone. If difficulty is encountered,withdraw the needle slightly (2-3 mm, do not replace obturator), redirecttip at new angle, and readvance 2-3 mm with rotation, to break off thebiopsy core.

Rotate needle during withdrawal through bone, periosteum, and skin. Apply pressure to biopsy site until bleeding and oozing ceases. Use the small blunt obturator included with each biopsy needle to

remove the biopsy core. Hold the needle vertically with the beveled(distal) end up and the hub approximately 2 cm above a clean glassmicroscope slide or piece of sterile gauze held by the technicalassistant. Insert the obturator through the distal end of the needle and

gently force the biopsy through the hub of the needle unto the glassslide or gauze. In patients with extremely dense bone, the tip of the beveled end of the

needle may be bent during the biopsy procedure, making it difficult toinsert the obturator. Several attempts may be necessary. Be careful notto puncture your gloves!



Fig 12.Delivery of biopsycore untoa glass

microscope slide.The corehas beenforcedthroughthe hub of the needleusing asmall bluntobturator.

Inspect the biopsy for adequacy and atypical features. A normal biopsycore is dark red with a fine white trabecular network. In patients with amarkedly hypocellular marrow the trabecular network remains butreddish marrow is not visible. Cartilage is homogenous, white, andglistening, while cortical bone is white. A mottled appearance mayindicate focal replacement with tumor or granulomas.

Additional biopsy cores should be obtained if the specimen isinadequate in size or has an atypical gross appearance.

Several touch imprints of the biopsy core should be obtained. No biopsy specimen? Is it inside the skin incision? can it be withdrawn

with forceps? Repeat several times until specimen obtained. Try "tricks"to obtain core -- syringe with gentle vacuum over needle hub as you

withdraw, firmly rock needle back and forth before withdrawing, try newneedle, etc.



Fig 13.Preparingtouchpreparationsfrom the

biopsy core.The medicaltechnologistis gentlytouching aclear glassmicroscopeslide to thebiopsy coreresting onanother

glass slide.Cells on thesurface of the corestick to theclean slide,which islater stainedby theWright-Giemsa

technique.Cytologicdetail of thecells can bevisualizedandcomplements theaspirate andbiopsy.

"Ive finished getting the biopsy. Now I will remove the drape, clean thearea off with some alcohol swabs, and place a bandage over the site.Please continue to lie on your side for a few more minutes"

Finishing Up



After procurement of the marrow specimens, bleeding must be stopped, theprocedure site must be cleaned up, needles properly disposed of in a Sharpscontainer, and the site bandaged. A procedure note must be placed on thepatientIs chart.

Apply pressure with thumb or fingers to procedure site until bleedinghas completely ceased.

Gently remove and dispose of the fenestrated drape. Completely remove povidone-iodine from the skin with alcohol swabs.

Residual povidone-iodine may cause itching and lead to a future allergicresponse.

Double a gauze square an place over the procedure site. Cover the area with at least two pieces of surgical tape approximately 2-

3 inches in length. Pressure tape should be used if unusual oozing wasencountered during the procedure, and in patients withthrombocytopenia or a history of a hemostatic disorder.

Advise the patient to remove the dressing the following day, wetting thetape first to make removal easier. "I've finished the procedure. I would like you to roll over on your back andremain in that position for at least thirty minutes. You can pull the bandageoff 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 dontbelieve you will have any problems from the procedure, but get in touchwith your doctor here in the unlikely event you notice severe pain, swellingor bleeding from the area. I greatly appreciated your cooperation"



Fig 14.Disposalof usedequipment in a

Sharpscontainer.

Have the patient lie supine, putting pressure on the procedure site for at

least 30 minutes. Advise the patient to contact their physician if tenderness or bleeding is noted at the procedure site during the nextfew days. Thank the patient for their cooperation.

Carefully dispose of the syringes and needles in a sharps container. Advise the patients nurse or physician that you have completed the

procedure and remind them to keep the patient supine for 30 minutes. Place a note on the patients chart. This is required for medicolegal and

billing purposes, as well as to alert the patient care team to theperformance of the procedure and any complications that wereencountered.

The contents and style of the note can vary according to personal styleand hospital requirements. At the Medical College of Virginia, a notesimilar to the following is used. I personally performed a ____________ (right, left, bilateral) bone marrow



After returning to the laboratory, have one or two aspirate smears immediatelystained by the Wright-Giemsa technique and examine microscopically. Informthe attending physician of the result by telephone, and place a message in thechart if necessary.

Summary The bone marrow examination includes the following studies:

Peripheral smear evaluation Bone marrow aspirate Bone marrow tissue section (core biopsy)

The posterior superior iliac spine (posterior iliac crest) is the preferred sourceof diagnostic bone marrow in adults and children > 2 years of age. Theposterior iliac crest is located three to five cm. from the midline and five toseven cm caudal to the level of the superior margin of the iliac crest. Biopsiesare safely obtained from this site, and the procedure can be obtained out of vision of the patient. Complications (infection, retroperitoneal hemorrhage) areexceedingly 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 mildsedative has been administered (if necessary), the patient is placed in a

supine or lateral recumbent position, the biopsy site is located, and theoverlying skin is surgically prepared and draped. Disposable, sterilized trayswith all necessary components to perform a bone marrow aspirate and biopsyare commercially available and currently preferred for bone marrowexamination. The skin, subcutaneous tissue, and periosteum are infiltratedwith 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 sharpscalpel. A No. 18 Illinois or other suitable aspiration marrow needle is insertedinto 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 isgently compressed between two cover slips which are then spread apart anddried for later staining and microscopic examination.

The bone marrow needle biopsy is usually obtained after the marrowaspiration. A Jamshidi needle with the stylus in place is insertedperpendicularly 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 rotarymotion through the bone between the cortical tables. A decrease in resistanceafter 1-2 cm of advance signifies entrance into the cancellous portion of thebone. The obturator is then removed and the needle is slowly advanced with aclockwise-counterclockwise motion. The needle is then withdrawn slightly,

redirected at a slightly different angle, rotated several times, and slowlywithdrawn while turning. The biopsy core is pushed out of the needle with aprobe inserted into the cutting end. Touch imprints are made from the biopsycore by gently touching with a glass microscope slide, and the core is thenplaced into 10% formalin or another fixative. Sections of the marrow are cutand stained following brief decalcification. Local pressure is applied to thebiopsy site for approximately five minutes or until the bleeding has stopped, apressure 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 severaldays, although many patients have no residual pain or discomfort.

Source: http://www.pathology.vcu.edu/education/PathLab/pages/hematopath/bm.html

http://www.pathology.vcu.edu/education/PathLab/pages/hematopath/bm.html



An Illustrated Guide to Performing Bone Marrow Puncture (without picture)

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Transcript of An Illustrated Guide to Performing Bone Marrow Puncture (without picture)