Patient Education and Consent
Most education initially includes indications for bone biopsy in the case, potential complications, and benefits from the result that will guide appropriate treatment.
Explain the nature of the procedure. The patient should be instructed to fast before the procedure because moderate-to-deep intravenous (IV) sedation might be required as well as local anesthesia at the side of biopsy.
Instruct the patient to take tetracycline and avoid certain diets, in case dynamic histomorphometry is planned after tetracycline double-labeling.
Advise the patient undergoing peritoneal dialysis (PD) not to have a day dwell of PD fluid on the day of the biopsy. Suggest to the relatively dehydrated postdialysis patient that the dialysate dextrose concentrate should be decreased on the night before the biopsy to prevent hypotension.
Most patients can go home on the same day of the biopsy except for selected cases, such as elderly or sick patients who might require an overnight stay.
Preprocedural Planning
Determine platelet counts and coagulation function. Thrombocytopenia and coagulopathy can potentiate bleeding after the procedure. Determine blood urea nitrogen (BUN) and serum creatinine. Renal failure can cause platelet dysfunction and increase the risk of bleeding.
Equipment
Iliac crest biopsies can be obtained from either the right or left iliac crest in a horizontal and vertical direction. In either approach, equipment includes the following (see the image below) [3] :
-
A pointed trocar with core diameter of 5-7 mm
-
A guide sleeve with sharp, serrated edges
-
A trephine biopsy needle
-
A blunt extractor
Modified Bordier trephine, from top to bottom, includes pointed trocar, outer guide or sleeve, trephine, and blunt extractor. Image courtesy of Clin J Am Soc Nephrol 3:S164-S169, 2008.
If an electric drill is to be used instead of the manual instruments listed above, equipment includes the following:
-
Electric drill (see the image below)
-
Funnel-shaped positioner
-
Trephine that consists of a precutter drill bit and a core drill or actual trephine
-
Scalpel with a No. 11 blade
-
Keyhole surgical drape
-
Blunt dissector
-
Antiseptic solution
-
Syringe (20 mL) and a selection of needles
-
Skin suture with needle
-
Stitch holder, scissors, and forceps
-
Sterile gauze swabs and cotton wool balls
-
Sterile universal container filled with 10% formalin
-
Occlusive skin dressing
Electric drill for horizontal and vertical iliac crest biopsies. Image courtesy of Clin J Am Soc Nephrol 3:S164-S169, 2008.
Patient Preparation
Anesthesia
A combination of analgesia (fentanyl) with either sedation (propofol infusion) or a benzodiazepine (midazolam) has resulted in excellent biopsy conditions and rapid recovery. Local anesthesia should be used to decrease procedural stimulation and provide some postprocedure pain relief.
Positioning
In current practice, transiliac bone biopsy can be performed with the patient in either of the following two positions:
-
Supine
-
Lateral decubitus (left lateral decubitus for a right iliac crest biopsy, right lateral decubitus for a left iliac crest biopsy)
Monitoring & Follow-up
Vital signs should be monitored. Pulse oximetry and continuous cardiac monitoring are warranted in moderately sedated or deeply sedated patients.
After the procedure, the patient should be advised to maintain bed rest for 3-6 hours, mainly to allow the effects of the sedation to wear off. The patient can then get out of bed and go home the same day, except in selected cases where overnight monitoring is required.
At 24 hours after the biopsy, the patient should be instructed to remove the pressure dressing and replace it with a small adhesive pad. After 48 hours, the patient can shower, clean the incision site with soap and water, and then cover the site with a small adhesive pad.
At 7-10 days after the procedure, the sutures can be removed. The patient should be advised to watch for potential complications (eg, bleeding, hematoma, or skin infection).
-
Tetracycline double-labeling on bone-osteoid surface as seen in fluorescent light. Image courtesy of Clin J Am Soc Nephrol 3:S164-S169, 2008.
-
Electric drill for horizontal and vertical iliac crest biopsies. Image courtesy of Clin J Am Soc Nephrol 3:S164-S169, 2008.
-
Modified Bordier trephine, from top to bottom, includes pointed trocar, outer guide or sleeve, trephine, and blunt extractor. Image courtesy of Clin J Am Soc Nephrol 3:S164-S169, 2008.
-
Biopsy site is identified 2 cm posterior to anterior iliac crest (dotted line outlines iliac crest). Image courtesy of Clin J Am Soc Nephrol 3:S164-S169, 2008.
-
Lidocaine (10%) is used to anesthetize skin, subcutaneous tissue, and periosteum. Image courtesy of Clin J Am Soc Nephrol 3:S164-S169, 2008.
-
After incision is made, muscle and fascia are separated by blunt dissection until periosteum is exposed. Image courtesy of Clin J Am Soc Nephrol 3:S164-S169, 2008.
-
Pointed obturator, together with outer guide, is inserted and applied firmly to exposed bone. Guide is rotated and implanted on lateral ilium. Image courtesy of Clin J Am Soc Nephrol 3:S164-S169, 2008.
-
Trephine is inserted into outer guide and rotated counterclockwise with steady pressure until cutting action of trephine on bone is felt. Image courtesy of Clin J Am Soc Nephrol 3:S164-S169, 2008.
-
Trephine advancing through full length of iliac crest. Image courtesy of Clin J Am Soc Nephrol 3:S164-S169, 2008.
