Bone marrow aspiration and trephine (G089)

A bone marrow examination is a critical part of the evaluation of patients with a variety of hematopoietic and non-hematopoietic diseases. It is performed for diagnostic purposes in patients with splenomegaly, dysproteinemias, suspected lysosomal storage disease, an unexplained deficiency or excess of peripheral blood leukocyctes or platelets, or the presence of immature or morphologically atypical cells in the peripheral blood. The bone marrow examination may also be requested to obtain material for microbiological culture in patients with unexplained fever or other diseases, and to search for infectious organisms, neoplasms, granulomatous disease, or other lesions in these patients. Bone marrow examination is also part of the staging process for newly diagnosed patients with lymphoproliferative diseases and certain non-hematopoietic malignancies. Moreover, marrow evaluation is essential to determine the efficacy of treatment and to monitor the recovery process in patients undergoing bone marrow transplantation or marrow-ablative Systemic Anti Cancer Therapy (SACT).

This guideline has been produced to ensure that the procedure for bone marrow aspiration and trephine is performed safely and to a high standard within NHS Ayrshire & Arran. 

This guideline will apply to all haematology medical staff and Advanced Clinical Nurse Specialists (ACNS) employed by NHS Ayrshire & Arran who are deemed competent in the advanced practice of bone marrow aspiration and trephine.

• To determine the diagnosis of many haematological diseases.

• All haematology medical staff and ACNSs who have been deemed competent in the advanced practice of bone marrow aspiration and trephine (posterior iliac crest only).

Bone Marrow Procedures: Involve the removal of haemopoietic tissue, usually from the iliac crest or sternum, using a special needle.

Aspiration: A needle is inserted into the marrow and a liquid sample of marrow is aspirated into a syringe.  This is then spread onto a slide for microscopy and stained. A large amount of morphological information can be obtained by examining the stained slide of the aspirated marrow. An aspirate sample may also be used for a number of specialised investigations (See section 5.4 Comparison of bone marrow aspiration and trephine biopsy).

Trephine: A trephine biopsy provides a solid core of bone including marrow and is examined as a histological specimen after fixation in formalin, decalcification and sectioning. The indications for undertaking trephine are shown in section 5.4. Immmunophenotyping may also be undertaken with a trephine needle.

Examination of the bone marrow, together with the prior examination of the blood, remains the gold standard required for the diagnosis of many haematological diseases². Bone marrow is harvested for autologous or allogenic transplantation or cryopreservation for both malignant and non-malignant conditions³, however this procedure is not encompassed in this guideline.

The figures below indicate the common sites for bone marrow aspiration, arranged in order of preference. Normally, only aspirations and not biopsies are done on the sternum because of its small size and proximity to vital organs.

Patients having a bone marrow aspiration obtained by an appropriately trained nurse may only have the sample taken from the posterior iliac crest.

A successful bone marrow evaluation requires knowledge of the patient and the reason(s) the study was requested. The following information should be obtained when a bone marrow aspiration and trephine is requested:

• Patient name.
• Patient age and gender.
• Patient location / requested time of examination.
• Primary diagnosis.
• Clinical indication(s) for examination.
• Allergies (especially to povidone iodine and lidocaine).
• Recent SACT, radiation therapy, bone marrow transplantation, or blood transfusions.
• Dietary, racial, and family history.
• Medications (iron, B12/ folate, G-CSF, aspirin, heparin, antibiotics etc). If a patient is taking vitamin K dependent anti-coagulants, such as warfarin, phenindione or acenocoumanol (examples not exhaustive), the patient's INR must be checked prior to the procedure and INR should be <3 if patient is taking a direct oral anticoagulant (DOAC), the patient must omit the DOAC on the morning of the BMA.
• Special studies requested (immunophenotypic analysis, cytogenetic analysis, cultures etc).
• Special medical problems that may warrant caution when obtaining written consent or complicate the procedure (i.e. unresponsive or lacking mental capacity, aversion to medical procedures, anxiety, pain intolerance, disease or recent surgery involving the pelvic bone, haemophilia or other bleeding disorders, severe cardiac or pulmonary disease, morbid obesity etc).
• Name / pager # / telephone# of person requesting examination.
• Provide patient pre- bone marrow information leaflet.

Since bone marrow procedures are usually performed at the bedside, appropriate supplies and equipment must be taken to the site. This includes the patient's case notes, signed organisational consent form and patient care pathway. The responsible practitioner must ensure that they obtain the appropriate “Silver Box” from the Laboratory Department.

• sterile dressing pack
• antiseptic skin cleansing agent (chlorhexidine gluconate 0.5% in alcohol 70%)
• 1 x 10ml syringe
• 1 x luer lock 20ml syringe
• 1 x orange needle
• 1x green needle
• 1x white needle
• local anaesthetic – 2% plain lidocaine
• sterile gloves
• sterile scalpel blade
• disposable bone marrow aspirate needle
• disposable bone marrow trephine needle
• specimen bottles –
  
  • 2 x 4.5ml EDTA blood tube
  • 1x pathology specimen Gentafix pot containing formalin
• microscope slides for smear preparations and trephine rolls
• slide tray, pencil
• sample request forms
• polyurethane semi-permeable dressing
• opsite spray
• skintact 5 x 5
• mepore 9 x 10 

Where indicated:

• 2 x 4.5ml EDTA tube for cytogenetics (labelled 1 & 2)
• 4.5ml EDTA tube for immunophenotyping
• 4.5ml EDTA tube for molecular haematology

Procedure only to be performed by suitably trained haematology practitioner or haematology specialist nurse.

• There is no requirement to stop aspirin monotherapy prior to undertaking a BMA. A full blood count must be obtained within 48hrs of the procedure to ensure the patient platelet count in great or equal to 20. If a patient is on dual anti-platelet therapy their clinical case should be discussed with the duty haematologist when booking the patient in for a BMA to decide on an individualised plan based on clinical history.
• If a patient is taking vitamin K dependent anti-coagulants such as warfarin, phenindione or acenocoumanol (examples not exhaustive) the patient’s INR must be checked prior to the procedure and INR should be <3.
• If patient is taking a direct oral anticoagulant (DOAC), the patient must omit the DOAC on the morning of the BMA.
• For other antiplatelet agents and/or anticoagulation, it is generally considered safe to continue monotherapy.

Prior to procedure it is necessary to establish exactly which investigations are required on the aspirate sample (see appendix 1). Check whether a bone marrow trephine is necessary (appendix 2).

1. Explain and discuss procedure with patient.
2. Ensure consent has been obtained using the NHSA&A consent form.
3. Ensure patient has no known allergies.
4. Plastic apron to be worn.
5. Help the patient into the correct position on their side for iliac crest aspirate and trephine biopsy. The practitioner then identifies site for injection of local anaesthetic.
6. Practitioner involved should perform hand hygiene and put on gloves to reduce risk of cross infection.
7. Observe the patient throughout the procedure and offer reassurance.
8. Skin is cleansed with antiseptic solution to avoid a risk of wound contamination.
9. Infiltrate the area with local anaesthetic and allow a minimum of 5 minutes for it to take effect (see section 5.6.1 for local anaesthetic technique).
10. Obtain the bone marrow aspirate (see section 5.7 for technique).
11. Obtain bone marrow trephine (see section 5.7.1 for technique).
12. Apply pressure over the puncture site using a sterile topical swab until bleeding stops. Caution is needed if patient has low platelet count / taking anticoagulants or has a bleeding disorder.
13. Once the bleeding stops, cover the site with polyurethane semi-permeable dressing or a pressure dressing if patient is at risk of bleeding. Ask the patient not to wash or bathe the area for 24 hours.
14. Make the patient comfortable. Patient is to wait in the department for 20 minutes.
15. Ensure all equipment is removed and disposed of correctly, including the safe disposal of sharps.
16. Record the necessary information in the patient records. Ensure that all specimens are sent to the laboratory department, correctly labelled with the necessary request forms. Request samples for cytogenetics are to be sent to the laboratory urgently.
17. Patient advised to use simple analgesics if required (e.g. Paracetamol or co-codamol). NSAIDS such as ibuprofen should be avoided.
18. Patient advised if any problems develop post procedure to immediately contact the relevant unit.

Once a sterile site has been achieved, a local anaesthetic is utilised to “numb” the skin and periosteum over the chosen area of the posterior iliac crest. Lidocaine or a similar anaesthetic can be used, providing the patient has no history of an allergic reaction to this medication. During this process, local anaesthetic is first infiltrated into the skin and subcutaneous tissue to anesthetise an area approximately 1cm in diameter.

After the skin is numb, lidocaine is infiltrated directly over the periosteum to numb an area approximately 2-3cm in diameter. Discomfort can be avoided during the remainder of the procedure if adequate time is taken to assure good anaesthesia.

Local anaesthesia is administered as follows:

• Aspirate 2% plain lidocaine into a 10ml syringe.
• Slowly infiltrate the skin with the lidocaine, raising a “10 pence sized” intradermal wheal with a 26-gauge needle.
• Infiltrate the subcutaneous tissue and periosteum, using a 22-gauge needle (or spinal needle for overweight patients). This usually requires 2-5mL of lidocaine. Assess the thickness of the subcutaneous tissue and the depth to the periosteum for later reference.
• Determine the adequacy of local anaesthesia after several minutes by gently tapping the periosteum with the sharp point of the numbing needle. If sharp pain is stilled experienced, the injection of additional lidocaine is required.

Caution! – Adverse reaction of a neurologic, cardiovascular, and allergic nature can occur to lidocaine. If anaesthesia is not achieved with 15ml of lidocaine 2% then advice should be sought.

Marrow aspiration from the posterior iliac crest is performed as follows:

• Inspect the desired marrow aspirate needle for signs of manufacturing defects.
• Loosen and remove the plastic guard from the needle (if one is present).
• Loosen and remove the obturator to make certain that it can be removed with ease.
• Insert obturator and relock.
• Hold the needle with index finger near needle tip to control the depth of penetration.
• Hold needle horizontally (for a patient lying on their side) to puncture the anesthetised skin. If the skin is tough, make a small incision with a sterile scalpel.
• Advance the needle with steady pressure and a slight twisting motion to the centre of the posterior iliac prominence (PIC). Angle the needle 15 degrees caudal.
• Rotate the needle back and forth (90⁰ -180⁰) and carefully apply pressure to advance the needle through the cortical bone. The consistency of the bone varies considerably from patient to patient, but may have significance as follows:

Decreased resistance (usually) indicates penetration of cortex and entry into the marrow cavity.

• Prepare the slides and label with name, CHI and date of procedure.
• Advance needle about 1 cm into the marrow cavity. Unlock and slowly remove the obturator. Some patients may notice pain if the obturator is not removed carefully.
• Attach a 10ml syringe to the aspirate needle. Warn the patient that they may feel a sharp pain in their hip but that this lasts only a few seconds. Quickly (<5 seconds) aspirate 1.0ml marrow into the 10ml syringe (more than this dilutes the specimen with peripheral blood). Beware - the sudden sharp pain may cause the patient to shout, move suddenly, or even try to strike you. Remain alert, try to maintain sterility, and calm the patient quickly if this happens.
• Cap the needle while you prepare the specimen slides and evaluate the presence of granules.
• If granules are present, extra marrow specimen(s) for special studies can be obtained.
• If a “dry tap” (no fluid, no sharp pain) occurs, then reposition needle (depth, angle or location) and try again. As a “last resort” touch preparations can be prepared from the core biopsy. Try the opposite side if necessary.
• Remove aspiration needle and apply pressure with a sterile sponge until bleeding ceases.
• Perform a bone marrow biopsy or place a folded piece of gauze over the site, apply a pressure bandage and have the patient lie supine for at least 30 minutes.

1. Obtain a biopsy needle and inspect for bent, loose, or almost broken parts. Remove obturator and inspect, reinsert obturator and lock and twist.
2. Hold biopsy needle with hub in palm, index finger tip to skin to control needle penetration. Insert through skin incision site.
3. Using steady pressure, advance biopsy needle to the bone. At bone, advance needle through cortex with forceful rotating movement - decreased resistance (usually) indicates entry into marrow cavity.
4. Remove obturator when needle is firmly anchored in bone. Advance needle 1-2 cm more with continued “back and forth” rotation. To determine the length of the biopsy specimen in the needle, the obturator can be carefully reinserted into the needle. An ideal biopsy core is 2cm or greater in length.
5. To break off the biopsy specimen from the surrounding bone using a needle with a cut and retain attachment, deploy the grey lever by moving it from the ‘open’ to the ‘closed’ position.
6. Slowly withdraw the needle from the patient and place a piece of gauze over the exit site and apply pressure until any bleeding has stopped.
7. Rotate the grey lever from the ‘closed’ to the ‘open’ position.
8. Place the probe guide onto the distal tip of the cannula. Insert the probe into the distal end of the probe guide. Advance the probe into the needle and collect the biopsy specimen as it emerges from the opening in the handle (proximal end) onto the glass slide, gauze or directly into the pathology specimen pot.
9. Inspect the biopsy for adequacy and atypical features. A normal biopsy core is dark red with a fine white trabacular network. In patients with a markedly hypocellular marrow the trabacular network remains but reddish marrow is not visible. Cartilage is homogenous, white, and glistening, while cortical bone is white. A mottled appearance may indicate focal replacement with tumour or granulomas.
10. Additional biopsy cores should be obtained if the specimen is inadequate in size or has an atypical gross appearance. Several touch imprints of the biopsy core (trephine rolls) can be obtained if aspirate sample was obtained.
11. No biopsy specimen? Is it inside the skin incision - can it be withdrawn with forceps? Repeat several times until specimen obtained. Try  to obtain core by using a syringe with gentle vacuum over the needle hub as you withdraw, firmly rock needle back and forth before withdrawing, try new needle etc.

Patients may be anxious about the procedure and a mild sedative may be indicated. The procedure is performed under local anaesthetic, although owing to the nature of the pain (often described as a dragging sensation) the actual aspiration procedure may still remain painful even when the site is numb.  The posterior iliac crest is the preferred site for both aspiration and biopsy as there are no vital organs nearby that may be punctured. The position also means that the procedure can be performed outside the patient’s line of vision.

5.8.1 Medication for pain and anxiety reduction

Lorazepam 0.5mg-1mg orally or sublingually. Dosages may vary with weight, age, etc, and should be adjusted to the individual patient and desired level of sedation.

1. Observe puncture site for leakage and redress if necessary.
2. Encourage patient to lie in a position that puts pressure over the puncture site.
3. Pain may be experienced over the puncture for 1-2 days following the procedure; administer a mild analgesia as prescribed.
4. Provide patient with written after care leaflet.
5. If the patient is discharged after the procedure, give advice regarding the care of the puncture site, what level of discomfort may be experienced, who to contact should any adverse reaction occur (Contact Ward 3A/5E, Kyle Unit) Inform when results will be available and date and time of next outpatient appointment.
6. Any returnees with bleeding should be admitted overnight for observation.
7. Any clinical incidents should be reported on Datix.

Complications of bone marrow procedures are extremely rare but include the following:

Haemorrhage: this occurs almost exclusively in those patients with coagulopathy. It may be avoided by applying pressure to the puncture site for a few minutes following the procedure and by the administration of platelet transfusions where indicated.

Infection: particularly in the neutropenic patient.

Bone fractures: owing to the pressure exerted.

1. Hoffbrand, A.V., Pettit, J.E. & Moss, P.A.H. (2001) Essential Haematology. Blackwell Science, Oxford.
2. Ryan, D. (2001) Examination of the marrow. In: Williams’ Haematology, 6^th edn (eds E.Beutler, B.S.Coler, M.Litchmann et al.). McGraw-Hill. London.
3. Cottler-Fox, M. (1999) Marrow collection and processing. In: The Clinical Practice of Stem-Cell Transportation (eds J.Barrett & J.Treleaven). Isis Medical Media, Oxford.
4. Ryan, D. (2001) Examination of the marrow. In: Williams’ Haematology, 6^th edn (eds E.Beutler, B.S.Coler, M.Litchmann et al.). McGraw-Hill. London.
5. Beutler,E.,Coller, B.S.,Litchmann, M.,Kipps,T.J. & Seligshohn,V. (2001) Williams’ Haematology, 6^th edn McGraw-Hill. London.
6. ADTC117: Perioperative Management of the Patient on Oral Anticoagulants and Antiplatelet Agent
7. Wang, T., Sanfilippo, K. M., Douketis, J., Falanga, A., Karageorgiou, J., Maraveyas, A., Ortel, T. L., Soff, G., Vedantham, S., & Zwicker, J. I. (2022). Peri‐procedure management of antithrombotic agents and thrombocytopenia for common procedures in oncology: Guidance from the SSC of the ISTH. Journal of Thrombosis and Haemostasis, 20(12), 3026–3038. https://doi.org/10.1111/jth.15896.

Investigations, staging and follow up of the following suspected disorders:

• Non Hodgkins lymphoma
• Hodgkins disease
• Lymphoproliferative disorders
• Multiple myeloma
• Myelodysplastic syndromes
• Aplastic anaemia.

Investigation of:

• Leucoerythroblastic blood film
• PUO
• Suspected bone disease
• Unexplained cytopenias except ITP (aspirate only)

Investigation of the following disorders, if the aspirate is dry:

• Acute lymphoblastic leukaemia
• Acute myeloid leukaemia

Trephines are not necessary for response assessment in acute leukaemia unless the aspirate is dry or counts fail to recover due to suspected marrow hypoplasia.

Nurse led bone marrow aspirate and trephine service patient information leaflet

Nurse led bone marrow aspirate and trephine service statement of patient

Patient information - after bone marrow sampling