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Aspiration of bone marrow from iliac crest (child)


Medical editor Bernward Zeller MD
Pediatric Oncologist
Oslo University Hospital

General

The cells in the blood and lymphatic system, in general, originate from stem cells in the bone marrow. In lymphoma and leukemia, as well as in some other tumors, a bone marrow examination is performed. In pediatrics, an aspiration and/or biopsy is taken from the iliac crest (hip bone). When doing a work-up for Hodgkin's lymphoma and some solid tumors, an aspirate and biopsy are taken from both sides. Sternal punctures are not performed on children.  

In children, a bone marrow puncture is almost always performed under general anesthesia.

A bone marrow examination includes

  • A smear for the primary work-up and later for monitoring of treatment response for leukemia or for evaluation of marrow involvement from lymphomas/solid tumors
  • Aspirate samples for flow cytometry, cytogenetics, molecular genetics testing, and sometimes for research studies
  • Biopsy
  • Peripheral blood smear 

For diagnostics, the following is performed:

  • Immunophenotyping (marker testing) using flow cytometry
  • Cytogenetics (chromosome testing)
  • Molecular genetic testing (for example PCR: polymerase chain reaction, FISH: fluorescence in situ hybridization) 
  • Special tests for research studies

Indications

Evaluation for:

  • Lymphoma and leukemia
  • Serious anemia
  • Thrombocytopenia
  • Ambiguous bone pain/rheumatic symptoms
  • Fever that is ambiguous
  • Testing for possible tumor metastases in bone marrow
  • Assessment of treatment effect 

The only contraindication for a bone marrow biopsy is serious hemophilia. In this case, it must be performed in collaboration with a hemophilia clinic.   

If treating with warfarin, INR should be ≤ 3.

NSAID/ASA treatment does not need to be postponed. Be aware of possible thrombocytopenia.

Goal

  • Diagnose or exclude disease involvement of bone marrow
  • Monitor response to treatment

Equipment

  • Equipment for bone marrow biopsy/aspiration

Preparation

  • Prior to the examination, the child and parents should be thoroughly informed about the purpose of the test and how it will be carried out.  
  • The child should fast for 4-5 hours before the examination. Breastfed children need only fast for 2 hours.
  • Blood tests
  • The examination is performed by a doctor and takes about 10 minutes.
  • The child is given general anesthesia. The parents should stay with the child until he/she is asleep.
  • The child should lie as comfortable as possible on the non-puncture side.

Implementation

This procedure is performed aseptically.

Identifying the area for sampling

  • Upper iliac crest, on the posterior iliac spine. Feel the edge of the iliac crest between the fingers with the left hand. Be sure not to confuse the posterior iliac spine with the spinous process.
  • Wash with chlorhexidine 5 mg/ml.
  • Use a sterile drape.

Bone marrow biopsy

It is recommended to take the biopsy before the bone marrow aspiration. It is easier to avoid the biopsy canal than the puncture canal. (This procedure is for use of a regular punch biopsy needle. Improved needles are available which grasp the biopsy during rotation and retrieval of the needle.)

  • Use a biopsy needle.
  • Insert the biopsy needle with the stylet through the subcutaneous tissue. The tip of the needle rests now on the periosteum. 
  • Remove the stylet and rotate carefully through the cortex, preferably without too much rotation.
  • When resistance is reduced, the needle has reached the bone marrow. Carefully go an additional centimeter, preferably without rotation.
  • Rotate the needle firmly several times.
  • Carefully pull out the needle.
  • Apply pressure.
  • Put the biopsy in B+ medium.

Bone marrow aspiration

This is a continuation of the above procedure.

  • Puncture the posterior superior iliac spine, but avoid making a biopsy hole. Carefully push the needle under rotation until it penetrates the cortex.
  • When the cannula enters the spongous bone, the resistance will be significantly less.
  • Remove the stylet. 
  • Attach a 10 ml syringe to the aspirate needle.
  • Aspirate fast and powerfully.
  • Aspirate only a small amount (0.5-1 ml maximum). If too much is aspirated, peripheral blood increases in the mixture. If marrow cannot be aspirated, try to rotate the needle or reintroduce the stylet and go a little deeper.
  • Aspirate more bone marrow for any supplementary examinations (see below).
  • Retrieve the needle. 
  • Wash off any spilled blood. Do not use alcohol, as this will coagulate the blood. Use sterile swabs and NaCl or cold water. 
  • Cover the wound with a self-adhesive bandage.

Make a smear

  • The doctor sprays the bone marrow in the upper portion of the petri dish while it is held at an angle to allow the blood to run off.
  • Dip the slide carefully on the edge of the bone marrow, not right in the middle.
  • Hold the slide with an index finger and thumb and start smearing from where the name field is on the slide. Drag lightly and raise the slide gradually so there is less bone marrow at the end of the slide. The smears should be thin.
  • The smears should be air-dried before they are stained.

Aspirate for other bone marrow testing

If there is suspicion of leukemia/lymphoma, more bone marrow tests are taken. An aspirate is taken for flow cytometry, cytogenetics, molecular genetics, and possibly additional studies. At later follow-ups, MRD is taken. For an aspirate for flow cytometry and cytogenetics, the syringe should be heparinized with heparin 5000 IE/ml. Otherwise, the procedure is the same.

  • Remove 2-3 ml aspirate from the inserted aspirate needle used earlier.
  • Place the aspirate into a specimen container and carefully agitate the container to mix the contents.
  • This is repeated if more tests are taken.
  • Pull the aspiration needle carefully out.  
  • Squeeze the aspiration area with a gauze.

Follow-up

  • The risk is minimal for complications.
  • During anticoagulation/thrombocytopenia, the wound should be observed for local bleeding. Bleeding is rarely serious and usually stops by compression. Thrombocytopenia is not a contraindication for bone marrow examinations and thrombocyte concentrate is usually not given before the procedure.
  • There are no other restrictions or observations.

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