Performing a Bone Marrow Aspiration
Introduction
The field of regenerative medicine is growing in orthopedics. Harvesting mesenchymal stem cells in order to treat common conditions like osteoarthritis are being advertised. However, the more appropriate term than mesenchymal stem cell is medicinal signaling cells. A bone marrow aspirate concentrate (BMAC) exerts its benefit by its paracrine signaling bone marrow stromal cells, hematopoietic cells, endothelial progenitor cells, and pericytes (1).
Bone marrow biopsies are typically thought of as high risk procedures. However, a review was performed in 2010 looking at the safety of bone marrow aspiration. They found that pain at the site of the procedure is the most common side effect from the procedure (2). In a large study of more than 27,000 bone marrow aspirations, only one fatal event was seen, which was found to be secondary to a pulmonary embolism (2). Providers should review a patient’s medications prior to performing a bone marrow aspiration, as aspirin and anticoagulants can increase the risk of a post-procedure hematoma (12).
Due to the size of the bone in the posterior iliac crest, this is a common location to perform a bone marrow aspiration. The posterior iliac crest has also been found to produce the highest amount of colony forming progenitor cells compared to other harvesting locations (10). This review will look at the procedure of obtaining a bone marrow sample from the posterior iliac crest.
Patient positioning for bone marrow aspiration
Procedure
In an average woman and small man, it is safe to take up to 60mL of bone marrow (1). A hand trocar or drill powered trochar can be used to enter the marrow cavity (1). Entry of the trochar into the bone marrow typically requires a significant amount of downward pressure (3). As a result, when the trochar loses contact with the bone there can be injury to the surrounding viscera, sciatic nerve, and gluteal nerves (3). Risks for medial and lateral table breaches can occur as well (4). The trochar should be preloaded with heparin to prevent clot formation (1). The ratio is 500 to 1000 IU of heparin per 1mL of bone marrow (12).
Providers will place the patient in a prone position. The patient should have sterile drapes placed around the site of the procedure (7). One mL of heparin (1000 U/mL) is preloaded in the syringes (7). The target for the injection is the posterior superior iliac spine. The posterior iliac crest can be located with a low frequency ultrasound assistance. The probe can be moved in a superior and inferior direction to look for the most central portion of bone (8). The PSIS is typically identified by placing the probe perpendicular on the ilium and looking for the mountain peak shaped PSIS (12). The target for the aspiration is typically 1cm inferior to the most superior tip of bone to help reduce the chance of slipping off (12). A starting position that is too lateral and superior can injure the cluneal nerves, as they come over the iliac crest (8).
Cluneal nerves location (13)
Once the posterior superior iliac spine (PSIS) has been localized and marked, anesthetic can be injected. The injection can be performed with in-plane guidance (8). Typically, a 22g 3.5inch needle is needed to reach the periosteum (1).
Localizing posterior iliac crest with ultrasound (8)
The anesthetic, which is typically 1% Lidocaine without epinephrine, should be directed from the skin to the periosteum (5).
Process of anesthesia and then trochar insertion (7)
A stab incision is first made into the skin prior to the trochar (8). An 11 gauge 4 inch trochar will be placed vertically over the skin and then angled laterally by dropping the hand towards the midline (8). The trochar direction should be approximately 24 degrees (8). A drill or mallet can be used to breach the dense cortical bone (7). If not using a drill or mallet, a counterclockwise/clockwise motion should be applied to the bone to penetrate through the cortex (12). The trochar should be advanced 3 to 5 cm into the bone depending on the size of the patient (8). The average length to reach the anterior portion of the ilium is 7cm (8). Studies have shown that drawing smaller volumes 5-10mLs from multiple spots in the marrow lead to more mesenchymal stem cells than large volumes >10mLs from a single site in the marrow (1).
Conclusion
A bone marrow aspiration can be safely obtained from the posterior superior iliac spine. Ultrasound guidance can help decrease the risk of vessel injury during trochar introduction. Further studies need to be performed to strengthen the evidence of a BMAC injection.
By Gregory Rubin, DO
rubinsportsmed.com
Read more on Wiki Sports Medicine: https://wikism.org/Bone_Marrow_Aspiration
References
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