Atlas of Procedures in Neonatology, 4th Edition

Miscellaneous Sampling


Tibial Bone Marrow Biopsy

Martha C. Sola-Visner

Lisa M. Rimsza

Robert D. Christensen

  1. Purpose
  2. To obtain a bone marrow clot sample for histologic evaluation of the following1
  3. Bone marrow cellularity
  4. Relative abundance of myeloid, erythroid, lymphoid, and megakaryocytic lineages, using specific immunohistochemical stains on multiple cuts if necessary
  5. Maturation and morphology of cells of all lineages
  6. Presence of infiltrative nonmalignant diseases
  7. Presence of infiltrative malignant diseases (hematologic and nonhematologic)
  8. Presence of granulomas or infectious organisms
  9. To obtain emergent cytogenetic studies
  10. Indications
  11. Evaluation of hematologic disorders (1,2,3,4,5,6)
  12. Suspected neonatal aplastic anemia (pancytopenia)
  13. Suspected leukemia, when blood studies are insufficient to confirm the diagnosis
  14. Neutropenia of unclear etiology, which is severe (absolute neutrophil count <500/mL) and persists for more than 1 week
  15. Severe neutropenia (<500/mL), which is unresponsive to 3 days of treatment with recombinant granulocyte colony-stimulating factor
  16. Neutropenia of unclear etiology, which is moderately severe (500 to 999/mL) and persists for more than 2 weeks
  17. Thrombocytopenia of unclear etiology, which is severe (platelets <50,000/mL) and persists for more than 1 week
  18. Evaluation of suspected metabolic storage disease (e.g., Niemann-Pick disease) (2)
  19. Evaluation of suspected hemophagocytic syndrome or familial hemophagocytic lymphohistiocytosis (7,8)
  20. Detection of infiltrating tumor cells (9,10,11,12) or of congenital systemic Langerhans' cell histiocytosis (13)
  21. Certain cultures, e.g., in disseminated tuberculosis or fungal disease (14)
  22. Cytogenetic studies, for chromosomal analysis (even after transfusion of donor blood) within 3 to 4 hours (15)
  23. Contraindications
  24. Sampling from the sternum is not recommended because of danger of damage to intrathoracic and mediastinal organs (2,16).
  25. Sampling from the anterior iliac crest is not recommended, particularly in the smallest preterm infants, owing to the proximity to intra-abdominal organs.
  26. Risks/benefits should be considered carefully in the presence of coagulopathy or when administering anticoagulants or thrombolytics.
  27. Risks/benefits should be carefully considered in preterm infants with severe osteopenia of prematurity (17).
  28. Limitations
  29. In very small preterm infants, the tibial bone marrow biopsy technique sometimes yields no marrow or a very hemodilute sample, mostly because of the small size of the marrow compartment within the tibia.
  30. Equipment


  1. Surgical gloves
  2. Cup with antiseptic solution
  3. Gauze squares
  4. Sterile drapes
  5. 1% lidocaine without epinephrine in 1-mL syringe, with 27-gauge needle


  1. 19-gauge, ½-in Osgood bone marrow needle (Popper and Sons, New Hyde Park, NY, USA) (Fig. 21.1)
  2. 3-mL syringe without Luer-Lok


  1. Cup containing fixative
  2. 1- to 2-in needle to aid in removal of clot from the syringe

FIG. 21.1. View of the 19-gauge, ½-in Osgood bone marrow needle. The trocar must be completely inserted in the Osgood needle prior to the procedure.

  1. Precautions
  2. Correct coagulopathy as far as possible prior to procedure.
  3. Use a total of 0.2 to 0.4 mL of lidocaine. Aspirate before injection to avoid intravascular injection.
  4. Stabilize the leg in your hand, between your thumb and forefinger. To avoid bone fracture, be sure to apply counterpressure with your palm directly opposite the site of penetration.
  5. Be aware that less pressure is required to insert the bone marrow needle in neonates (particularly in very low-birthweight infants) than in older children.
  6. Be careful to enter the bone 1 to 2 cm below the tibial tuberosity, to minimize the risk of injuring the growth plate.
  7. After the procedure, apply adequate pressure to control bleeding.
  8. Special Circumstances
  9. In cases of suspected osteopetrosis, obtaining an iliac crest bone/bone marrow biopsy is preferable, because it allows quantification of osteoclasts and evaluation of marrow and bony changes consistent with osteopetrosis. In these cases, the tibial bone marrow biopsy technique usually yields only blood or no sample.
  10. Technique
  11. Place the infant in the supine position.
  12. Use the triangular area at the proximal end of the medial (flat) surface of the tibia, approximately 1 to 2 cm distal to the tibial tuberosity (18).
  13. Prepare and drape as for a major procedure (see Chapter 4).
  14. Infiltrate subcutaneous tissue with lidocaine as the needle is slowly advanced. Inject further small volume when the needle reaches the bone, making sure that the tip of the needle is inserted into the bone for subperiosteal injection.
  15. Remove the needle and wait 2 to 3 minutes.
  16. Use your nondominant hand to firmly stabilize the leg, providing support with your palm directly oppositethe site of marrow puncture. This hand cannot be reintroduced into the sterile field.
  17. Make sure that the trocar is completely inserted in the Osgood needle.
  18. Hold the needle between the thumb and forefinger of your dominant hand.
  19. Introduce the needle at a 90-degree angle, and advance it into the marrow cavity with a slow, twisting motion (Fig. 21.2).
  20. Continue to advance the needle until it is firmly fixed in bone (does not move when touched) (Fig. 21.3).



  1. Remove the trocar from the needle and advance the hollow needle an additional 2 to 3 mm into the marrow space (this trephinates marrow spicules into the needle).
  2. Attach a 3-mL syringe (without a Luer-Lok) firmly to the needle.
  3. Withdraw the plunger forcefully until a small drop of marrow (<0.05 mL) appears in the syringe hub. Suction should be stopped as soon as the smallest amount of marrow is obtained, because excessive suction will dilute the sample with peripheral blood.
  4. If no marrow is obtained initially, rotate, advance, or retract the needle and try again.
  5. Remove the syringe as soon as bone marrow is obtained and withdraw the plunger (with marrow attached) to the bottom of the syringe. Allow the marrow to clot there.
  6. Remove the needle and apply pressure over the site to achieve hemostasis.

Preparation of the Bone Marrow Clot

  1. Once the marrow specimen has clotted, dislodge the clot gently with the use of a 1- or 2-in needle and place it into the fixative solution (Fig. 21.4).
  2. Process the bone marrow clot in a manner identical to a typical bone marrow biopsy, except that decalcification is not required (Fig. 21.5).

FIG. 21.2. The Osgood needle is introduced into the tibial marrow cavity with a slow, twisting motion. Notice that the leg is firmly stabilized in the operator's nondominant hand.


FIG. 21.3. The Osgood needle is firmly fixed in the bone.

  1. Complications2
  2. Subperiosteal bleeding (19)
  3. Cellulitis or osteomyelitis (20)
  4. Limb fracture (21)
  5. Injury to blood vessels (19)
  6. Bone changes on x-ray film (22,23)
  7. Lytic lesions
  8. Exostoses
  9. Subperiosteal calcification (secondary to hematoma)

FIG. 21.4. A small amount of bone marrow has been obtained in a 3-mL syringe and allowed to clot at the bottom of the syringe. The plunger has been removed, and the clot is now being gently dislodged from the plunger (with the use of a 1- or 2-in needle) and placed into the fixative solution.


FIG. 21.5. Photomicrograph of a bone marrow clot section obtained from a neutropenic neonate. The cellularity is near 100%. Myeloid precursors, scattered erythroid cells, lymphocytes, and several megakaryocytes are clearly identified. Hematoxylin and eosin; original magnification x200.



  1. Advantages of the Tibial Site
  2. It is a safe site, particularly in very small preterm infants, because it avoids any proximity to vital organs.
  3. The tibia can be easily positioned without disturbing even the sickest infants (usually maintained in the supine position while on mechanical ventilation).
  4. It can be adequately stabilized and supported by the nondominant hand of the person performing the procedure.


This work was partially supported by National Institutes of Health grant HL69990.


  1. Calhoun DA, Christensen RD, Edstrom CS, et al. Consistent approaches to procedures and practices in neonatal hematology. Clin Perinatol. 2000;27:733.
  2. Downing V.Bone marrow examination in children. Pediatr Clin North Am. 1955;2:243.
  3. Garcia L, Valcarcel M, Santiago-Borrero PJ.Chemotherapy during pregnancy and its effects on the fetus—neonatal myelosuppression: two case reports. J Perinatol. 1999;19:230.
  4. Juul SE, Calhoun DA, Christensen RD.“Idiopathic neutropenia” in very-low birthweight infants. Acta Paediatr. 1998;87:963.
  5. Calhoun DA, Kirk JF, Christensen RD.Incidence, significance, and kinetic mechanism responsible for leukemoid reactions in patients in the neonatal intensive care unit: a prospective evaluation. J Pediatr. 1996;129:403.
  6. Mizutani K, Azuma E, Komada Y, et al. An infantile case of cytomegalovirus induced idiopathic thrombocytopenic purpura with predominant proliferation of CD10 positive lymphoblasts in bone marrow. Acta Paediatr Jpn.1995;37:71.
  7. Aygun C, Tekinalp G, Gurgey A.Infection-associated hemophagocytic syndrome due to Pseudomonas aeruginosa in preterm infants.J Pediatr Hematol Oncol. 2003;25:665.
  8. Rugolotto S, Marradi PL, Balter R, et al. Familial haemophagocytic lymphohistiocytosis: survival of a premature twin with immuno-chemotherapy and bone marrow transplantation from an HLA-identical unrelated donor. Acta Paediatr. 2005;94:971.
  9. Karcioglu ZA, Al-Mesfer SA, Abboud E, et al. Workup for metastatic retinoblastoma. A review of 261 patients. Ophthalmology.1997;104:307.
  10. Moscinski LC, Pendergrass TW, Weiss A, et al. Recommendations for the use of routine bone marrow aspirations and lumbar punctures in the follow up of patients with retinoblastoma. J Pediatr Hematol Oncol.1996;18:130.
  11. Osmanagaoglu K, Lippens M, Benoit Y, et al. A comparison of iodine-123 meta-iodobenzylguanidine scintigraphy and single bone marrow aspiration biopsy in the diagnosis and follow-up of 26 children with neuroblastoma. Eur J Nucl Med.1993;20:1154.
  12. Penchansky L.Bone marrow biopsy in the metastatic work-up of solid tumors in children. Cancer. 1984;54:1447.
  13. Stiakaki E, Giannakopoulou C, Kouvidi E.Congenital systemic Langerhans cell histiocytosis (report of two cases). Haematologia(Budap). 1997;28:215.
  14. Machin GA, Honore LH, Fanning EA, et al. Perinatally acquired neonatal tuberculosis: report of two cases. Pediatr Pathol.1992;12:707.
  15. Page BM, Coulter JB.Bone marrow aspiration for chromosome analysis in newborn. Br Med J. 1978;1:1455.
  16. Bakir F.Fatal sternal puncture. Dis Chest. 1963;44:435.
  17. Dabezies EJ, Warren PD.Fractures in very low birth weight infants with rickets. Clin Orthop Relat Res. 1997;335:233.
  18. Sola MC, Rimsza LM, Christensen RD.A bone marrow biopsy technique suitable for use in neonates. Br J Haematol. 1999;107:458.
  19. McNutt DR, Fudenberg HH.Bone-marrow biopsy and osteoporosis. N Engl J Med. 1972;1:46.
  20. Shah M, Watanakunakorn C.Staphylococcus aureus sternal osteomyelitis complicating bone marrow aspiration. South Med J.1978;71:348.
  21. Miller D.Normal values and examination of the blood: perinatal period, infancy, childhood, and adolescence. In: Miller D, Pearson H, Bachner R, et al., eds. Smith's Blood Diseases of Infancy and Childhood. St. Louis, MO: Mosby; 1978:20–21.
  22. Gilsanz V, Grunebaum M.Radiographic appearance of iliac marrow biopsy sites. AJR. 1977;128:597.
  23. Murphy WA.Exostosis after iliac bone marrow biopsy. AJR. 1977;129:1114.