Paeds · investigations-procedures-and-technology
Bone-marrow aspiration and biopsy principles
Also known as Bone marrow aspirate · Trephine biopsy · Bone marrow examination · Jamshidi needle procedure · Marrow sampling
A fellowship approach to bone marrow aspiration and biopsy in children covering the principle that aspirate and trephine are two complementary samples taken at one sitting (the aspirate for cells in suspension — morphology, flow cytometry, cytogenetics, molecular and culture; the trephine core for cellularity, architecture and infiltration), the posterior superior iliac spine as the standard paediatric site and the reasons the sternum is avoided in young children, the manual Jamshidi and Salah needles and the powered OnControl drill, the stepwise procedure of positioning and landmark, asepsis and local anaesthetic infiltration to the periosteum with lidocaine one per cent three milligrams per kilogram plain or seven milligrams per kilogram with adrenaline, aspirating the first pull for morphology and cytogenetics then taking a trephine core from a new track, the meaning of a dry tap and the need for a trephine, the complications of pain bleeding infection and retropneumoperitoneum, and the staging and risk-stratification decisions that rest on a correctly handled first pull.
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Target exams
Red flags
- An unexplained pancytopenia, or blasts on the peripheral film, in a child — a bone marrow examination is the diagnostic step and must not be delayed
- A planned trephine in a child with a platelet count under 20 to 50 or a deranged INR — give platelet and clotting-factor cover first, because the trephine core bleeds more than the aspirate
- A dry tap that is abandoned as a failed procedure — it is a sign of marrow fibrosis or a packed marrow, and the correct response is a trephine biopsy
- A bone marrow needle aimed at the sternum in a young child — the sternum is thin and the needle can enter the mediastinum; use the posterior superior iliac spine
- Sending a late, blood-diluted aspirate pull for morphology and cytogenetics — the first pull is the only reliable sample and drives the leukaemia risk group
- A unilateral trephine when staging a solid tumour or lymphoma — focal marrow disease is missed on one side, so take bilateral trephines
Life stages
Care settings
Clinical exam formats
Board mappings
- General and Community Paediatrics
- Recognition of cytopenias and the indications for bone marrow examination
- Haematology and oncology — diagnostic and procedural reasoning
- Informed consent and procedural sedation in children
- Clinical Applications
- Medical Sciences
- Procedural skills and informed consent
- Short Cases
- Structured oral on a child with pancytopenia or suspected leukaemia
- 1.4 Safely and appropriately performs practical procedures and uses medical devices
- 2.4 Uses information for clinical decision-making
- 8. Patient safety
- Foundation of Practice (FOP)
- Applied Knowledge in Practice (AKP)
- Clinical — communication and consent for a painful procedure
- General Pediatrics Content Outline — Haematology/Oncology; Procedural skills
- Universal Task 4: Management and Treatment
- Patient Care 1: procedural competency and informed consent
- Systems-Based Practice
- Medical Expert
- Communicator
- Collaborator
Overview & Definition
Picture a six-year-old referred after a routine count shows a haemoglobin of sixty, a platelet count of twenty, and blasts on the film. The diagnosis is in the marrow, not the blood, and the act that names the disease is the bone marrow examination. For paediatrician principle is simple to hold and easy to forget under pressure: the aspirate and the trephine answer different questions, and you take both at the same sitting so the child is not brought back twice. [2] [3]
Bone marrow aspiration withdraws liquid marrow from the medullary cavity. It holds the cells in suspension, so it is the sample for anything that needs intact or dividing cells: smear morphology, immunophenotyping by flow cytometry, cytogenetics, molecular studies, and culture. Bone marrow trephine biopsy removes a core of bone that still contains the marrow in its native arrangement, so it is the only sample that shows overall cellularity, the pattern of infiltration, fibrosis, granulomas, and metastatic tumour. [1] [2]
The reason a fellowship candidate must hold both at once is that each sample fails where the other succeeds. A leukaemia may be diagnostic on aspirate flow cytometry but invisible on a trephine core; a severely aplastic marrow may look deceptively normal on a liquid aspirate taken from a surviving pocket, and only the trephine reveals the empty, fatty marrow that defines aplastic anaemia. Sending one without the other is the commonest avoidable error. [1] [10]
References11ShowHide
- [1]Bhaskar N Bone Marrow Aspiration and Biopsy in Critical Pediatric Patients: A Pathologist's Perspective Cureus, 2021.PMID 34589333
- [2]Riley RS, Hogan TF, Pavot DR, et al A pathologist's perspective on bone marrow aspiration and biopsy: I. Performing a bone marrow examination Journal of Clinical Laboratory Analysis, 2004.PMID 15065211
- [3]Trewhitt KG Bone marrow aspiration and biopsy: collection and interpretation Oncology Nursing Forum, 2001.PMID 11683311
- [4]Helgestad J, Rosthøj S, Johansen P, et al Bone marrow aspiration technique may have an impact on therapy stratification in children with acute lymphoblastic leukaemia Pediatric Blood and Cancer, 2011.PMID 21360660
- [5]Valdés-Sánchez M, Nava-Ocampo AA, Palacios-González RV, et al Diagnosis of bone marrow metastases in children with solid tumors and lymphomas. Aspiration, or unilateral or bilateral biopsy? Archives of Medical Research, 2000.PMID 10767482
- [6]Forwood KM, Lee E, Crispin PJ Comparison of the bone marrow trephine sample quality between OnControl drill system and the Jamshidi needle International Journal of Laboratory Hematology, 2019.PMID 30779423
- [7]Kato Y, Maeda M, Aoki Y, et al Pain management during bone marrow aspiration and biopsy in pediatric cancer patients Pediatrics International, 2014.PMID 24417881
- [8]Antmen B, Saşmaz I, Birbiçer H, et al Safe and effective sedation and analgesia for bone marrow aspiration procedures in children with alfentanil, remifentanil and combinations with midazolam Paediatric Anaesthesia, 2005.PMID 15725319
- [9]Aslam SL, Haque A, Jamil MT, et al Safety and Efficacy of Procedural Sedation and Analgesia in Pediatric Oncology Patients Cureus, 2020.PMID 32351822
- [10]Bain BJ Bone marrow biopsy morbidity: review of 2003 Journal of Clinical Pathology, 2005.PMID 15790706
- [11]Liu B, Limback J, Kendall M, et al Safety of CT-Guided Bone Marrow Biopsy in Thrombocytopenic Patients: A Retrospective Review Journal of Vascular and Interventional Radiology, 2017.PMID 29042170