123

Martha C. Sola-Visner

Lisa M. Rimsza

Robert D. Christensen

22 Tibial Bone Marrow Biopsy

A. Purpose

To obtain a bone marrow clot sample for histologic evaluation of the following1

1. Bone marrow cellularity

2. Relative abundance of myeloid, erythroid, lymphoid,

and megakaryocytic lineages, using specific immunohistochemical stains on multiple cuts if necessary

3. Maturation and morphology of cells of all lineages

4. Presence of infiltrative nonmalignant diseases

5. Presence of infiltrative malignant diseases (hematologic

and nonhematologic)

6. Presence of granulomas or infectious organisms

B. Indications

1. Evaluation of primary hematologic disorders (1–6)

a. Suspected neonatal aplastic anemia (pancytopenia)

b. Suspected leukemia, when blood studies are insufficient to confirm the diagnosis

c. Neutropenia of unclear etiology, which is severe

(absolute neutrophil count <500/mL) and persistent.

d. Thrombocytopenia of unclear etiology, which is

severe (platelets <50,000/mL) and persistent

2. Evaluation of suspected metabolic storage disease (e.g.,

Niemann–Pick disease) (2)

3. Evaluation of suspected hemophagocytic syndrome or

familial hemophagocytic lymphohistiocytosis (7,8)

4. Detection of infiltrating tumor cells (9–12) or of congenital systemic Langerhans’ cell histiocytosis (13)

5. Certain cultures (e.g., in disseminated tuberculosis or

fungal disease) (14)

6. Cytogenetic studies, for chromosomal analysis (even

after transfusion of donor blood) within 3 to 4 hours

(15). Note: This requires an aspirate rather than a clot.

7. Staging of solid tumors (16,17)

C. Contraindications

1. Sampling from the sternum is not recommended in

any neonate because of danger of damage to intrathoracic and mediastinal organs (2,18).

2. Sampling from the anterior iliac crest is not recommended, particularly in the smallest preterm infants,

owing to the proximity to intra-abdominal organs.

3. Risks/benefits should be considered carefully in the

presence of coagulopathy or when administering anticoagulants or thrombolytics.

4. Risks/benefits should be carefully considered in preterm infants with severe osteopenia of prematurity (19).

D. Limitations

In small preterm infants, the tibial bone marrow biopsy

technique sometimes yields no marrow or a very hemodilute sample, mostly because of the small size of the marrow

compartment within the tibia.

E. Equipment

Sterile

1. Surgical gloves

2. Cup with antiseptic solution

3. Gauze squares

4. Sterile drapes

5. 1% lidocaine without epinephrine in 1-mL syringe,

with 27-gauge needle

6. 19-gauge, 0.5-inch Osgood bone marrow needle

(Popper and Sons, New Hyde Park, New York) (Fig.

22.1)

7. 3-mL syringe without Luer-Lok

Nonsterile

1. Cup containing 10% neutral buffered formalin or other

appropriate fixative

2. 1- to 2-inch needle to aid in removal of clot from the

syringe

1

The information listed below (except for maturation and morphology of

the cells of all lineages) can be obtained more reliably from biopsies or clot

sections than from traditional aspirates (24).

124 Section IV ■ Miscellaneous Sampling

F. Precautions

1. Correct coagulopathy as far as possible prior to procedure.

2. Use a total of 0.2 to 0.4 mL of lidocaine. Aspirate before

injection to avoid intravascular injection.

3. Stabilize the leg in your hand, between your thumb

and forefinger. To avoid bone fracture, be sure to apply

counterpressure with your palm directly opposite the

site of penetration.

4. Be aware that less pressure is required to insert the bone

marrow needle in neonates (particularly in very lowbirthweight infants) than in older children.

5. Be careful to enter the bone 1 to 2 cm below the tibial

tuberosity, to minimize the risk of injuring the growth

plate.

6. After the procedure, apply adequate pressure to control

bleeding.

G. Special Circumstances

In cases of suspected osteopetrosis, obtaining a posterior iliac

crest bone/bone marrow biopsy is preferable, because it

allows quantification of osteoclasts and evaluation of marrow

and bony changes consistent with osteopetrosis. In these

cases, the tibial bone marrow biopsy technique usually yields

only blood or no sample.

H. Technique

1. Place the infant in the supine position.

2. Use the triangular area at the proximal end of the

medial (flat) surface of the tibia, approximately 1 to

2 cm distal to the tibial tuberosity (20).

3. Prepare and drape as for a major procedure (see

Chapter 5).

4. Infiltrate subcutaneous tissue with lidocaine as the needle is slowly advanced. Inject further small volume

when the needle reaches the bone, making sure that

the tip of the needle is inserted into the bone for subperiosteal injection.

5. Remove the needle and wait 2 to 3 minutes.

6. Use your nondominant hand to firmly stabilize the leg,

providing support with your palm directly opposite the

site of marrow puncture. This hand cannot be reintroduced into the sterile field.

7. Make sure that the trocar is completely inserted in the

Osgood needle.

8. Hold the needle between the thumb and forefinger of

your dominant hand.

9. Introduce the needle at a 90-degree angle, and advance

it into the marrow cavity with a slow, twisting motion

(Fig. 22.2).

10. Continue to advance the needle until it is firmly fixed

in bone (does not move when touched) (Fig. 22.3).

Fig. 22.1. View of the 19-gauge, 0.5-inch Osgood bone marrow

needle. The trocar must be completely inserted in the Osgood

needle prior to the procedure.

Fig. 22.2. The Osgood needle is introduced into the tibial marrow cavity with a slow, twisting motion. Notice that the leg is

firmly stabilized in the operator’s nondominant hand.

Fig. 22.3. The Osgood needle is firmly fixed in the bone.