Trepanobiopsy of the bone marrow - indications and contraindications, preparation. Trephine biopsy of the ilium Bone marrow from the ilium

To identify various pathologies of the human hematopoietic system. Sometimes this procedure is useful in the diagnosis and treatment of certain bone diseases. During a trepanobiopsy, a fragment of the bone marrow is extracted with the preservation of its structure, due to which the method is quite informative. For the manipulation, a special trocar needle 4 cm long and 2 mm in diameter is used, equipped with a shield, a mandrin and a handle. The peripheral end of the needle has a spiral shape, due to which it acquires the ability to cut bone tissue during rotation. The puncture is performed under local anesthesia in the scallop area ilium. After the procedure, a fragment of bone tissue 6-10 cm long is removed from the needle, which undergoes appropriate processing in the laboratory. Often, trepanobiopsy is used as the main research method in.

This manipulation is carried out with the obligatory presence of a “fresh” result (no more than 5 days) of a detailed general analysis blood.

Sternal puncture of the bone marrow

In newborns and infants, it is preferable to puncture in the region of the upper third of the tibia due to existing danger chest puncture.

Complications

Bone marrow puncture is the only source of reliable assessment of the state of stem cells in leukemia, hemoblastoses, and lymphomas. The procedure is invasive, but is necessary for accurate verification of the type and severity of blood cancer.

What is a bone marrow puncture - is it dangerous to health

Technically, it is not difficult to perform a puncture. The procedure is necessary to verify the diagnosis, assess the quality of treatment. Microscopic examination of the punctate makes it possible to determine the ratio of different elements, which is important for planning therapy tactics.

The essence of the procedure is the taking of material from the middle part of the sternum, thigh. To do this, a puncture is carried out with a special needle with a limiter, which excludes penetration to a great depth.

The sternal sterile needle enters perpendicular to the sternum. After penetration to a certain depth, the bone marrow punctate is aspirated in a volume of about 1 ml. When taking material from the thigh, the procedure is similar, except for a different approach.

After removing the needle, a patch is applied to the puncture site. The bone marrow aspirate is sent to the laboratory for immediate examination, as there is an increased likelihood of clotting blood cells. The resulting excess blood is removed with filter paper.

When patients take corticosteroids for a long time, the tendency to osteoporotic bone changes increases. Sternal puncture in such a situation is carried out carefully.

As a rule, there are no complications after bone marrow puncture of the sternum. It is possible to bring an infection into the cavity only with a gross violation of safety precautions. There are no large vessels around the sternum, so heavy bleeding does not occur. The penetration of the needle into the chest cavity is impossible due to the presence of a stopper on the needle. Only equipment is not suitable for puncturing the sternum of children, so the sampling in newborns is carried out from calcaneus or upper thigh.

Trepanobiopsy

Classical trepanobiopsy of the bone marrow is used to analyze the bone marrow structure, to study the characteristics of blood cells. Morphological analysis of punctate is important for hemoblastoses, leukemias, lymphomas, and other types of blood cancer.

The human bone marrow consists of a solid and a liquid part. To remove it, aspiration is performed, which allows you to take the right amount of material, but such manipulation reduces the quality of diagnosis, since the bone marrow contents are diluted with blood. Difficulties arise with access to large bones, but for these purposes, standardized interventions have been developed with the destruction of the external bone structure (trephine biopsy).

Life-time study of histological preparations obtained by trephine biopsy becomes necessary in cases where a sufficient amount of bone marrow cannot be obtained during puncture, confirming a particular pathological process. The histological method acquires special importance in diseases such as leukemia, erythremia, osteomyelosclerosis, hypo- and aplastic processes, etc.

For puncture and extraction of a piece of bone tissue M.G. Abramov suggested using a trocar needle. The needle is designed according to the principle of Kassirsky's sternal needle.

Trocar needle thickness- 3 mm, inner diameter - 2 mm, length - 6 cm. The peripheral end of the needle has a similarity to a cutter and a spiral shape, due to which the needle acquires the ability to cut bone tissue when it rotates. The components of the needle are the mandrin (stylet with a pointed end) and the handle. V.A. Ershov, N.A. Klimkov modernized Abramov's trocar needle, making it more convenient to use. The needle differs from the one described above in that its mandrin is screwed into the lower end of the handle and, when the cortical layer is punctured, is quickly removed from the needle without prior disassembly, which speeds up the trepanobiopsy process.

A puncture is made into the iliac crest, retreating 2-3 cm posteriorly from its anterior superior spine. It is technically more convenient to pierce the left iliac bone. The puncture site is disinfected with alcohol and iodine tincture. The needle is pre-sterilized by the dry method or by boiling and dried with alcohol and ether. On a dry needle, using a screw thread, a limiter guard is set to the required puncture depth, taking into account the thickness of the subcutaneous fat. Before the introduction of the trocar needle, anesthesia of the skin is performed, subcutaneous tissue and periosteum with a 2% solution of novocaine.

Penetrating with a trocar needle into soft tissues, grope with the end of the pointed mandrin the place of the bone where the puncture should be made. The needle is inserted into the bone tissue under some pressure with rotational movements. When a feeling of firm fixation of the needle appears, the mandrin is removed. Having separated the mandrin and the handle, the latter is again screwed onto the needle fixed in the bone. By making a rotational movement in a clockwise direction, the needle can be easily inserted into the spongy substance of the bone tissue without much difficulty.

After that, the needle is removed with a rotational movement. A cylindrical column of bone tissue located in the needle is pushed out with a mandrin from the lumen of the needle onto a glass slide, and from there it is transferred to a formalin jar and sent for histological examination. From the remaining on the glass, in the needle and on the mandrin of the bone marrow, smears are made. Most often, it is possible to cut and extract a piece of bone tissue from 6 to 10 mm long, sometimes more.

Trepanat (spongy bone tissue) in healthy people and in patients with hyperplastic processes it is rich in bone marrow. In severe aplastic processes, the trepanate has a yellow color, which is due to the almost complete disappearance of bone marrow elements and their replacement with adipose tissue.

With all forms of osteomyelosclerosis and myelofibrosis, the extracted piece of bone tissue often looks “dry”, and only a very small amount of bone marrow can be extracted from it for the preparation of smears.

Bone marrow trephine biopsy is a procedure for taking a sample of bone marrow and sending it to a laboratory for further histological examination. Bone marrow is taken if the patient has blood diseases. Trepanobiopsy has similar features to such an analysis as puncture, but the biopsy result is as informative and extended as possible.

Indications

Trepanobiopsy is performed if the patient has the following pathological conditions:

• to changes in the number of blood cells erythrocytes and leukocytes;
• anemia, what is severe and not amenable to traditional treatment;
• increased sweating with unknown etiology;
• constantly elevated temperature body;
• frequent infectious and viral diseases
• any disease blood;
• Availability oncological neoplasms in the bone marrow.

Trepanobiopsy is mandatory for patients who have to undergo chemotherapy for the treatment of oncological neoplasms. At the end of the course of chemotherapy, a second biopsy is performed to determine whether such treatment has given a positive result.

Contraindications

Trepanobiopsy is an absolutely safe procedure with minimal contraindications. A bone marrow biopsy is not performed in the elderly, as they are difficult to tolerate any type of anesthesia and take a long time to recover.

It is necessary to postpone the procedure if the patient has infectious and viral diseases that flow in acute stage. There are also relative contraindications, in the presence of which trepanobiopsy can be performed, but with extreme caution due to the high risk of complications.

Relative contraindications include: diabetes, the presence of a severe stage of heart failure.

Difficulty in performing a bone marrow biopsy may occur in obese patients when they are not able to lie on their stomach for 10-20 minutes.

Training

To avoid possible complications, 2-3 days before the trepanobiopsy, you must stop taking medicines that affect the degree of blood clotting. Avoid using antiperspirants and cosmetic preparations, including flavored hygiene products.

In the morning before the scheduled trepanobiopsy, you can have a light breakfast, but at least 4 hours must pass between the meal and the procedure.

You can drink water, but in limited quantities. Half an hour before the bone marrow biopsy, the patient is given sedative drugs.

Preparation for a trepanobiopsy includes the passage of a general and detailed blood test and ultrasound.

How do they do

The patient is placed on a couch on his stomach or on his side, the procedure is allowed while sitting, but only if the doctor has extensive experience in trephine biopsy.

The puncture site of the skin is carefully treated with disinfectants, injected local anesthetic. After a few minutes, the doctor checks the degree of sensitivity skin, and if the anesthetic has begun to act, proceed directly to the trepanobiopsy.

With the help of a special thin and long needle, slowly, with rotational movements, it is introduced into the ilium. A few millimeters of bone marrow is removed for histological examination.

1-2 hours after the procedure, the patient does not need medical supervision and goes home. Do not wet the puncture site for 3 days.

Does it hurt

Trepanobiopsy is performed using local anesthesia. A bone marrow biopsy is not painful, but rather unpleasant.

The patient will experience pressure at the insertion site, discomfort may be felt in the groin and thighs. To reduce the intensity of discomfort after a biopsy, an ice pack is applied to the puncture site.

What diseases does it show

Trepanobiopsy of the bone marrow helps to identify the following diseases: Hodgkin's disease, lymphoma, retinoblastoma, neuroblastoma, Ewing's sarcoma.

Trepanobiopsy is used to diagnose diseases such as leukemia, the presence of metastases from oncological neoplasms, and Gaucher's disease.

Contributes to trepanobiopsy exact definition foci of accumulation of cancer cells.

Decryption

If there are abnormalities in the number of certain blood elements in the bone marrow, which may be caused by blood diseases, the concentration of myelokaryocytes in the test sample will be significantly reduced.

To make an accurate diagnosis, blood test data and a decoding of the histological examination of the bone marrow obtained during trepanobiopsy are taken into account.

An increase in blood elements in the bone marrow indicates the presence of blood diseases, but if their concentration is significantly reduced, this may indicate autoimmune diseases, the development of a severe form of anemia.

Complications

There is no likelihood of complications with proper and thorough treatment of the puncture site on the skin with antiseptic preparations.

Trepanobiopsy is a safe diagnostic procedure, but theoretically it allows the patient to experience complications after it, such as infection, bleeding. The risks of infection are higher in patients with diseases and defects of the heart muscle, with the presence of osteoporosis.

Temporary complications after trepanobiopsy, which are present for several hours, disappear on their own and do not require treatment - a feeling of internal chills, fever, pain at the injection site of the needle.

Signs in which you need to see a doctor immediately - rapid deterioration general condition, strong pain, which cannot be stopped with painkillers, shortness of breath, nausea and vomiting, fever.

Pros and cons

Trepanobiopsy is a highly effective and most informative diagnostic procedure for detecting various blood diseases.

The advantage of the method is that it does not require serious and special preparation, contraindications to trepanobiopsy, unlike other methods, are minimal.

The likelihood of complications, in the absence of contraindications in the patient and the work of a qualified, experienced doctor, is practically absent.

As such rehabilitation period after a trepanobiopsy of the bone marrow is absent, recommendations relate to abstinence for several days from taking a bath, visiting a solarium, baths and saunas.

The disadvantages of trepanobiopsy include long time waiting for histology results, which takes 1 to 2 weeks. Taking a bone marrow sample is accompanied by sufficient unpleasant sensations, and if the patient has a high pain threshold, for carrying out a trepanobiopsy it is necessary to use potent anesthetics of the local spectrum of action, after which the patient may experience a slight malaise.

The disadvantages of bone marrow trepanobiopsy include the rather high cost of the procedure, but the price is fully justified by the maximum information content and the ability to quickly make a diagnosis.

VOLUME 7 NUMBER 3 2014

CLINICAL

ONCO HEMATOLOGY

CLINIC, DIAGNOSIS AND TREATMENT OF LYMPHOID TUMORS

Technical aspects of performing bone marrow trepanobiopsies

Yu.A. Crooked-legged

GOU VPO "North-Western State medical University named after I.I. Mechnikov,

191015, st. Kirochnaya, 41, St. Petersburg, Russian Federation

The purpose of bone marrow trepanobiopsy is to obtain a complete sample for histological examination of hematopoietic tissue. The article provides information on indications and contraindications for performing this manipulation. The technique of trepanobiopsy with a Jamshidi needle is described with the necessary details; possible complications procedures and flaws in their execution.

Keywords: trepanobiopsy, bone marrow examination, Jamshidi needle, manipulation technique.

Yu.A. Krivolapov - dr honey. Sci., Professor, Head of the Department of Clinical Molecular Morphology, +7 812 303 5039, [email protected]

For correspondence: Yu.A. Krivolapov, 191015, st. Kirochnaya, 41, St. Petersburg, Russian Federation, +7 812 303 5039, [email protected] For citation: Krivolapov Yu.A. Technical aspects of bone marrow trepanobiopsy. Wedge. oncohematol. 2014; 7(3): 290-5.

Procedural Considerations for Bone Marrow Trephine Biopsy

I.I. Mechnikov North-Western State Medical University, Kirochnaya str., 41, St. Petersburg, 191015, Russian Federation

The aim of the bone marrow trephine biopsy procedure is to obtain a proper specimen for histological evaluation of hematopoietic tissue. The provides review information for indications and contraindications for the procedure. It also describes the procedure of trephine biopsy using a Jamshidi needle in detail and discusses procedural errors and potential complications.

Keywords: trephine biopsy, bone marrow examination, Jamshidi needle, biopsy technique.

Accepted: May 14, 2014

Yu.A. Krivolapov - DSci, Professor, Head of the department of clinical molecular morphology, +7 812 303 5039, [email protected] Address correspondence to: Yu.A. Krivolapov, Kirochnaya str., 41, St. Petersburg, 191015, Russian Federation, +7 812 303 5039, [email protected]

For citation: Krivolapov Yu.A. Procedural Considerations for Bone Marrow Trephine Biopsy. Klin. oncohematol. 2014; 7(3): 290-5 (In Russ.).

INDICATIONS AND CONTRAINDICATIONS FOR BONE MARROW TREPANOBIOPSIES

Trepanobiopsy of the bone marrow is a medical diagnostic manipulation, the purpose of which is to obtain a sample of spongy bone and hematopoietic tissue for histological examination. Trepanobiopsy and histological examination are used in cases where it is necessary to quantify the ratio of hematopoietic tissue and fat cells in the bone marrow, to study the spatial distribution and relative position of bone marrow cells, to exclude fibrosis and metastatic lesions of the bone marrow, to examine bone tissue.

Indications for trephine biopsy

brain

Diagnosis and determination of the prevalence (stage) of Hodgkin's lymphoma and non-Hodgkin's lymphomas.

Chronic lymphocytic leukemia (primary diagnosis and confirmation of remission).

Hairy cell leukemia (in the case of a "dry" aspirate).

Examination of a patient with suspected plasma cell myeloma.

Chronic myeloproliferative diseases (polycythemia vera, essential thrombocythemia, primary myelofibrosis, systemic mastocytosis).

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Diagnosis and evaluation of the effect of treatment of aplastic anemia, differential diagnosis with hypoplastic forms of myelodysplastic syndromes and acute myeloid leukemias.

Diagnosis, determination of prevalence (staging) and evaluation of the effect of treatment of solid tumors in children (neuroblastoma, rhabdomyosarcoma, PNET/Ewing's sarcoma, etc.).

Diagnosis (in some cases) and assessment of response to treatment of acute myeloid leukemia.

Diagnosis (in some cases) of myelodysplastic syndromes.

Bone marrow assessment before autologous bone marrow transplantation.

Examination of a patient with a leukoerythroblastic blood picture (an increase in the number of metamyelocytes and stab granulocytes, the appearance of normoblasts).

Examination of a patient with fever of unknown origin.

Suspicion of dissemination of granulomatous infectious diseases(tuberculosis, mycoses).

Diagnosis (in some cases) of storage diseases.

Examination of a patient with suspected primary amyloidosis.

Examination of patients with diseases of the bone tissue.

Inability to obtain adequate diagnostic material during bone marrow puncture (“dry” aspirate).

There are practically no absolute contraindications for performing a bone marrow trephine biopsy, as well as for obtaining an aspirate. With the necessary precautions, these manipulations can be performed in all patients in need, including those with deep thrombocytopenia or deficiency of blood clotting factors (hemophilia). Relative contraindications for obtaining a column of bone tissue from the posterior superior iliac spine should be considered a local infection of the skin and subcutaneous tissue, burns or mechanical trauma.

Perhaps the only contraindication for bone marrow trepanobiopsy is the absence of clearly formulated indications.

MANIPULATION TECHNIQUE

The most convenient tool for performing a bone marrow trephine biopsy is the Jamshidi needle. The instrument is a cylindrical needle more than 15 cm long, the distal part of which, for about 1.5 cm, has a conical narrowing of the outer contour and the inner cavity. The needle ends with a sharply sharpened cut. A stylet obturator is placed inside the needle, having a cut, the plane of which coincides with the cut of the Jamshidi needle. Sometimes the stylet has a sharp pyramidal tetrahedral shape, and the needle has a sharpening in the form of a crown. The stylet-obturator is firmly fixed inside the needle with the help of a locking device. In addition to a needle with an obturator, the standard kit includes a pusher rod designed to extract the trephine biopsy from the needle.

Rice. 1. Topography of anatomical landmarks required for bone marrow trepanobiopsy. The angle between the vertical line and the line on which the posterior superior iliac spine is located is approximately 30° in men and slightly larger in women.

Trepanobiopsy is performed in the region of the posterior superior spine of the right and/or left iliac bones (spina iliaca posterior superior) (Fig. 1). The patient is satisfied in one of the positions:

1) sitting on a high couch with his back to the doctor, the body is somewhat brought to the hips, a pillow can be placed on the knees to rest on the knees, the patient's legs are on the bench;

2) lying on his side on a high couch, legs bent at the knees and brought to the chest, the back is slightly bent;

3) lying on his stomach on a low couch.

In exceptional cases (extremely serious condition of the patient, mechanical ventilation, late dates pregnancy, obesity, etc.), when none of these positions is possible, the manipulation is performed in the supine position and the anterosuperior iliac spine is subjected to trepanobiopsy. The volume of trephine biopsy obtained from the anterior superior spine is always much less.

Most often, when performing a trepanobiopsy, the patient is conscious, while he does not see the place of manipulation, so the doctor must comment on all his actions and warn the patient about all the sensations that may accompany the procedure. In children, manipulation is carried out under anesthesia.

After palpation of the crest, posterior superior iliac spines, sacroiliac joint and selection of the trephine biopsy site, a mark is applied to the skin with an indelible marker. The skin is treated with antiseptic solutions, as for surgical intervention. With the help of a thin needle, a local anesthetic solution (selected taking into account the allergic history) is used to anaesthetize the skin (“lemon peel”). A syringe containing 5-10 ml of a solution for local anesthesia, with a needle, the length of which is greater than the thickness of the subcutaneous tissues, is used to anaesthetize the tissues in layers up to the periosteum. The periosteum should be especially carefully infiltrated by injecting the anesthetic solution with force at several adjacent points, each time through a new puncture of the fibrous membrane enveloping the bone. The first puncture of the periosteum is accompanied by a feeling of a prick, which should be warned about

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Rice. 2. A transparent lamellar horizontal section of the pelvis passing through the anterior superior and postero superior iliac spines. The angle between the sagittal axis (red line) and the direction of movement of the needle (yellow line) is approximately 30° for men and slightly more for women

patient. After the periosteum is infiltrated with an anesthetic solution, it is necessary to wait for the onset of anesthesia for at least 1 min. A test prick with a needle into the periosteum, which has lost pain sensitivity, is perceived as a tactile sensation without acute pain(the patient is asked: "Acute? Stupid?").

After anesthesia with a scalpel with a narrow blade, an incision of the skin and subcutaneous tissue is made, about 3-5 mm long and deep to the periosteum. A Jamshidi needle with a stylet-obturator fixed inside the needle is inserted through the incision and advanced through the soft tissues to the periosteum. In the direction somewhat laterally and upwards (towards the anterior superior spine of the same iliac bone; Fig. 1.2), with rotational-translational movements, the needle is inserted deep into the bone mass with effort. Rotational movements around the axis of the needle should be performed alternately clockwise and counterclockwise by no more than 120 ° in either direction. The needle should not be screwed in like a corkscrew. Penetration through the cortical plate is perceived by the doctor as a feeling of "failure" into the tissue of lesser density.

After the cortical plate has been passed, the doctor removes the stylet-obturator from the Jamshidi needle and with a rotational motion deepens into the bone by 3-4 cm (Fig. 3). The advancement of the Jamshidi needle in the thickness of the spongy bone may be accompanied by discomfort for the patient with irradiation to the thigh, which the patient must be warned about. Infiltration of cancellous bone with an anesthetic solution through a Jamshidi needle is unacceptable to reduce possible subsequent pain, since even small amounts of injected fluid lead to significant changes in the histological structure of the bone marrow, in which the cells of the myeloid tissue are “mixed”.

During insertion into the ilium, the trephine should always be directed somewhat laterally and upward towards the anterior superior spine. Screwing movements with an amplitude of about 120 ° in one direction and the other must be carefully coordinated with the force of the translational movement of the needle forward. If effort

Rice. 3. Patient during bone marrow trepanobiopsy

will be redundant and forward movement prevailing, the needle will crush the spongy bone, and will not cut out the cylindrical column. After the needle has penetrated the bone to a sufficient depth, it is possible to probe the contents of its lumen without effort through the outer hole of the needle with a sterile pusher rod to make sure that the length of the bone column is sufficient and it is not wrinkled.

To separate from the bone mass of the column, cut out with a needle and located in its lumen, its base must be "cut". To do this, you first need to turn the needle several times in one and the other direction around the axis. Further, with non-sweeping rotational movements, the needle is withdrawn 2-3 mm (no more) back from the bone. Taking special care not to bend the needle, the instrument is forcefully given a slightly different direction (by 5-10 °), for example, upwards, and with rotational-translational movements it is again introduced a little obliquely 2-3 mm deep. Then the needle is again withdrawn 2-3 mm from the bone and, giving it the opposite direction with force, is again screwed 2-3 mm deep. The described action is repeated only 4 times, changing the inclination of the needle by 5-10 ° up and down, right and left in any sequence. If the last part of the manipulation is not done carefully enough, then when the Jamshidi needle is removed, the column of bone tissue, connected by the base to the bone, will remain in place, and the needle will come out empty. The needle is slowly withdrawn by rotational-translational movements. As the needle is removed from the bone with a sterile pusher rod, it is possible to probe through its outer hole from the side of the handle whether the bone column remains in the needle. If the base of the bone column was poorly cut, then the column will be “pulled out” of the needle and, when probing, the pusher rod will penetrate deeper into the needle as the needle is withdrawn. If the column comes out with the needle, then the probe in the lumen (pusher rod) will remain in place.

It is not necessary to separate the column of bone tissue using a simple rotation and loosening of the needle inside the bone mass.

At correct execution manipulations with the needle, a trepanobioptate 3.0-3.5 cm long or more is removed (Fig. 4), sometimes up to 5-6 cm.

Clinical oncohematology

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Trepanobiopsy of the bone marrow

Rice. 4. Bone marrow trephine biopsy of optimal quality: a whole cylindrical piece of cancellous bone 3 mm in diameter and 30 mm long

the meter of which is less than the diameter of the distal hole of the Jamshidi needle, the trepanobioptate is pushed out in the direction from the tip to the handle, i.e. through the hole in the handle of the instrument, and not through the hole in the cutting end.

The extraction of the trephine biopsy from the bone mass is greatly simplified by a device in the form of a thin wire fixator with an obturator, which is supplied with some commercial disposable kits for trephine biopsy of the bone marrow. The obturator has a stylet-like handle and is 35 mm shorter than the Jamshidi needle. A sharply sharpened elastic thin wire, which has a length of 35 mm, so that in the assembled state the sharpened end of the wire reaches the cutting crown-shaped edge of the needle. This wire retainer obturator is very easy to use. After a column of tissue of the required length has been cut out with a Jamshidi needle in the bone mass (it is important that it be no more than 35 mm), an obturator with a wire fixator is inserted into the lumen of the needle to the very end. The handle of the obturator snaps into the handle of the needle, which must now be rotated around its axis several times without any effort, together with the obturator-lock, and slowly removed by rotational-translational movements. Since the latch is springy and soldered at an angle, it passes along the inner wall in the lumen of the needle to the very edge of the cutting edge, without touching or deforming the bone column. At the edge of the cutting edge, a sharp wire clamp presses the base of the bone column against the wall of the needle and prevents it from remaining in place when the trephine is removed from the bone mass. The disadvantage of the wire retainer is the limited length of the extracted column (35 mm).

Performing a bone marrow trepanobiopsy, as a rule, does not require great physical effort, it is more important to have a good command of the manipulation technique and use a convenient high-quality instrument.

After performing a trepanobiopsy, a bone marrow aspirate can be obtained through the same skin incision by puncturing the posterior superior iliac spine away from the burr hole. Almost all needles for bone marrow trephine biopsy have a conical sleeve on the side of the handle, which allows you to attach a syringe to create a vacuum in the needle lumen and aspirate the bone marrow. If you start to suck

Rice. 5. Changes in the bone marrow resulting from aspiration. The upper part of the visual field contains a mixture of myeloid tissue cells and crushed small fat droplets. Coloring azure II - eosin, x400

the contents of the bone marrow cells before the removal of the bone column, then the blood from the ruptured vessels, rushing into the syringe, destroys fat cells, washes out and mixes the cells of the myeloid tissue - a fat emulsion and cell homogenate are formed in the interstitial spaces, which do not have a tissue structure (Fig. 5).

Bone marrow can only be aspirated after the trephine biopsy has been removed from the patient's bone (and from the needle lumen). Using a Jamshidi aspiration needle is not very convenient, it is better to use special, thinner and shorter needles. To do this, it is necessary to go through an existing skin incision with an aspiration needle to the bone and, having displaced the needle together with soft tissues, drill the cortical plate again at some distance (> 1.5 cm) from the first hole made, plunge into the cancellous bone in the adjacent area and only after that, aspirate the bone marrow from there for the preparation of smears. An attempt to aspirate bone marrow from areas in close proximity to the site of bone trepanation may be unsuccessful due to thrombosis of small blood vessels of the bone marrow around the burr canal, since mechanical trauma to the bone and bone marrow (trepanobiopsy) leads to the release of tissue thromboplastins.

At the end of the manipulation, an aseptic dressing (sticker) is applied to the skin. The patient should spend 2-3 hours under the supervision of medical personnel, lying on his back on a hard surface (you can put a book in hard cover), if necessary with an ice bubble in the area where the trephine biopsy was performed. The next day, the biopsy site should be examined, the skin around the incision should be cleaned, and the bandage changed. At hygiene procedures the patient should avoid getting the dressing (sticker) wet.

Complications of a manipulation performed technically correctly, with a serviceable instrument and taking into account contraindications, are extremely rare. B. Bain (2003) collected information about complications during 54,890 trephine biopsies performed by hematologists in the UK from 1995 to 2001. She registered 26 complications, one of which became fatal. by the most frequent complications there were bleeding (14, including 1 fatal),

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Rice. 6. Trephine biopsy contains a section of the articular surface of the sacroiliac joint with several subcortical bone marrow cells

needle breakage (7), local infection (3) . In my practice, complications during trepanobiopsies were also very rare. In the period from 1999 to 2013, I examined bone marrow trephine biopsies of 4887 patients; complications occurred in 3 cases. In two of them, the needle broke: once the handle broke off (the needle had to be removed by grabbing the part sticking out of the bone with ordinary pliers), another time the needle broke at the bone (the fragment was removed by surgeons through a small incision). The third complication was the sudden "failure" of the needle for its entire length with exit through the bone into the retroperitoneal space in a patient with thrombocytopenia. The "failure" of the needle led to the development of a growing hematoma of the retroperitoneal space, which required surgical intervention, but everything ended well.

DEFECTS IN THE TECHNIQUE FOR PERFORMING BONE MARROW TREPANOBIOPSIES

In bone marrow trephine biopsies, changes may occur that are in no way associated with diseases of the hematopoietic tissue, but are due to the performance of the trephine biopsy itself and the histological technique of processing the trephine biopsy, preparation and staining of sections. Most common causes obtaining a bone marrow sample that turns out to be unsuitable for research is an error in the trepanobiopsy technique. Uninformative trepanobio-optate, as a rule, of small size, contains mainly the periosteum, the cortical plate of spongy bone and 2-3 subcortical bone marrow cells. Evaluation of bone marrow cellularity by subcortical cells, if only they were found in the trephine biopsy, can lead to an erroneous conclusion about hypoplasia (or even aplasia). In these cells, the normal bone marrow contains less myeloid tissue than in deep cells, this is especially noticeable in the elderly.

In some cases, trephine biopsies 25-30 mm long contain only compact bone of the cortical plate. Such a biopsy is obtained if the trepanation needle was directed not into the thickness of the spongy bone mass when the posterior superior iliac spine is trepanned, but tangentially, along the cortical plate (too lateral) or along the articular surface of the sacroiliac joint (too sagittal) (Fig. 6) .

Another defect in the manipulation technique is the insufficient volume of the trepanobioptate. The volume of the trephine biopsy is crucial in the diagnosis focal changes bone marrow, for example, when looking for metastases and determining the prevalence of lymphomas.

A bad tool and "bad hands" often cause a sharp mechanical deformation of the bone tissue column. Technically, it is most difficult to obtain the desired tissue column in patients with osteoporosis or from a focus of bone tissue destruction (for example, in plasma cell myeloma). Great physical effort has to be applied when performing a trepanobiopsy in athletes and, especially, in young men who were engaged in weightlifting and used anabolic steroids. In these cases, deformation of the trepanobioptate occurs quite often. In histological preparations, the trepanobioptate is represented by fragments of bone beams, crumpled bone marrow, and unchanged blood between these fragments. However, at histological examination mechanically roughly deformed trephine biopsy specimens can sometimes provide important diagnostic information. For example, when it comes to the detection of cancer metastasis, the use of immunohistochemistry is sometimes very effective, since the expression of cytokeratins in the form of non-localized staining can be detected in a structureless deformed cell mass. In the interpretation of deformed trepanobiopsy specimens, it is necessary to avoid categorical diagnostic conclusions, limited to descriptive conclusions.

Pronounced changes in the structure of bone tissue and bone marrow can be detected if the patient has already undergone a trephine biopsy and the trephine accidentally fell into the area of ​​previous bone tissue damage during repeated manipulation. The changes turn out to be very diverse: this is a resolving hemorrhage with hemosiderosis, and necrosis of adipose tissue, and granulation tissue. Often, fields of fibrosis and restructuring of bone beams are found, which can be mistakenly regarded as manifestations of primary myelofibrosis.

The artificial changes, more precisely objects, in the trepanobioptate should include skin particles (epidermal epithelium, hair follicle, sweat or sebaceous gland), skeletal muscle fibers, sometimes even synovial tissue, which are brought into the biopsy specimen by a trepanation needle, capturing them when moving through soft tissues. As a rule, the recognition of such "passing" objects does not cause any particular difficulties.

Clinical oncohematology

ONCO_3_2014.indd Sec3:294

Trepanobiopsy of the bone marrow

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