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28 Part I: Clinical Evaluation of the Patient Chapter 3: Examination of the Marrow 29

MARROW ASPIRATION TECHNIQUE

At birth, all bones contain hematopoietic marrow. Fat cells begin to
replace hemopoietic marrow in the extremities in the fifth to seventh
year. By adulthood, the hemopoietic marrow is limited to the axial 1
skeleton and the proximal portions of the extremities (Chaps. 5 and 9). 2
Fatty marrow appears yellow, whereas hematopoietic marrow is red. 3
Red marrow contains fat, however, and fat droplets are visible grossly
in aspirated marrow specimens. Histologically, yellow marrow consists
almost entirely of fat cells and supporting connective tissue. Red mar-
row contains an abundance of hematopoietic cells, fat cells, and con-
nective tissue. The marrow fills the spaces between the trabeculae of
bone in the marrow cavity. Marrow is soft and friable and can be readily
aspirated or biopsied with a needle.
The posterior iliac crest (Fig. 3–1) is the preferred site for marrow
aspiration and biopsy. In adults, the anterior iliac crest and rarely the Figure 3–2. Sites used for marrow aspiration. (Modified with permis-
sternum have been used (Fig. 3–2). The sternum should be used for sion from Schwartz SO, Hartz WH Jr, Robbins JH: Hematology in Practice.
New York, NY: McGraw-Hill; 1961.)
aspiration only. The anterior iliac crest is less preferred than the pos-
terior crest in adults because of its thick cortical bone. The anterome- episodes of prolonged but not permanent disability were reported in
dial surface of the tibia is an option for infants younger than 1 year old nearly 55,000 marrow biopsies. Morbidity most frequently involved
9
(particularly newborns), but the posterior iliac crest is still the preferred hemorrhage, which was associated more with platelet function impair-
site. Serious adverse outcomes after marrow aspiration or biopsy are ment than thrombocytopenia or coagulation factor defects. Infection
9
rare, occurring in less than 0.05 percent. One direct fatality and three and reactions to anesthetic agents are other infrequent complications.
Penetration of the bone with damage to the underlying structures is
possible with all marrow aspirations, but the hazard is greatest in sternal
aspirations because the sternum at the second interspace is only approx-
3 mm 2 mm imately 1 cm thick in adults, and the distance from posterior sternal
1
1 cm taper cortex to the ascending aorta varies greatly and may be as little as 4 to
2
5 mm, giving rise to the rare but dramatic consequence of aortal wall
10
1 tear. To prevent this, a guard should be in place on the needle if a sternal
cm 10 cm aspirate needs to be done.
For either a marrow biopsy or aspiration, sedation minimizes anx-
12
11
Biopsy needle iety and pain, particularly in children, for whom propofol, with or
1
1cm without fentanyl, administered under carefully controlled conditions
13
2
taper with monitoring of oxygen saturation, blood pressure, and vital signs,
Stylet is frequently used. Midazolam (Versed) is a popular choice for con-
2 mm scious sedation of adult patients, although a variety of other premed-
ications have been used. There is a relative lack of empirical research
Probe
A and consensus guidelines on the subject of pain reduction during adult
marrow procedures. 14,15 The experience of marrow procedures from the
patient’s point of view is worth reading. The only significant correlates
16
with severe/unbearable pain (experienced by 4 percent of patients)
Posterior superior iliac spine during marrow examination were quality of the information about
the procedure provided before the examination and previous painful
17
experiences. Marrow biopsies and aspirations for lymphoma staging
purposes often can be performed while the patient is under anesthesia
for other procedures. Several different types of needles are available for
marrow aspiration. For adults, a 16-gauge needle is sufficiently large to
3
permit aspiration of adequate specimens; larger needles are unneces-
sary. The patient is prone or in the left or right lateral decubitus position.
Sterile precautions must be observed. The skin over the puncture site is
shaved if necessary and cleansed with a disinfectant solution. The skin,
subcutaneous tissues, and periosteum are infiltrated with a local anes-
thetic solution, such as 1 percent lidocaine. Adequate infiltration of the
anesthetic at the periosteal surface is important to minimize severe pain
during the procedure, but no more than 20 mL of 1 percent lidocaine
18
should be used in an adult. Adequate anesthesia can be achieved with
B much less lidocaine in virtually all cases. An air gun can be used to anes-
Figure 3–1. A. Jamshidi biopsy instrument. B. Site of marrow biopsy. thetize the skin surface prior to application of anesthetic to the periosteal
96
(A, reproduced with permission from Jamshidi K, Swaim WR: Bone marrow surface by injection. After the anesthesia has taken effect, usually in 3 to
biopsy with unaltered architecture: A new biopsy device. J Lab Clin Med 5 minutes, the marrow needle is inserted through the skin, subcuta-
77(2):335–342, 1971.) neous tissue, and cortex of the bone using a slight twisting motion. In

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