Bone Marrow Biopsy

Lauren M. Yorek, MD
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Subject: Bone Marrow Biopsy

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Introduction

Bone marrow biopsy is an elective procedure that can be performed in an outpatient setting. Evaluation of bone marrow samples can be important in the diagnosis of many hematologic and malignant processes. In adults, bone marrow is usually obtained from the pelvis, which is the major site of cellular production after childhood. In infants, the tibia is also a possible site of bone marrow aspiration. 
Be sure to obtain informed consent from the patient. Many practices employ standard procedure consent forms with detailed information specific to bone marrow biopsy. The listed procedural risks should include bleeding, bone fracture, infection, and pain. Before starting the procedure, consent forms should be signed by physician, patient, and a witness. 

Equipment

  • Bone marrow biopsy needle

  • Sterile collection tubes for both aspirate and marrow biopsy

  • Scalpel blade size no. 10 or 15

Indications

  • Unexplained anemia—can determine both iron stores and underlying etiology

  • Metastatic disease

  • Lymphoma and leukemia diagnosis, staging, and response to treatment

  • Evaluation of cytopenias

  • Bone marrow transplant

  • Chromosomal analysis

  • Immunocompromised states, to evaluate for infection or white cell line deficiencies

  • Thrombocytopenia, to assist in differentiation of bone marrow disorders from splenic sequestration and increased peripheral platelet destruction

  • Infection, particularly fungal and tubercular infections

  • Fever of unknown origin, to evaluate for malignancy or infection

Contraindications

  • Bleeding diathesis.

  • Thrombocytopenia—platelet levels of <20,000 to 50,000 usually require platelet transfusion prior to invasive procedure. Assistance from a hematologist or other qualified specialist is advised in this situation.

  • Severe osteoporosis—evaluate for risk of fracture due to procedure.

  • Previous radiation at the site—marrow site may be sclerotic and may not provide good sample material.

  • Infection or osteomyelitis at or near the puncture site.

The Procedure

Step 1

If an intravenous (IV) line for conscious sedation is desired to augment local anesthetic, establish IV access. See Procedural (Conscious) Sedation and Pediatric Sedation. Place the patient in the prone position and identify the iliac crests bilaterally. Then follow the iliac crests to the posterior superior iliac spine. 
  • PITFALL: Medical personnel with expertise in the use of conscious sedation should be present.

  • Pearl: The use of conscious sedation with intravenous propofol, midazolam, and fentanyl has been studied in the outpatient setting. This conscious sedation is in addition to local anesthesia. The use of conscious sedation has been shown to be as safe as using local anesthesia alone.

  • Pearl: The use of oral premedication may be helpful in some patients.

Step 2

Sterile technique should be employed including the use of sterile gloves. Prep the area (see Appendix E). Place a fenestrated drape over the biopsy site. 

Step 3

Inject 1% lidocaine to anesthetize the area. Make an initial wheal in the skin with a 25-gauge needle. 

Step 4

A 22-gauge needle should then be advanced through the area to the level of the periosteum. The periosteum will feel solid with some porous “give” to it. Up to 10 to 20 cc of lidocaine may be used to anesthetize the periosteum. It is important to adequately anesthetize the periosteum prior to the procedure. 

Step 5

Once the lidocaine is injected, make a small stab wound at the site with a no. 11 scalpel blade. 

Step 6

Examine the biopsy needle to ensure that the obturator is locked into place. Most biopsy needles will have a cap that is screwed on to secure the obturator. 

Step 7

Grasp the needle by placing the second and third finger (index and middle finger) around the handle. The capped end of the needle should rest firmly in the palm of the hand to allow the necessary pressure to be applied. Insert the needle through the puncture site until the periosteum of the iliac crest is felt. Make sure that the needle is angled perpendicular to the posterior superior spine of the iliac crest and slowly advance the needle toward the marrow cavity. 

Step 8

To advance the needle to the marrow cavity, rotate it alternately in a clockwise and counterclockwise manner while exerting firm pressure. Continue the pressure to penetrate the bony cortex, which is approximately 1 cm thick. Once the marrow cavity is entered, the needle will advance much more easily. Then advance the needle approximately 1 to 2 more mm. 
  • Pearl: The amount of pressure required often requires the full use of upper body strength rather than just arm strength (as with chest compressions during cardiopulmonary resuscitation).

  • PITFALL: If the needle is not angled correctly, it may slip down the iliac crest and not enter the marrow cavity.

Step 9

Remove the obturator. 

Step 10

Withdraw approximately 5 cc of marrow into an ethylenediaminetetraacetic (EDTA) syringe and transfer to an EDTA test tube. 
  • PITFALL: The aspiration process is painful. Warn the patient before the actual aspiration is performed.

  • PITFALL: If no marrow is aspirated, replace the obturator and advance the needle 1 to 2 more mm and attempt aspiration again.

  • PITFALL: If the needle is advanced without the obturator in place it may become clogged with bony material.

  • Pearl: If no marrow is obtained, then change biopsy sites.

Step 10
Step 10

Step 11

To obtain a biopsy after marrow aspiration has been performed, replace the obturator and withdraw the needle to the level of the cortex. Angle the needle anteriorly within the iliac spine and advance it to the marrow cavity. The resistance will decrease as the marrow cavity is entered as before. 
  • Pearl: This forward motion within the marrow cavity should be performed with the same clockwise and counterclockwise rotation used to penetrate the bony cortex.

Step 11
Step 11

Step 12

Once the marrow cavity is entered, remove the obturator and advance the needle approximately 2 cm. After rotating the needle back and forth approximately 5 times, withdraw the needle 2 to 3 mm and angle it 15 degrees. 
Step 12
Step 12

Step 13

Advance the needle approximately 2 to 3 mm at this angle. This maneuver will dislodge the marrow. Once the marrow has been dislodged within the cavity, withdraw the biopsy needle with your thumb covering the hub of the needle. After the needle is fully withdrawn, place the obturator into the needle and push the specimen into a specimen container. 
  • PITFALL: Do not replace the obturator until the needle is fully withdrawn.

Step 13
Step 13

Step 14

Place a pressure dressing over the biopsy site. Allow the patient to lie supine for 1 hour to assist with direct pressure. 
Step 14
Step 14

Complications

  • The bone marrow needle can break and must be retrieved with either a hemostat or with the assistance of a surgeon.

  • Hemorrhage may occur at the biopsy site and is treated with local pressure at the biopsy site. (This is more of a risk in patients with thrombocytopenia.)

  • Retroperitoneal hematoma from bleeding complication.

  • Pulmonary emboli can occur after sternal aspiration.

  • Infection of bone marrow aspiration sites. (This is more of a risk in immunocompromised patients.)

  • Fracture of bone.

Pediatric Considerations

In many premature infants and some full-term infants, the iliac bone has not completely ossified, and an alternative bone such as the anterior tibia is used. In children, conscious sedation has been successfully used to reduce pain and distress. 

Postprocedure Instructions

After applying a pressure dressing to the site, have the patient lie supine for 1 hour. If sedation was administered, then appropriate monitoring should be performed until the patient has reached the presedation level of consciousness. Before patient discharge, examine the biopsy site for any bleeding. 

Coding Information and Supply Sources

Note that Medicare may not reimburse the cost of a bone marrow biopsy if it is not done at an approved facility. 

ICD-9 Codes

Bibliography

Burkle CM, Harrison BA, Koenig LF Morbidity and mortality of deep sedation in outpatient bone marrow biopsy. Am J Hematol .  2004;77(3):250–256. [View Abstract]
Hertzog JH, Dalton HJ, Anderson BD Prospective evaluation of propofol anesthesia in the pediatric intensive care unit for elective oncology procedures in ambulatory and hospitalized children. Pediatrics.  2000;106(4):742–747. [View Abstract]
Lutehr JM, Lakey DL, Larson RS Utility of bone marrow biopsy for rapid diagnosis of febrile illness in patients with human immunodeficiency virus. South Med J.  2000;93(7):692–697.
Riley RS, Hogan TF, Pavot DR A pathologist’s perspective on bone marrow aspiration and biopsy: performing a bone marrow examination. J Clin Lab Anal .  2004;18(2):70–90. [View Abstract]
Ryan DH, Cohen HJ. Bone marrow examination. In: Hoffman R, Benz EJ Jr, Shattil SJ, eds. Hoffman Hematology: Basic Principles and Practice. 4th ed. New York: Churchill Livingstone;  2005.
Ryan DH, Felgar RE. Examination of the marrow. In: Lichtman MA, Beutler E, Kipps TJ, eds. Williams Hematology . 7th ed. New York: McGraw-Hill;  2006.
Von Heijne M, Bredlov B, Soderhall S Propofol or propofol-alfentanil anesthesia for painful procedures in the pediatric oncology ward. Paediatr Anaesth .  2004;14(8):670–675.
Wolanskyj AP, Schroeder G, Wilson PR A randomized, placebo-controlled study of outpatient premedication for bone marrow biopsy in adults with lymphoma. Clin Lymphoma.  2000;1(2):154–157. [View Abstract]
2008 MAG Mutual Healthcare Solutions, Inc.’s Physicians’ Fee and Coding Guide. Duluth, Georgia. MAG Mutual Healthcare Solutions, Inc. 2007.
 
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