Bone Marrow Biopsy
Martha C. Sola-Visner
Lisa M. Rimsza
Tung T. Wynn
Jolie S. Ramesar
A. Definitions
1. Bone marrow aspirate: Small amount of bone marrow fluid aspirated through a needle placed into a bone.
2. Bone marrow biopsy: Small sample of solid bone marrow tissue obtained using a specific needle.
3. Bone marrow clot: Bone marrow aspirate particles (and possible clot) placed in fixative, embedded in paraffin, and sectioned. This is commonly referred to as the “clot.”
B. Indications
c. Neutropenia of unclear etiology, which is severe (absolute neutrophil count <500/mL) and persistent (8, 9)
d. Thrombocytopenia of unclear etiology, which is severe (platelets <50,000/mL) and persistent (3, 10)
2. Evaluation of suspected metabolic/storage disorder (e.g., Niemann-Pick disease) (11)
3. Evaluation of suspected hemophagocytic syndrome or familial hemophagocytic lymphohistiocytosis (12, 13)
4. Detection of infiltrating tumor cells, such as Hodgkin and non-Hodgkin lymphoma, neuroblastoma (14), rhabdomyosarcoma, Ewing sarcoma (15), or congenital systemic Langerhans cell histiocytosis
5. Microbiologic cultures (e.g., in disseminated tuberculosis or fungal disease)
6. Cytogenetic studies, for chromosomal analysis (7)
7. Evaluation of suspected osteopetrosis (16)
C. Contraindications
Bone marrow aspirations and biopsies have no absolute contraindications, but there may be relative contraindications based on the general condition of the patient, especially related to the risk of anesthesia or deep sedation.
Note the following considerations:
1. Sampling from the sternum is not recommended in any neonate because of danger of damage to intrathoracic and mediastinal organs
2. Risks/benefits should be considered carefully in the presence of coagulopathy or when administering anticoagulants or thrombolytics
3. Risks/benefits should be carefully considered in preterm infants with severe osteopenia of prematurity
D. Precautions
1. Correct any coagulopathy as much as possible prior to procedure (keep in mind that even in the setting of severe thrombocytopenia, a bone marrow aspirate can be performed safely).
2. Use a total of 0.2 to 0.4 mL of lidocaine.
3. Be aware that less pressure is required to insert the bone marrow needle in neonates (particularly in very low-birth-weight infants) than in older children.
4. When choosing the most appropriate site (tibia vs. iliac crest) and what needle to use (depending on the size and weight of the infant), the clinical stability, the ability to tolerate repositioning, and the personal preference of the person performing the procedure should be considered.
a. The preferred site for obtaining bone marrow in older children is the posterior superior iliac crest for various reasons (it contains the most cellular marrow, there are no vital organs in close proximity, and it is a non-weight-bearing structure) (17).
b. In children younger than 18 months of age, the anteromedial face of the tibia is the preferred site for bone marrow aspiration (17). However, this site may fail to yield adequate samples depending on the experience of the person performing it. There
is also the risk of fracturing the bone; this is only a risk for the tibial site, unless the child has a condition associated with bone fragility (i.e., osteogenesis imperfecta).
is also the risk of fracturing the bone; this is only a risk for the tibial site, unless the child has a condition associated with bone fragility (i.e., osteogenesis imperfecta).
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