Jump to content
We need you! See something you could improve? Make an edit and help improve WikSM for everyone.

Bone Marrow Aspiration

From WikiSM


Other Names

  • Bone Marrow Aspiration (BMA)
  • Bone Marrow Biopsy

Background

This image shows a patient lying prone on a table, prepped and draped for BMA from the posterior superior iliac spine.[1]
Cross section of the iliac crest showing thick and thin areas. Penetrating the thin area of the pelvis increases the likelihood of passing through the marrow space. The thick area has a large marrow space with less risk of passing through the marrow-rich area and much higher likelihood of drawing whole marrow[1]
  • Bone marrow aspiration is a technique used to harvest stem cells for use in regenerative medicine

Key Points

  • It is safe to aspirate up to 60 mL of bone marrow in an average adult[1]
  • Ultrasound or fluoroscopy guidance is superior to palpation guided techniques

Anatomy

  • Posterior Iliac Crest
    • Produces the highest amount of colony forming progenitor cells compared to other harvesting locations[2]

Aspiration Volume

  • Small woman/ child (under 50 kg): no more than 50 mL
  • Average woman/ small man/ anemic patient: 60 to 70 mL
  • Larger man/woman (Over 70 kg): Up to 120 mL

General Volume Requirements for Different Joints

  • Bilateral knee: 120 mL
  • Unilateral knee: 60-90 mL
  • Medium Joint (elbow, ankle): 60 mL
  • Small joints: 40-60 mL
  • Very small joints (fingers, toes): 30 mL

Indications

Contraindications

  • Clinically significant Anemia
  • Local or systemic infection
  • Active hematologic neoplasm
  • Anticoagulation which can not be stopped for the procedure
  • Inability to be properly positioned for the procedure
  • Immunocompromised
  • Cancer may be a contraindication
    • One study showed no increased risk of tumor growth when stem cells were used in conjunction with resection of bone cancer and graft placement[3]
  • Rheumatoid disease
    • The effect of immunosuppression or biological therapies for rheumatoid disease on stem cell treatment is unknown
  • Medications that must be avoided
    • Corticosteroids should be avoided for 4-6 weeks before treatment due to anti-inflammatory, antianabolic effects[4]
    • Statins should be avoided due to negative effects on stem cell proliferation[5]
    • NSAIDS should be avoided for 1 week pretreatment and 6 weeks post treatment[6]

Relative Contraindications

  • Increased BMI/ Body Habitus
    • Increased soft tissue to be penetrated, require larger trochars
    • Imaging is more difficult on these patients, fluoroscopy may be beneficial in these patients
    • Increased risk for errors and pain
    • Larger patients may have trouble laying prone

Procedure

The single-entry, multiple direction draw technique. Arrows, orientation of the trocar.[1]
Basic equipment for BMA: (A) Jamshidi needle, (B) syringes, and (C) Arrow On Control Driver[1]
(A) US head orientation to the ilium, (B) the view on the US machine of the appropriate approach of anesthetizing needle or trocar, and (C) the relationship of the trocar and US head to the pelvis. MSK, musculoskeletal. Arrows show orientation of the trocar.[1]
Target site for anesthesia, relative to the SI joint, the gluteal nerves, and the superior gluteal NAV bundle.[1]

Maximizing Yield

  • Target PSIS, it contains more JSC than other bone marrow sites[7]
  • Target the thickest part of the Ilium
  • Drawing small volume of 5-15 mL from many sites increases yield
  • Drawing a large volume of more than 10-15 mL from one site decreases yield
  • Consider going deeper into the marrow and extracting at different depths
  • Consider manipulating the trochar into different directions

Equipment

  • Local anesthetic
    • 20 mL of preferred local anesthetic
    • 27 guage, 0.5 inch needle for skin
    • 22 guage, 3.5 inch needle for deeper anesthesia
    • Ropivacaine is thought to be less toxic to stem cells than lidocaine and bupivacaine[8]
  • Scalpel blade
  • Trochar
    • Hand driven vs powered driver
    • Preference is based on physician
    • Harder to penetrate bone of younger individuals
    • Hand driver is recommended for patients older than 55 or those with osteoporosis
  • Heparin
    • 500 to 1000 IU per 1 mL of bone marrow[9]
    • 5 mL syringe with 5000 IU heparin in normal saline
    • Two 30 mL syringes preloaded with 30,000 IU of heparin
  • Steri strips, gauze, tape

Guidance

  • Using guidance allows for greater precision with anesthesia and placement of trochar
  • Allows the ilium to be penetrated at predefined intervals to maximize MSC harvest
  • Fluoroscopy
    • Easier to learn, facilitates exact placement of trochar within the anethestized area
    • Possibly more comfortable for patients as there is a steeper insertion angle (not targeting under probe)
  • Ultrasound
    • No radiation exposure
    • Does not require a large procedural suite (smaller footprint)
    • Can be more difficult to properly position the trochar

Clot Prevention

  • Clots trap stem cells, make them unable for intended use
  • Heparin, administered through trocar, is used to prevent clotting before aspiration
  • Preload the syringe to be used for withdrawing the aspirate with heparin

Technique

  • Patient positioning
    • For the posterior iliac crest approach, the patient should be prone
    • For volumes more than 30 mL, both left and right iliac crest should be prepped
    • Place a pillow under the abdomen to reduce lordosis of the lumbar spine
  • Guidance
    • Fluoroscopy: orient the beam 15 inpsilateral oblique
    • Ultrasound: use a curvilinear, low frequency looking for the thickest part of the ilium
  • Posterior Iliac crest
    • Can be located with ultrasound assistance
    • Move the probe superior-inferior to look for the most central portion of bone
    • PSIS is identified by placing the probe perpendicular to the ilium, looking for a mountain peak shaped PSIS
  • Target for aspiration
    • 1 cm inferior to the most superior tip of the bone to help reduce the chance of slipping
    • If too lateral or superior, can injury the cluneal nerves as they come over the iliac crest
    • Mark the PSIS and locations that will be needed to perform 3-5 aspirations
  • Sterile prep the patient
    • Place sterile drapes around the site of the procedure
  • Inject local anesthetic
    • Direct from the skin down to the periosteum
    • Penetrate the pereostium at each target site
    • This should be performed under ultrasound guidance
    • Avoid anesthetizing too laterally or inferiorly avoiding the cluneal nerves and the superior gluteal neurovscular bundle
  • Stab incision should be made prior to insertion of the trochar
  • Trochar insertion[10]
    • The 11g, 4 inch trochar is placed perpendicular to the skin
    • Then angle laterally by dropping the hand towards midline, making the trochar perpendicular to the bone
    • A drill or mallet can be used to help breach the dense cortical bone
    • If no drill or mallet, a clockwise-counter clockwise motion should be applied to pierce the bone
    • Patients should feel only pressure but not pain
    • When the trochar reaches the marrow cavity, it should be "stuck", if it is loose, continue advancing
    • Once pierced, the trochar should be advanced 3-5 cm into the bone depending on the body habitus
    • The average length to reach the anterior portion of the ileum is 7 cm
    • To prevent clots, remove the stylet and inject 0.3 to 0.5 mL of heparin
  • Aspiration of Bone Marrow
    • Attach one of the 30 mL syringes preloaded with heparin (3-5 mL) and begin withdrawing marrow
    • Withdraw 5-15 mL from each site
    • If not aspirating easily, go deeper or redirect altogether
    • Tap/ Shake the syringe to ensure the marrow and heparin mix
    • Pull the trochar back carefully, carefully redirect to the next target
    • Repat up to 3 times with the first syringe, using the second to continue on further sites
    • When complete, withdraw the trochar and apply pressure to achieve hemostasis

Aftercare

  • Have patients lay on back, knees bent for 5 minutes to place pressure on wounds, achieve hemostasis
  • Redress wounds if needed
  • Consider tegaderm dressing to keep them dry for 24 hours
  • Consider acetaminophen and opiates for postprocedural pain
  • Avoid NSAIDS for 6 weeks

Complications

  • Generally considered very safe
  • Pain at the site of the procedure
    • Most common side effect[11]
  • Post procedure Hematoma
  • Injury to surrounding structures

See Also

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 Friedlis, Mayo F., and Christopher J. Centeno. "Performing a better bone marrow aspiration." Physical Medicine and Rehabilitation Clinics 27.4 (2016): 919-939.
  2. ↑ Anz, Adam, and Benjamin Sherman. "Concentrated bone marrow aspirate is more cellular and proliferative when harvested from the posterior superior iliac spine than the proximal humerus." Arthroscopy: The Journal of Arthroscopic & Related Surgery 38.4 (2022): 1110-1114.
  3. ↑ Hernigou P, Flouzat Lachaniette CH, Delambre J, et al. Regenerative therapy with mesenchymal stem cells at the site of malignant primary bone tumour resection: what are the risks of early or late local recurrence? Int Orthop 2014;38(9): 1825–35.
  4. ↑ Wyles CC, Houdek MT, Wyles SP, et al. Differential cytotoxicity of corticosteroids on human mesenchymal stem cells. Clin Orthop Relat Res 2015;473(3):1155–64.
  5. ↑ Izadpanah R, Scha¨chtele DJ, Pfnu¨ r AB, et al. The impact of statins on biological characteristics of stem cells provides a novel explanation for their pleotropic beneficial and adverse clinical effects. Am J Physiol Cell Physiol 2015;309(8): C522–31.
  6. ↑ Schippinger G, Pruller F, Divjak M, et al. Autologous platelet-rich plasma preparations: influence of nonsteroidal anti-Inflammatory drugs on platelet function. Orthop J Sports Med 2015;3(6). 2325967115588896. p. 3.
  7. ↑ Marx RE, Tursun R. A qualitative and quantitative analysis of autologous human multipotent adult stem cells derived from three anatomic areas by marrow aspiration: tibia, anterior ilium, and posterior ilium. Int J Oral Maxillofac Implants 2013;28(5):e290–4.
  8. ↑ Rahnama R, Wang M, Dang AC, et al. Cytotoxicity of local anesthetics on human mesenchymal stem cells. J Bone Jt Surg 2013;95(2):132–7.
  9. ↑ Williams, Christopher J., Walter Sussman, and John Pitts, eds. Atlas of Interventional Orthopedics Procedures, E-Book: Essential Guide for Fluoroscopy and Ultrasound Guided Procedures. Elsevier Health Sciences, 2022.
  10. ↑ Hirahara, Alan M., Alberto Panero, and Wyatt J. Andersen. "An MRI Analysis of the Pelvis to Determine the Ideal Method for Ultrasound-Guided Bone Marrow Aspiration from the Iliac Crest." American Journal of Orthopedics (Belle Mead, NJ) 47.5 (2018).
  11. ↑ Bosi, Alberto, and B. Bartolozzi. "Safety of bone marrow stem cell donation: a review." Transplantation proceedings. Vol. 42. No. 6. Elsevier, 2010.
Created by:
John Kiel on 27 August 2023 15:36:17
Authors:
Last edited:
27 August 2023 18:39:25
Categories:
Retrieved from "https://wikism.org/w/index.php?title=Bone_Marrow_Aspiration&oldid=20817"