Visualization of the bone marrow biopsy needle track
Authors: Shirin Attarian, Louis Reed, Shashi Singh, Alexander Shestopalov, Aditi P Singh, Anjali Budhathoki, Simon Abi‐Aad, Urvi A Shah, Salem Kim, Kimo Bachiashvili, Tarek Elrafei, Weijuan Li, Conway Yee, Ellen W Friedman
Journal: American Journal of Hematology (2017)

Bone marrow biopsy and aspiration are frequently performed to diagnose hematologic and oncologic diseases. The bone marrow procedure (BMP) is generally considered to be a low risk procedure, albeit briefly painful. The safety data of the procedure is largely based on retrospective surveys of British hematologists between 1995 and 2006, with reported major complication rate ranging from 0.05% to 0.12%. Hemorrhage was the most commonly reported adverse event. Anaphylactic reactions, persistent pain and pelvic fractures were also seen.1, 2 The majority of BMPs in adults in the US are performed on the posterior superior iliac spine (PSIS). Over the last 50 years, there have been many case reports and small series of neurovascular injuries, postprocedure hemorrhage, arteriovenous fistula formation, gluteal compartment syndrome, and pseudoaneurysm formation following BMPs.3 A cadaver study at our institution showed that advancement of the biopsy needle perpendicular to the body's coronal plane was associated with increased likelihood of neurovascular injuries.4 We conducted a prospective study of adult patients undergoing an elective diagnostic BMP to visualize the bone marrow biopsy needle track with use of low dose, noncontrast computer tomography (CT) scan performed 5 days after the BMP. Patients 40 years of age and older, undergoing an elective BMP, were recruited for participation in this study. All BMPs were performed by first or second year hematology-oncology fellows using a Jamshidi needle with a Snarecoil device (Ranfac Corp. Avon, MA). All procedures were supervised by an attending investigator. Prior to performing the BMP, fellows were trained on localization of the PSIS and were instructed to advance the biopsy needle towards the anterior superior iliac spine (ASIS) after needle penetrated the PSIS, and to obtain at least a 2 cm biopsy core (also known as the lateral angulation technique). All patients underwent a low dose, noncontrast pelvic CT scan 5 days after the BMP. Two radiologists independently reviewed all CT scans to report the visualized needle track as well as any complications. Study protocol was approved by institutional review board. The average age of the 25 study patients was 64 years, 56% were male, and the average BMI was 25.7 kg/m2. All patients had successful BMP's under local anesthesia. In 3 (12%) patients, the needle track traversed the ilium and penetrated the sacro-iliac joint and the sacrum (Figure 1). The needle track in these cases was at approximately 90 degrees to the coronal plane of the body. None of the 3 patients with sacral penetration reported significant pain or neurological symptoms. In 6 cases, the needle tracks were visualized at various angles in the ilium. In 16 scans, no needle track was seen. Of the 25 CT scans, none revealed a significant hematoma or other vascular complication. The lengths of the biopsy cores have been reported elsewhere.5 (A) A needle track (arrow) is seen entering the PSIS and traversing the left sacroiliac joint and the hemi-sacrum. (B) A needle track is seen penetrating the PSIS (arrow), the needle track is seen crossing the left sacroiliac joint and penetrating the left hemi-sacrum. (C) A needle track is seen penetrating the PSIS (Arrow). It penetrates the inner table of the ilium entering the right sacroiliac joint There is little data available on the safest techniques for the BMP. In a study on cadavers, Konda et al demonstrated that advancement of the biopsy needle perpendicular to the body's coronal plane was associated with increased risk of injury to the iliac and iliolumbar arteries, femoral and obturator nerves, and the sacro-iliac joint, if penetration of the inner table of the ilium occurred. Retroperitoneal hemorrhage following a BMP, although uncommon, likely occurs due to traversal of the ilium by the needle. In contrast, penetration of the inner iliac cortex while advancing the biopsy needle laterally towards the ASIS is significantly less likely to result in neurovascular damage or trauma to the sacroiliac joint. It seems reasonable to conclude that fewer neurovascular injuries will occur by targeting the ASIS.4, 6 In our study, 3 patients (12%) had penetration of the inner table of the ilium through the sacro-iliac joint and into the sacrum. Analysis of CT scans shows that a 9 degree change in needle angulation can lead to penetration of the sacrum (Figure 1). No adverse consequences of inadvertent penetration of the sacrum were noted in this small series. Study limitations include the relatively small sample size and lack of control for objectively comparing the technique and tools used. Despite these limitations, this study presents novel information about real-world visualization of needle tracks after a blind BMP. Further studies are needed to determine the safest and most efficacious technique for the BMP. None of the authors have any conflict of interest to report.