Chapter 22 ■ Tibial Bone Marrow Biopsy 125

11. Remove the trocar from the needle and advance the

hollow needle an additional 2 to 3 mm into the marrow space (this trephinates marrow spicules into the

needle).

12. Attach a 3-mL syringe (without a Luer-Lok) firmly to

the needle.

13. Withdraw the plunger forcefully until a small drop of

marrow (∼0.1 mL) appears in the syringe hub. Suction

should be stopped as soon as the smallest amount of

marrow is obtained, because excessive suction will

dilute the sample with peripheral blood.

14. If no marrow is obtained initially, rotate, advance, or

retract the needle and try again.

15. Remove the syringe as soon as bone marrow is obtained

and withdraw the plunger (with marrow attached) to the

bottom of the syringe. Allow the marrow to clot there.

16. Remove the needle and apply pressure over the site to

achieve hemostasis.

Preparation of the Bone Marrow Clot

1. After the marrow specimen has clotted, dislodge the

clot gently with the use of a 1- or 2-inch needle and

place it into the fixative solution (Fig. 22.4).

2. Process the bone marrow clot in a manner identical to

a typical bone marrow biopsy, except that decalcification is not required (Fig. 22.5).

I. Complications2

1. Subperiosteal bleeding (21)

2. Cellulitis or osteomyelitis (22)

Fig. 22.4. A small amount of bone marrow has been obtained

in a 3-mL syringe and allowed to clot at the bottom of the syringe.

The plunger has been removed, and the clot is now being gently

dislodged from the plunger (with the use of a 1- or 2-inch needle)

and placed into the fixative solution.

Fig. 22.5. Photomicrograph of a bone marrow clot section

obtained from a neutropenic neonate. The cellularity is near

100%. Myeloid precursors, scattered erythroid cells, lymphocytes,

and several megakaryocytes are clearly identified. Hematoxylin

and eosin; original magnification × 200.

3. Limb fracture (23)

4. Injury to blood vessels (21)

5. Bone changes on x-ray film (24,25)

a. Lytic lesions

b. Exostoses

c. Subperiosteal calcification (secondary to hematoma)

J. Advantages of the Tibial Site

1. It is a safe site, particularly in very small preterm infants,

because it avoids any proximity to vital organs.

2. The tibia can be easily positioned without disturbing

even the sickest infants (usually maintained in the

supine position while on mechanical ventilation).

3. It can be adequately stabilized and supported by the nondominant hand of the person performing the procedure.

Acknowledgments

This work was partially supported by National Institutes of

Health grant HL69990.

References

1. Calhoun DA, Christensen RD, Edstrom CS, et al. Consistent

approaches to procedures and practices in neonatal hematology.

Clin Perinatol. 2000;27:733.

2. Downing V. Bone marrow examination in children. Pediatr Clin

North Am. 1955;2:243.

3. Garcia L, Valcarcel M, Santiago-Borrero PJ. Chemotherapy during pregnancy and its effects on the fetus—neonatal myelosuppression: two case reports. J Perinatol. 1999;19:230.

4. Juul SE, Calhoun DA, Christensen RD. “Idiopathic neutropenia”

in very-low birthweight infants. Acta Paediatr. 1998;87:963.

5. Calhoun DA, Kirk JF, Christensen RD. Incidence, significance,

and kinetic mechanism responsible for leukemoid reactions in

patients in the neonatal intensive care unit: a prospective evaluation. J Pediatr. 1996;129:403.

2

These complications refer to the bone marrow biopsy procedure in general, not to the tibial site in particular.