Bone Marrow Aspiration and Biopsy Periprocedural Care

Obtain informed patient consent that provides procedural information and potential complications (eg, hemorrhage, infections, and pain ^[13] ). This will minimize any apprehension that the patient may have.

An initial review of the patient’s clinical background is necessary to determine whether a bone marrow evaluation is warranted.

The medical history should include the following so as to faciliate determination of which samples are to be collected:

• Travel history - Exposure to parasites (leishmaniasis), fungi (histoplasmosis,  Cryptococcus), or mycobacteria
• Immune compromise or immune deficiency status - This may contribute to a high  infection risk, as in patients with  HIV infection, underlying autoimmune deficiency (eg, Wiskott-Aldrich syndrome), or the use of immunosuppressive agents
• Risk of bone fragility - Previous surgeries, chemotherapy, and radiation therapy can increase the risk of bone fragility, as well as pathologic processes that may contribute to bone resorption (eg,  osteoporosis,  multiple myeloma)
• Previous diagnosis of malignancies - These are a risk for metastasis to bone, especially breast and prostate cancer
• Glycogen storage diseases
• Risk for hematologic anomalies - Contributing factors include a patient's  nutrition status, alcoholism, medications, and history of a coagulation factor deficiency
• Allergies - Testing for or knowledge of a patient's allergy status can help in preventing reactions to the potential allergens exposed during bone marrow sampling, such as latex, anesthetics (eg, lidocaine), and antiseptics (eg, povidone-iodine)

Perform a thorough physical examination to assess the patient for signs of malignancy, infections, lesions associated with hemorrhagic injury, as well as disorders of hemostasis and coagulation.

Laboratory tests should initially include the following:

• Complete blood count (CBC)
• Reticulocyte count
• Peripheral blood smears
• Prothrombin time (PT)/international normalized ratio (INR)
• Activated partial thromboplastin time (aPTT)

Other studies take into account the clinical presentation and may consist of the following ^[14] :

• Serum iron studies
• Serum ferritin study
• Vitamin B-12 and folate levels
• Peripheral flow cytometry
• Quantitative polymerase chain reaction (PCR) of known translocations ( BCR-ABL, JAK2)
• Erythrocyte sedimentation rate (ESR)
• Serum protein electrophoresis
• Platelet function studies
• Coagulation mixing study
• Fibrin D-dimers
• Serum fibrinogen levels
• Serum bilirubin levels
• Radiography

Special procedural concerns

Special concerns to be taken into account include the following:

• Corrective action is required for coagulation disorders before bone marrow sampling
• Dry tap (ie, failure to obtain a specimen during the aspiration sampling process) is most commonly due to technical problems such as misalignment of the needle; other conditions that should be considered and may contribute to the decision of obtaining a biopsy are recent radiation therapy exposure, aplastic anemia, myelofibrosis, and bone-infiltrating neoplasm
• Given that tissue shrinkage can occur at an approximate rate of 25% after processing, the desired biopsy sampling size should initially be greater than 1.5 cm, preferably 2-3 cm in length (pediatric samples may be as small as 0.5 cm); such a size will allow evaluation of five or six intertrabecular spaces, which is considered sufficient sampling for a diagnosis ^{[2, 3, 15]}
• Rarely, chronic pain may occur at the site of bone marrow sampling, thus necessitating further clinical management

Unilateral vs bilateral iliac crest biopsies

Performance of bilateral iliac biopsies increases the probability of detecting focal lesions in which there is a possibility of patchy bone involvement, as in the case of carcinoma and lymphoma staging, where 11-16% of cases may be missed with unilateral biopsies. ^[16] ​

Wang et al reported improved identification of bone malignancy in the following pathologic cases ^[17] :

• Hodgkin disease (19.5% improvement)
• Sarcomas (14%)
• Carcinomas (11.5%)
• Non-Hodgkin lymphoma (4.6%)

Unilateral iliac sampling was considered sufficient in patients diagnosed with multiple myeloma, chronic myeloproliferative disorders, and myelodysplastic syndromes. ^[17]

At present, in view of the utility of positron emission tomography (PET) in staging lymphomas and the current inclusion of PET-positive bone disease as indicative of bone involvement in lymphoma, bilateral bone marrow biopsies are rarely done.

Bone marrow biopsies can be done regardless of the platelet count and while the patient is on anticoagulation, provided that the INR is not severely abnormal (eg, INR ≥5). Care should be taken to maintain hemostatic pressure longer in patients with bleeding diatheses.

Anesthesia

Local anesthesia is employed. General anesthesia is required for pediatric cases, some sternal bone marrow sampling cases, and in those patients who are highly anxious

Positioning

The patient is placed in the lateral decubitus position, with the top leg flexed and the lower leg straight. Alternatively, the patient may be placed in the prone position.