‘Bone marrow procedure’

Ayesha

Introduction

• Essential investigation for the diagnosis and management

• final interpretation requires the integration of peripheral blood, bone marrow aspirate and trephine biopsy findings, together with the results of supplementary tests such as, immunophenotyping, cytogenetic analysis and molecular genetic studies

History

• Trepanning, also known as trephination, trephining or making a burr hole is the oldest known procedure.

• Cave paintings indicate that people believed the practice would cure epileptic seizures, migraines, and mental disorders

Dr. John Clarke trepanning a skull, ca. 1664, in one of the earliest American portraits. Clarke is alleged to have been the first physician to have performed the operation in the New England Colonies.

Detail from The Extraction of the Stone of Madness, a painting by Hieronymus Bosch depicting trepanation (c.1488-1516).

History of bone marrow examination

• 1905, the Italian physician Pianese reported bone marrow infiltration by the parasite Leishmania

• In 1923, Seyfarth used a surgical trephine to obtain marrow from the ribs and the sternum.

• 1945, Vandenberghe and Blitstein were the first to use the iliac crest to obtain bone marrow

• In 1952,Bierman used the posterior iliac crest as the site forbone marrow aspiration, claiming it to be a safe site.

Indications for bone marrow examination

• Investigation of unexplained anaemia, abnormal red cell indices or cytopenias

• Investigation of abnormal peripheral blood smear morphology

• Diagnosis, staging and follow-up of malignant haematological disorders (e.g. acute and chronic leukaemias, myelodysplastic syndromes, myeloproliferative disorders, lymphomas, plasma cell myeloma).

• Investigation of suspected bone marrow metastases.

Indications for bone marrow examination

• Unexplained focal bony lesions on radiological imaging.

• Unexplained organomegaly or presence of mass lesions inaccessible for biopsy.

• Microbiological culture for investigations of pyrexia of unknown origin or specific infections, e.g. miliary tuberculosis, leishmaniasis, malaria.

Indications

• Evaluation of iron stores.

• Investigation of lipid/glycogen storage disorders.

• Exclusion of haematological disease in potential allogeneic stem cell transplant donors.

Trephine not needed!

• Investigations of suspected storage disease• Investigation of suspected acute leukaemia• Assessment of remission status after

treatment of acute leukaemia• Investigation of suspected chronic myeloid

leukaemia• Follow up of chronic myeloid leukaemia

Contraindication

• Presence of hemophilia• Severe disseminated intravascular

coagulopathy • Severe bleeding disorders• Infection or previous radiation

therapy • Sternal bone marrow aspiration in

multiple myeloma

Preparations prior to the procedure

• The procedure should be explained in detail to the patient.

• The past clinical history of the patient should be obtained, any allergies and co-morbidities documented and any premedications explained.

• Informed consent should be obtained from the patient.

• A blood count and smear should be obtained.

• Consider site for BM examination carefully.

Choosing a site

• preferred anatomic site for BM aspiration and trephine biopsy is the posterior iliac crest.

• The anterior iliac crest can be used if the patient is immobile.

• The medial surface of the tibia can also be used in infants.

• Sternum, Greater trochanter of the femur, individual vertebral bodies, or ribs – selected cases.

• Occasionally, in obese or large patients, it may be necessary to use a trephine biopsy needle for both the aspiration and biopsy at the iliac crest, as this needle tends to be longer than a standard aspiration needle.

Sternal puncture

• The usual site for puncture is the manubrium or the first or second parts of the body of the sternum.

• The site for puncture of the manubrium should be about 1 cm above the sterno-manubrial angle

• It is essential to use a needle with a guard

Sternal marrow needle

Comparison of Different Sites

for Marrow Puncture• There is considerable variation in the

composition of cellular marrow withdrawn from adjacent or different sites.

• Aspiration from only one site may give misleading information; this is particularly true in aplastic anaemia since the marrow may be affected patchily.

The procedure

• It is recommended that the aspirate and trephine biopsy be obtained using the respective needles separately, and not through a trephine needle.

• If the aspirate is performed with a trephine needle, the aspirate sample may be haemodiluted. If the biopsy is then performed using the same needle, the trephine core may be damaged or haemorrhagic.

Use of an assistant

• Bone marrow aspirates often clot within minutes of being obtained.

• During this time, the person performing the procedure may still be busy performing an aspiration or biopsy at the same or another site.

• It is therefore important that bone marrow aspiration and biopsy be carried out with the help of a trained assistant

Needle selection

• Disposable aspiration and biopsy needles are preferred in order to guarantee sterility and sharpness, as well as to reduce procedure-related pain and "failure" rates.

Needles

• Should be Stout

• 7-8 cm in length

• Adjustable guard

• Well-fitted stylet

• Edges well sharpened

Salah aspiration needle

Islam trephine needle

Illinois Bone MarrowAspiration Needles

Technique

• Cover the patient• Examine the site• Mark the site in the skin• Clean the area with pyodine solution• Anesthetize with 5cc – 10cc lidocaine• General anesthesia is required for

pediatric cases, some sternal bone marrow sampling cases, and in those patients who are highly anxious

Application of anesthesia

Marrow aspiration

• Hold bone marrow needle with stylet perpendicular to skin & gently advance

• Use a steady twisting motion to enter the marrow cavity

• Take 20cc syringe & attach it to the aspirate needle

• Remove the bone marrow needle using the twisting motion

Aspiration

Aspiration/Trephine

• Smear should be immediately prepared to ensure adequate particles and prevent contamination & clotting.

• Change the needle position slightly to a different area of bone after aspiration is obtained.as , aspiration artifact may be created.

• The needle, with stylet locked in place, is held with the palm and index finger and repositioned so that a new insertion site is created for biopsy sampling.

Trephine

Trephine

• Once the needle touches the bone surface, the stylet is removed.

• Using firm pressure, slowly rotate the needle in an alternating clockwise-counterclockwise motion, and advance it into the bone marrow cavity to obtain an adequate bone marrow specimen measuring approximately 1.6-3 cm in length.

Trephine

• biopsy touch prints are useful, especially if the aspirate is dry and the only sample available is the bone marrow biopsy

Preparation of Slides

• An aspirate smear (or wedge) is the most simplistic of the methods, similar in presentation as a peripheral blood smear.

• A drop of the acquired specimen is placed 1 cm from the edge that opposes the frosted "labeled" end and, with a second glass slide placed at a 30º angle, the sample is pushed toward the opposing side in one rapid smooth stroke.

• Squash (or crush) preparations are prepared on glass slides by placing marrow particles on a slide and pressing the particles with another slide.

• These preparations are used to better observe cellular interactions as the architecture of the marrow unit is preserved.

Post Procedure Care

• After the procedure, firm pressure is applied for 5 minutes placed over the wound site.

• If hemorrhage from the wound persists, then place the gauze over the wound site, consistent pressure can be applied for a minimum of 30 minutes.

• The patient is to be discharged with orders that the wound dressing is to be maintained in a dry state for 48 hours.

• The wound site is to be checked frequently, and if persistent bleeding or worsening pain occurs, these findings are to be reported to the clinician’s office.

COMPLICATIONS

• Infection• Tumor seeding • fracture of bone• Needle breakage • Sternal bone marrow aspiration:

Penetration of the underlying mediastinal organs can result in mediastinitis, pulmonary embolism, pneumothorax, cardiac tamponade, and cardiac tissue injury.

REFERENCES• Trepanning or trephines: a history of bone marrow biopsy Liakat

A. Parapia 2007 British Journal of Haematology, 139, 14–19.

• ICSH guidelines for the standardization of bone marrow specimens and reports S.-H. LEE Int. Jnl. Lab. Hem. 2008, 30, 349–364.

• Bone marrow aspiration and Biopsy A.I. Onaga Annals of Ibadan Postgraduate Medicine. Vol.8 No.1 June, 2010.

• Dacie & Lewis Ninth Edition.

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