Puncture of the sternum, or sternal puncture. Sternal puncture: technique, indications and complications Assisting when a doctor performs a sternal puncture

This method consists of bone marrow puncture of the anterior wall of the sternum using a special needle. Sternal puncture is performed both in hospital and outpatient settings. It doesn’t matter where the puncture is performed, the main thing is that the rules are followed during it

Equipment

For puncture you need: 70º alcohol, 5% iodine solution, lidocaine or novocaine for pain relief, two syringes - 10 and 20 ml, a Kassirsky sternal puncture needle (a short needle that has a nut at the distal end, a mandrel and a removable handle), gauze napkin and adhesive plaster.

Patient preparation

This procedure does not require special preparation. The patient is on a normal diet the day before and on the day of the puncture. The puncture is performed two to three hours after eating. All medications are canceled, except for those that are necessary for health reasons. It is also necessary to discontinue medications containing heparin. On the day of the procedure, it is prohibited to perform other diagnostic or surgical procedures. It is advisable to empty your bladder and bowels before the procedure.

The puncture site must be treated with 70º alcohol and 5% iodine solution. In the future, it is necessary to numb the pain. An anesthetic - lidocaine or novocaine - is drawn into a 10 ml syringe and a needle is inserted at an angle of 90º, numbing the pain. 3 minutes after the administration of lidocaine, the puncture can begin. The anterior wall of the sternum is pierced with a Kassirsky needle at the level of the III-IV rib along the midclavicular line; it is possible and the needle must be inserted quickly. The needle passes through the compact substance of the frontal surface of the sternum and enters the medullary space, and a failure is felt. Signs of entry into the spongy space are the operator feeling the cavity, and the patient experiencing short-term pain. Next, you need to remove the mandrin from the sternal needle and attach a 20 ml syringe to it, which is used to aspirate the bone contents. By creating a vacuum, no more than 0.20-0.30 ml is aspirated. blood. After this, you need to remove the syringe along with the needle. A gauze pad is applied at the puncture site and an adhesive plaster is applied. The contents of the syringe are applied to the glass and a smear is prepared. When performing a puncture on children, it is necessary to remember that the needle can pass through, this is due to the sufficient elasticity of the sternum. Sternal puncture in patients taking long-term corticosteroids should be performed with caution, as they are prone to osteoporosis.

Complications. Indications for sternal puncture

The main complications are through puncture and bleeding. In the bone marrow, the formation of cellular elements of blood occurs, that is, hematopoiesis. Sternal puncture is necessary to confirm the diagnosis of many diseases: anemia, leukopenia or leukocytosis, thrombocytosis or thrombopenia, as well as functional bone marrow failure. Having received the result, you can accurately assess the activity of the hematopoietic process, the condition and structural changes of the cells. Sternal puncture is also performed in patients with suspected malignant neoplasms and metastasis.

Sternal puncture is one of the ways to examine the bone marrow, which is performed by puncturing the anterior wall of the sternum. Bone marrow is the central organ of hematopoiesis, which is a soft mass that fills all the spaces in the bones that are not occupied by bone tissue.

Puncture of the sternum (sternal puncture) is performed to diagnose blood diseases. It is performed in a hospital in a treatment room or small operating room using a special needle (Kassirsky).

Cashier's needle(I.A. Kassirsky, 1898-1971, Soviet therapist and hematologist) - a short, durable tubular needle equipped with a nut to limit the depth of immersion, a mandrel and a removable handle to facilitate puncture.

The puncture is performed by a doctor. He also explains the procedure to the patient, informs about possible complications, convinces of its necessity and obtains the patient’s consent.

Equipment: 70° ethanol, 5% alcohol solution of iodine, 2% novocaine solution, 10-20 ml syringe, sterile wipes, adhesive plaster, Kassirsky needle.

Patient preparation: the patient is on the usual water and food regimen on the day of the study. The study is carried out 2 hours after eating. All medications except those necessary for health reasons are excluded. On the day of the puncture, all other therapeutic and diagnostic procedures are canceled. Before the study, you must empty your bowels and bladder.

Role of the nurse:

ensure that the patient's consent is obtained;
prepare an office, instruments, dressings, disinfectants;
issue a referral;
invite a laboratory assistant to prepare bone marrow smears;
transport or accompany the patient to and from the office;
disinfect and sterilize instruments that come into contact with blood at the end of the procedure;
monitor the patient’s condition after the examination for 24 hours, and report to the doctor if the condition worsens;
place the research result in the medical history.

Complications: bleeding from the puncture site.

Puncture technique.

The puncture site is treated with ethyl alcohol and an alcohol solution of iodine. The skin is anesthetized with a 2% novocaine solution. The sternum is pierced with a Kassirsky needle at the level of attachment of the III-IV rib in the midline or the manubrium of the sternum is punctured. The needle is inserted with a quick rotational movement. When it passes through the layer of the cortical (compact) substance and enters the spongy (marrow space), a feeling of failure appears. After removing the mandrel, attach a syringe to the needle and suck in no more than 0.2-0.3 ml of bone marrow suspension. The needle is then removed from the sternum. A sterile napkin is applied to the puncture site and secured with an adhesive plaster.

A sternal puncture allows a specialist to trace the nature of hematopoiesis and the morphological characteristics of blood cells, through which a specialist obtains a bone marrow sample for examination.

Red bone marrow is the most important tissue of the body, ensuring the maturation of all blood cells without exception. It contains stem elements and cells of all stages of maturation, which, after full formation, enter the peripheral blood to ensure immunity, gas exchange, thrombus formation, etc.

In newborn children, red bone marrow fills all the bones, but as they grow, its volume decreases and by the age of five it begins to be replaced by fatty (yellow) bone marrow. In adults, hematopoietic tissue is concentrated in the sternum, pelvic bones, vertebral bodies, long tubular bones, and ribs, where it is available for aspiration for the purpose of diagnosing various pathological conditions.

The term "sternal" implies that the bone marrow will be taken from the sternum, although it can also be obtained from the ilium or calcaneus (in young children). Puncture of the sternum seems to be a fairly simple and safe diagnostic method, provided that all precautions and manipulation techniques are followed.

Indications and contraindications for sternal puncture

The reason for examining bone marrow aspirate obtained from the sternum is suspicion of hematological diseases, a planned bone marrow transplant, or some infectious processes when other routine examinations do not provide sufficient information. Sternal puncture is performed when:

Anemia - severe iron deficiency, megaloblastic, aplastic.
Tumors of hematopoietic tissue - leukemia, paraproteinemic hemoblastosis.
Myelodysplastic syndrome.
Leukemoid reactions, when the peripheral blood picture does not exclude tumor growth.
Storage diseases of hereditary nature, metabolic disorders (Gaucher disease, Niemann-Pick disease).
Visceral leishmaniasis.
Suspicion of the presence of metastases of other malignant neoplasms in the bones (prostate cancer, for example).
Assessing the effectiveness of treatment and monitoring the condition of hematological patients.
Research and procurement of the resulting stem cells for transplantation to a donor or the punctured patient himself after courses of chemotherapy or radiation.
Intraosseous administration of drugs.

An established diagnosis of chronic leukemia in the acute stage, as well as iron deficiency anemia, diagnosed through routine examinations, serve as relative indications for bone marrow puncture, that is, in these cases, the procedure can be abandoned.

There are also contraindications to sternal puncture:

Severe bleeding disorders.
Old age in cases where sternal puncture is not the only possible diagnostic method.
Acute inflammatory and infectious lesions at the site of the intended skin puncture.
Patient refusal to study.
Severe concomitant diseases in the stage of decompensation (the question of the advisability of a puncture is decided individually).

Preparation and technique for performing sternal puncture

Sternal puncture is not a complex procedure; it is safe, does not require anesthesia and is performed both in a hospital and on an outpatient basis. Preparation for sternal bone marrow aspiration is extremely simple:

The patient undergoes a blood clotting test and a general analysis no more than 5 days before the planned procedure;
Two hours before the puncture, the last meal and water is possible;
Before the procedure, the bladder and intestines are emptied;
All medications are canceled, except those that are vital;
On the day of the puncture, no other procedures are prescribed.

Before the manipulation, the patient must inform the doctor about all the medications he is taking, especially for anticoagulants and other blood-thinning agents, which should be discontinued due to the greatly increasing risk of bleeding while taking them.

The specialist who will perform the sternal puncture will find out information about the presence of allergies to medications, since the administration of anesthetics will be required. The patient is told in detail about the essence of the puncture, its purpose and the meaning of the upcoming operation. The doctor warns about the possible pain of the puncture and subsequent precautions. It is mandatory to obtain the written consent of the person being examined (or the parents during a puncture of the child) to carry out the procedure.

The technique of performing sternal puncture includes several stages:

Lay the patient on his back and place a cushion under his shoulder blades.
Treatment of the puncture site with antiseptic solutions (iodine, ethanol); in men, the hair is shaved.
For pain relief, local anesthetics (lidocaine, novocaine) are injected into the skin, subcutaneous tissue and periosteal space, since a puncture is a rather painful event, especially when the needle passes through the periosteum.
The puncture is performed at the level of attachment to the sternum of the third or fourth rib, along the midline, using a Kassirsky needle, which is inserted into the bone with a quick twisting motion. When the bone marrow enters the receptacle, the doctor will feel a dip, which indicates that the needle is passing through the surface of the bone. When the needle is immersed through the compact bone layer and the bone marrow is aspirated, the patient will feel a short-term pain.
When the needle is in the medullary canal of the sternum, a syringe is connected to it, through which the doctor aspirates 0.3 ml of bone contents.
After obtaining the required volume of hematopoietic tissue, the needle is removed, and a sterile napkin or patch is applied to the puncture site.

Special precautions should be taken when puncturing the sternum in children. Their bone is softer and more elastic, so careless actions can pierce it through. If possible, the child should be immobilized so that his movements do not disrupt the process of puncture of the sternum.

Features of sternum puncture in children:

Elderly people, patients receiving long-term corticosteroid drugs may suffer from osteoporosis, so precautions for through puncture, which is possible due to a decrease in bone tissue density, also apply to them.

The sternum puncture procedure is rarely performed without anesthesia - if it is unavoidable, and the patient has absolute contraindications to the administration of anesthetics. In such a situation, the patient is warned about the painfulness of the manipulation; it is possible to use tranquilizers before the procedure and analgesics.

The bone marrow obtained by puncturing the sternum is placed on a glass slide, then a cytological preparation is prepared, which is assessed by a cytologist. When diagnosing hematological pathology, the latter pays attention to the structure of blood cells, their number, degree of maturity, and the ratio of various elements in the total volume of punctate.

Bone marrow extracted from the sternum can also be subjected to cytochemical, immunological, and histological examination. Histological assessment of punctate provides more opportunities to assess the ratio of fatty and active bone marrow, the state of the vascular component and cellular elements of varying degrees of maturity.

The results of a sternal puncture can be obtained on the same day if a cytological examination of a bone marrow smear is expected. With histological analysis and other more technically complex studies, the diagnosis is extended for a period of 7-10 days.

The above method of sternal puncture was proposed in 1927 by Arinkin M.I. and is still practiced to this day. The Kassirsky needle has been successfully used by hematologists for decades. It is durable, wide, has a removable handle that is convenient for insertion, and is also equipped with a limiter that prevents the needle from moving too deeply.

Video: sternal puncture technique

Complications and features of the postoperative period

The procedure for collecting bone marrow lasts approximately 20 minutes, after which the patient is under observation for about an hour, general health, pulse and blood pressure are monitored. You can leave the hospital the same day, but it is highly undesirable to drive, as there is a risk of fainting.

The puncture site does not require any treatment at home, however, for the first three days it is recommended to exclude water procedures so as not to introduce an infection into the puncture hole. Sternal puncture does not imply any restrictions on diet and nutrition. If there is severe pain at the puncture site, the patient can take a painkiller.

Following the precise technique of sternal puncture, using a Kassirsky needle with a limiter, and treating the puncture site with antiseptics virtually eliminates the likelihood of complications. In rare cases, adverse consequences are possible in the form of:

Through puncture (in a child or patient with osteoporosis);
Bleeding from the puncture site;
Infection of the puncture site (extremely rare);
Fainting states in emotionally labile persons, hypotensive persons, with insufficiently thorough psychological preparation of the patient for manipulation;
Shock in case of severe pathology of the cardiovascular system in elderly people.

In general, the sternal puncture procedure is easily tolerated and is extremely rarely accompanied by complications. Feedback from patients is mostly positive, and well-being and attitude towards the manipulation largely depend on the quality of preparation and competent conversation between the doctor and the patient. Some people note severe pain at the time of puncture and removal of material from the sternum, and in the next 2-3 days, others feel only slight discomfort.

Interpretation of sternal puncture results

Analysis of bone marrow obtained through sternal puncture shows the number of cellular elements in it, their ratio and degree of maturity. The myelogram characterizes the qualitative and quantitative indicators of the white germ of hematopoiesis:

Myelokaryocytes (the total number of blood cells containing nuclei) are 10 9 per liter of blood;
Megakaryocytes (precursors of platelets) - 0.054-0.074x10 6 per liter;
Reticulocytes (precursors of red blood cells) make up 20-30% and increase with blood loss and hemolytic anemia;
Blast cells - 0.1-1.1%, myeloblasts - 0.2-1.7%, promyelocytes - 0.5-8.0% of all elements of the white lineage of the bone marrow, lymphocytes - 1.2-1.5 %, monocytes - 0.25-2.0%, plasma cells - no more than 1%.

A decrease in the number of myelokaryo- and megakaryocytes is possible due to errors in the puncture, when the bone marrow is diluted with liquid blood.

The specialist studying the bone marrow punctate reflects in the conclusion the type of hematopoiesis, cellularity, bone marrow indices, the presence and number of uncharacteristic cells (for example, Hodgkin's in lymphogranulomatosis). Each of the sprouts is analyzed separately.

Bone marrow indices

To assess the quantitative content of each type of bone marrow cells, their ratio in 500 cells is calculated. An important indicator is the bone marrow neutrophil maturation index, which is calculated by dividing the total number of white lineage precursor cells by the total number of band and segmented neutrophils. Normally, the indicator is 0.6-0.8.

Along with the assessment of the white sprout, the characteristics of erythropoiesis are also important. The maturation index of erythroid elements is calculated from the content of erythroblasts and normocytes and is 0.8-0.9. This indicator characterizes iron metabolism, the degree of saturation of red cells with hemoglobin, and increased erythropoiesis in anemia.

After calculating the number of granulocytes and the total number of red germ cells containing nuclei, their ratio is calculated, which is normally 3-4:1 - the leuko-erythroblastic ratio.

Bone marrow indices make it possible to objectify data on absolute numbers and percentages of specific cell populations. Thus, an increase in the leuko-erythroblastic index is characteristic of hyperplasia of the white germ of hematopoiesis, which is observed in chronic lympho- and myeloblastic leukemias, infectious diseases, intoxications, and it can also indicate hypoplastic anemia with a general depletion of bone marrow tissue.

A decrease in the leuko-erythroblastic index is indicative of hemolytic, post-hemorrhagic and megaloblastic anemia (with normal bone marrow cellularity), and in the case of bone marrow depletion, it indicates agranulocytosis (decreased leukocyte count).

The normal value of this ratio can indicate either complete health, or aplasia and hypoplasia of bone marrow tissue, when a more or less uniform decrease in the number of cells of both white and red sprouts is observed, which is why it is so important not to conduct isolated assessments of only the myelogram in order to avoid diagnostic errors.

The neutrophil maturation index, with sufficient cellularity of the punctate, increases with tumors of the hematopoietic tissue (leukemia), drug poisoning, and its decrease is usually characterized by dilution of the bone marrow due to errors during puncture.

The described myelogram criteria make it possible to assess hematopoiesis as a whole, but the specialist’s conclusion should not be categorical. It is important to correlate the results of the study of sternal puncture with the characteristics of the clinical picture and the data of peripheral blood analysis.

Patients and their relatives should especially be cautioned against independently assessing the results that may come into their hands. Such amateur activities usually lead to erroneous conclusions that can only harm the patient. Analysis of bone marrow puncture indicators is a complex process that requires utmost attention exclusively from a specialist in this field, who can accurately indicate whether there are changes and whether there is anything to worry about.

101. The concept of sternal puncture, lymph node and trepanobiopsy, interpretation of the results of bone marrow puncture examination.

Sternal puncture is one of the methods of intravital bone marrow examination; is a bone marrow puncture performed through the anterior wall of the sternum. Bone marrow examination is necessary for the diagnosis of anemia, leukemia, myelodysplastic syndromes, tumor metastases, etc. Sternal puncture can be performed on an outpatient basis.

The puncture site is treated with ethyl alcohol and an alcohol solution of iodine. For anesthesia, a 2% novocaine solution is usually used; You can do a puncture without pain relief. The sternum is pierced with a Kassirsky needle at the level of attachment of the III-IV rib in the midline or the manubrium of the sternum is punctured. The needle is inserted with a quick rotational movement. When it passes through the layer of cortical (compact) substance of the anterior surface of the sternum and enters the spongy (marrow space), a sensation of failure is noted. An indirect sign of a successful puncture is short-term pain. After removing the mandrin, a syringe (10 or 20 ml capacity) is attached to the needle, with which the bone marrow is aspirated. Gradually, creating a vacuum in the syringe, suck in no more than 0.2-0.3 ml of bone marrow suspension. The needle is then removed from the sternum. A sterile sticker is applied to the puncture site. The contents of the needle and syringe are squeezed onto a glass slide and smears are prepared.

Trephine biopsy provides more accurate information about the composition of the bone marrow. Special

a trocar needle is inserted into the iliac crest and its column is cut out from

bone marrow tissue from which histological preparations are made. In them

the structure of the bone marrow is preserved, and the absence of blood admixture makes it possible to evaluate it

cellular composition and identify focal and diffuse changes in it.

Often they resort to puncture of enlarged lymph nodes, which gives

the ability to determine the nature of changes in their cellular composition and clarify the diagnosis

a number of systemic diseases of the lymphatic system: lymphocytic leukemia,

lymphogranulomatosis, lymphosarcomatosis, detect tumor metastases, etc. More

Accurate data can be obtained using a lymph node biopsy. puncture

performed without anesthesia with a simple injection needle,

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

Bone marrow puncture: indications, preparation for the study, methodology

Bone marrow puncture (or sternal puncture, aspiration, bone marrow biopsy) is a diagnostic method that allows you to obtain a sample of red bone marrow tissue from the sternum or other bone by puncture with a special needle. After this, the obtained biopsy tissue is examined. This test is usually performed to detect blood disorders, but is sometimes performed to diagnose cancer or metastasis.

The collection of material for its implementation can be carried out both in outpatient and inpatient settings. The tissue obtained after puncture is sent to the laboratory to perform a myelogram, histochemical, immunophenotyping and cytogenetic analysis.

This article will provide information on the principle of execution, indications, contraindications, possible complications, advantages and method of performing bone marrow puncture. It will help you get an idea of this diagnostic procedure, and you can ask your doctor any questions you have.

A little anatomy

Bone marrow is located in the cavities of different bones - vertebrae, tubular and pelvic bones, sternum, etc. This body tissue produces new blood cells - leukocytes, red blood cells and platelets. It consists of stem cells, which are in a state of rest or division, and stroma - supporting cells.

Up to 5 years of age, bone marrow is present in all bones of the skeleton. With age, it moves to tubular bones (tibia, humerus, radius, femur), flat bones (pelvic bones, sternum, ribs, skull bones) and vertebrae. As the body ages, red bone marrow is gradually replaced by yellow bone marrow, a special fatty tissue that is no longer capable of producing blood cells.

Principle of bone marrow puncture

The most convenient bone for collecting bone marrow tissue in adults is the sternum, namely the area on its body located at the level of the II or III intercostal space. In addition, the arches or crest of the iliac bone and the spinous processes of the lumbar vertebrae can be used to perform the manipulation. In children under 2 years of age, the puncture can be performed on the calcaneus or tibial plateau, and in older adults - on the ilium.

To extract biopsy tissue, special needles and ordinary syringes (5, 10 or 20 ml) are used, which allow tissue to be aspirated (suctioned) from the sternum cavity. As a rule, bone marrow altered by pathology has a semi-liquid consistency and its collection is not difficult. After obtaining samples of the material, smears are made on glass slides, which are examined under a microscope.

What does a puncture needle look like?

To perform bone marrow puncture, non-oxidizing steel needles of various modifications are used. The diameter of their lumen is from 1 to 2 mm, and the length is from 3 to 5 cm. Inside these needles there is a mandrin - a special rod that prevents blockage of the needle lumen. Some models have a blocker that limits too deep penetration. At one end of the bone marrow puncture needle there is a scrolling element that allows you to comfortably hold the device while performing the puncture.

Before the procedure, the doctor adjusts the needle to the expected puncture depth. In adults it can be about 3-4 cm, and in children - from 1 to 2 cm (depending on age).

Indications

Puncture and analysis of bone marrow tissue may be prescribed in the following cases:

disorders of the leukocyte formula or clinical blood test: severe forms of anemia that are not amenable to standard therapy, increased amounts of hemoglobin or red blood cells, increased or decreased levels of leukocytes or platelets, inability to identify the causes of a high level of ESR;
diagnosis of diseases of the hematopoietic organs against the background of the appearance of symptoms: fever, swollen lymph nodes, weight loss, rash in the mouth, sweating, a tendency to frequent infectious diseases, etc.;
identification of storage diseases caused by a deficiency of one of the enzymes and accompanied by the accumulation of a certain substance in tissues;
histiocytosis (pathology of the macrophage system);
prolonged fever if lymphoma is suspected and another cause of fever cannot be identified;
determining the suitability of transplant tissue obtained from a donor before surgery;
assessment of the effectiveness of bone marrow transplantation;
detection of metastases in the bone marrow;
intraosseous administration of drugs;
preparation for chemotherapy for blood cancers and for assessing treatment results.

Contraindications

Contraindications to bone marrow puncture can be absolute or relative.

acute myocardial infarction;
decompensated form of heart failure;
acute cerebrovascular accident;
decompensated form of diabetes mellitus;
inflammatory or purulent skin diseases at the puncture site;
the result of the puncture will not have a significant impact on improving the effectiveness of treatment.

In some cases, doctors may have to refuse to perform a bone marrow tap because the patient (or their designee) refuses the procedure.

Preparation for the procedure

Before performing a bone marrow puncture, the doctor must familiarize the patient with the principle of its implementation. Before the examination, the patient is recommended to take a blood test (general and clotting tests). In addition, the patient is asked questions about the presence of allergic reactions to medications, medications taken, the presence of osteoporosis, or previous surgical interventions on the sternum.

If the patient is taking blood thinning medications (Heparin, Warfarin, Aspirin, Ibuprofen, etc.), then he is advised to stop using them several days before the intended procedure. If necessary, a test is performed to determine the absence of an allergic reaction to the local anesthetic that will be used to numb the puncture.

On the morning of the bone marrow puncture, the patient should take a shower. The man must shave the hair from the piercing site. The patient can eat a light breakfast 2-3 hours before the test. Before performing the procedure, he should empty his bladder and bowels. In addition, it is not recommended to carry out other diagnostic tests or surgical procedures on the day of puncture.

How is the procedure performed?

The collection of red bone marrow tissue is carried out in a hospital or diagnostic center (outpatient) in a specially equipped room in compliance with all the rules of asepsis and antiseptics.

The sternal puncture procedure is carried out as follows:

30 minutes before the start of the procedure, the patient takes a painkiller and a mild sedative.
The patient undresses to the waist and lies on his back.
The doctor treats the puncture site with an antiseptic and performs local anesthesia. A local anesthetic is injected not only under the skin, but also into the periosteum of the sternum.
After the painkiller begins to take effect, the doctor marks the puncture site (the space between the 2nd and 3rd rib) and selects the necessary needle.
To perform a puncture, the specialist makes gentle rotational movements and applies moderate pressure. The depth of the puncture may vary. When the end of the needle enters the sternum cavity, the doctor feels a decrease in tissue resistance. During the puncture, the patient may feel pressure, but not pain. After insertion, the needle itself is held in the bone.
After puncturing the sternum, the doctor removes the mandrel from the needle, attaches a syringe to it and performs a bone marrow aspiration. From 0.5 to 2 ml of biopsy material can be taken for analysis (depending on age and clinical case). At this point, the patient may feel slight pain.
After collecting material for research, the doctor removes the needle, disinfects the puncture site and applies a sterile bandage for 6-12 hours.

The duration of a sternal puncture is usually about minutes.

To obtain bone marrow tissue from the iliac bones, the doctor uses a special surgical instrument. When performing punctures on other bones, needles and appropriate techniques are used.

After the procedure

30 minutes after completion of the bone marrow puncture, the patient can go home (if the study was performed on an outpatient basis) accompanied by a relative or friend. On this day, he is not recommended to drive a car or operate other traumatic mechanisms. Over the next 3 days, you must refrain from bathing and showering (the puncture site must remain dry). The puncture area should be treated with a solution of an antiseptic prescribed by a doctor.

Examination of the material obtained after puncture

After obtaining red bone marrow tissue, they immediately begin to perform a smear for a myelogram, since the resulting material resembles blood in its structure and quickly clots. The biopsy sample is poured from a syringe at an angle of 45° onto a fat-free glass slide so that the contents flow freely from it. After this, thin strokes are made with the sanded end of the other glass. If the material for research contains a lot of blood, then before performing a smear, its excess is removed using filter paper.

To perform a cytological examination, 5 to 10 smears (sometimes up to 30) are prepared. And part of the material is placed in special tubes for histochemical, immunophenotyping and cytogenetic analysis.

The test results can be ready 2-4 hours after receiving the smears. If the material for research is sent to another medical institution, it may take up to 1 month to obtain a conclusion. The interpretation of the analysis result, which is a table or diagram, is carried out by the patient’s attending physician - hematologist, oncologist, surgeon, etc.

Possible complications

Complications almost never arise after a bone marrow puncture is performed by an experienced doctor. Sometimes the patient may feel slight pain at the puncture site, which disappears over time.

If the procedure is performed by an inexperienced specialist or the patient has been improperly prepared, the following undesirable consequences are possible:

In some cases, infection may occur at the puncture site. It is possible to avoid this complication of the bone marrow puncture procedure by using disposable instruments and following the rules of care for the puncture site.

Particular attention should be paid to patients suffering from osteoporosis. In such cases, the bone loses its strength, and its puncture can provoke a traumatic fracture of the sternum.

Benefits of bone marrow puncture

Carrying out a bone marrow puncture is an accessible, highly informative procedure that is easy to perform and prepare. Such a study does not put a serious burden on the patient, rarely causes complications, allows for an accurate diagnosis and assessment of the effectiveness of the treatment.

Bone marrow puncture plays an important role in the diagnosis of blood pathologies and oncological processes. Its implementation makes it possible to quickly and accurately make a diagnosis. After treatment, such a diagnostic technique can be carried out to assess its effectiveness.

Which doctor should I contact?

Typically, a bone marrow puncture is prescribed by a hematologist or oncologist. The reason for such a procedure may be various severe blood diseases, malignant tumors, suspicion of metastases, preparing the patient for bone marrow transplantation or chemotherapy, storage diseases, etc.

A specialist from the Moscow Doctor clinic talks about bone marrow puncture:

Myelogram - interpretation of bone marrow smear

For patients with severe anemia, if certain types of tumors and blood diseases are suspected, a myelogram is often prescribed during the diagnosis of the pathology.

This study helps to identify abnormalities in the bone marrow and hematopoietic processes. Based on the results of the myelogram, treatment is selected and the therapy is evaluated.

What is a myelogram?

A myelogram is actually not a diagnostic method itself, but the result of a microscopic analysis of a smear obtained from the bone marrow.

A puncture or biopsy of red bone marrow is also called a sternal puncture and is a standard diagnostic method in hematology. This study must be carried out simultaneously with a detailed analysis of peripheral blood.

The material is taken from the sternum or ilium from adults.

Indications and contraindications

A myelogram allows us to establish the nature of erythropoiesis and identifies cells that appear in various pathologies of the hematopoietic system.

Changes in the bone marrow are detected in Nimman-Pick and Gaucher diseases, and with the development of metastases.

An assessment of bone marrow hematopoiesis together with indicators of a general and complete blood count is required to clarify the cause of a decrease in hemoglobin, that is, anemia.

Absolute indications for which a bone marrow biopsy is required include:

All types of anemia, except typical iron deficiency anemia.
Cytopenia.
Acute leukemia and the chronic form of this disease at the initial stage of development.
A significant increase in ESR, in which it is not possible to find out the main cause of this pathology. An increase in ESR may occur in people with Waldenström's macroglobulinemia or multiple myeloma.
Increased risk of developing bone marrow metastases in patients with various malignancies.

In some cases, a myelogram is necessary to determine the cause of iron deficiency anemia and to determine changes in chronic long-term leukemia. These indications for obtaining bone marrow punctate are considered relative.

Sternal puncture is not performed on patients:

With acute myocardial infarction.
In acute cerebrovascular accident.
At the time of an attack of suffocation, angina pectoris and during a hypertensive crisis.

Preparing for analysis

Sternal puncture is a fairly common procedure and does not require special preparation of the patient.

There is no need to change your diet; you just need to eat two to three hours before the test.

The doctor must know about all the medications used; only those that are necessary for health reasons are left for several days. Be sure to stop heparin, as it thins the blood and can cause bleeding.

How is the procedure done?

Sternal puncture takes only a few minutes and is performed under local anesthesia.

The research consists of several stages:

The patient lies on his back on the couch.
The skin of the sternum is treated with an antiseptic.
Local anesthetic is injected under the skin and into the periosteum.
The sternum is punctured with a special needle with a hollow channel. Localization of the puncture site is the level of the sternum opposite the third rib and in the middle.
The depth of the puncture is controlled by a special disk located on the needle.
Approximately 0.3 ml of bone marrow is aspirated with a syringe.
After removing the needle, apply a sterile bandage to the puncture site.

If it is necessary to obtain punctate from the iliac crest, it is taken using a special surgical instrument. In young children, the sternum is usually not pierced, and the material is obtained from the calcaneus or tibia.

There is a high risk of sternum puncture in those patients taking corticosteroids. Under the influence of these drugs, osteoporosis often develops, leading to bone loss.

Interpretation of myelogram results

Not only hematologists, but also therapists, oncologists, and neurologists are involved in deciphering bone marrow smear parameters. Before making a definite diagnosis, the data of all other examinations and, necessarily, blood test results are taken into account.

Normal indicators

Myelogram in the table:

For what diseases is the rate increased?

An increase in the number of cellular elements of the bone marrow is possible with a variety of diseases of the blood system:

The growth of megakaryocytes indicates metastases in the bone marrow and myeloproliferative processes.
An increase in the ratio between erythrocytes and leukocytes indicates leukemoid reactions, chronic myeloid leukemia, subleukemic myelosis.
An increase in blasts by more than 20% of normal occurs in acute leukemia. Blasts also increase up to 20% in acute leukemia, but also in myeloid forms of chronic leukemia and in people with myelodysplastic syndrome.
The neutrophil maturation index increases in patients with blast crisis and chronic myeloid leukemia.
Myeloblasts increase by more than 20% during blast crisis, in patients with chronic myeloid leukemia. An increase in myeloblasts of less than 20% is also observed in myelodysplastic syndrome.
An increase in promyelocytes occurs in leukemoid reactions, promyelocytic leukemia, and in patients with chronic myeloid leukemia.
Neutrophilic myelocytes and metamyelocytes increase in chronic myeloid leukemia, subleukemic myelosis, and leukemoid reactions of the body.
The growth of band neutrophils indicates leukemoid reactions, subleukemic myelosis, chronic myeloid leukemia and the syndrome of “lazy” leukocytes.
Segmented neutrophils grow in patients with chronic myeloid leukemia and subleukemic myelosis. A change towards an increase in these elements can occur with the syndrome of “lazy” leukocytes and with leukemoid reactions.
Growing eosinophils are detected in allergic reactions, malignant tumors, helminthiasis, acute leukemia, chronic myeloid leukemia and lymphogranulomatosis.
Basophils increase in the chronic form of myeloid leukemia, erythremia, and basophilic leukemia.
An increase in lymphocytes indicates aplastic anemia or chronic lymphocytic leukemia.
A large number of monocytes can be present in leukemia, tuberculosis, sepsis, and chronic myeloid leukemia.
Bone marrow plasma cells increase in number during multiple myeloma, infections, aplastic anemia, and immune agranulocytosis.
Erythroblasts deviate from the norm towards an increase in different forms of anemia and in patients with acute erythromyelosis.

The norm has been lowered, what does this mean?

A decrease in megakaryocytes indicates hypoplastic and aplastic autoimmune and immune processes in the body. A decrease in megakaryocytes is determined in patients after radiation exposure and taking cytostatics.
A decrease in the ratio between leukocytes and erythrocytes can occur due to blood loss, hemolysis, erythremia and acute erythromyelosis.
A decrease in promyelocytes occurs with aplastic anemia, under the influence of ionizing radiation, and cytostatics.
A decrease in the erythroblast maturation index is observed in patients with B 12 deficiency anemia, with blood loss and reflects ineffective erythropoiesis during hemodialysis.
A decrease in the number of neutrophil myelocytes and metamyelocytes, band and segmented, indicates aplastic anemia, immune aphanulocytosis, which often develops under the influence of cytostatics and ionizing radiation.
A decrease in the number of erythroblasts occurs with aplastic anemia, partial red cell aplasia and develops when taking cytostatics and when the body is exposed to ionizing radiation.

Complications

Sternal puncture, when performed by an experienced doctor, practically does not cause complications.

Cost of analysis

The cost of a sternal puncture and myelogram in Moscow clinics starts from about 800 rubles. The average cost of the procedure is about three thousand.

It is also supplemented by puncture of the bone marrow itself.

Technique(according to Heilmeyer). After cleansing and disinfecting the skin in the area of the body of the sternum with iodine, the skin and especially the periosteum are numbed with several milliliters of anesthetic liquid. After the onset of anesthesia, a special needle for bone marrow puncture with an inserted mandrel is used to puncture the sternum along the midline at approximately the height of the II - III costal cartilage.

The safety shield (arrest) is installed at a level of 4 - 5 mm and then the cortical layer is pierced. In this case, the passage of the needle is felt quite clearly. With a thick and dense bone layer, this requires the use of quite significant force. If there is doubt whether the needle has penetrated the bone marrow, they resort to testing with aspiration test. About 0.5 - 1 ml of bone marrow is sucked in with a record syringe mounted on a needle so that air does not penetrate into it, which causes a pronounced pain reaction, which, however, soon subsides.

If it is not possible to obtain bone contents, then inject a little physiological solution of table salt and perform aspiration again. If necessary, you can penetrate the needle a little deeper. With careful and correct technique, this intervention is safe.

Erythropoiesis is found to be increased in most anemias. In the bone marrow with pernicious anemia, pronounced disturbances in cell maturation are detected, such as megaloblastic hematopoiesis. In contrast, with a decrease in erythropoietic function, the number of cells is significantly reduced, puncture reveals “empty” bone marrow: aplastic anemia is evident.

Leukopoiesis always occurs simultaneously with erythropoiesis. A significant increase in the leukopoietic function of the bone marrow occurs in myeloid leukemia, and complete depletion occurs in agranulocytosis.

Thrombocytopoiesis has its source in giant bone marrow cells - megakaryocytes, about a third of which, as it is found, form plates (functioning forms), while 2/3 are at rest.

Complete extinction of all hematopoietic functions leads to a severe, almost always fatal disease - panmyelophthisis (pancytopenia).

In this regard, when studying bone marrow smears, it is necessary to distinguish between:

Hypoplasia due to a variety of lesions of the hematopoietic organs and

Hyperplasias arising due to increased demands from the periphery, impaired maturation or leaching of cells and as a result of neoplastic processes.

Normal Heilmeyer myelogram

Per 100 leukocytes:

Proerythroblasts
Macroblasts
Normoblasts
Myeloblasts
Promyelocytes
Neutrophils	Myelocytes	23,9 (15,3-29,6)
Eosinophils
Basophils
Neutrophils	Metamyelocytes
Eosinophils
Basophils
Neutrophils	Rod
Eosinophils		23,4 (17,8-30,2)
Basophils
Neutrophils	Segmented leukocytes
Eosinophils
Basophils
Lymphocytes
Monocytes
Megakaryocytes
Lymphoid reticular cells		5.0 (0.6-12.2) according to Rohr
Plasma reticular cells		2.0 (1-3.6) according to Rohr

Moreover, each individual myelogram characterizes the constantly changing structure of the bone marrow at the moment, and repeated studies provide a kind of movie that, more clearly than any other test, allows one to judge the functional state of the bone marrow.

Quite similarly, with the help of a puncture, extramedullary foci of hematopoiesis in the spleen and lymph glands can also become available for research, however, the evaluation of the resulting preparations requires a lot of special experience in this area.

All materials on the site were prepared by specialists in the field of surgery, anatomy and specialized disciplines.
All recommendations are indicative in nature and are not applicable without consulting a doctor.

Blood tests, no matter how extensive they are, are not always able to provide a complete amount of information about the state of the bone marrow and its functioning, because mature cells are usually present in the bloodstream. A sternal puncture allows a specialist to trace the nature of hematopoiesis and the morphological characteristics of blood cells, through which a specialist obtains a bone marrow sample for examination.

The term "sternal" implies that the bone marrow will be taken from the sternum, although it can also be obtained from the ilium or calcaneus (in young children). Puncture of the sternum seems to be a fairly simple and safe diagnostic method, provided that all precautions and manipulation techniques are followed.

Indications and contraindications for sternal puncture

Anemia - severe iron deficiency, megaloblastic, aplastic.
Tumors of hematopoietic tissue - leukemia, paraproteinemic hemoblastosis.
Myelodysplastic syndrome.
Leukemoid reactions, when the peripheral blood picture does not exclude tumor growth.
Storage diseases of hereditary nature, metabolic disorders (Gaucher disease, Niemann-Pick disease).
Visceral leishmaniasis.
Suspicion of the presence of metastases of other malignant neoplasms in the bones (prostate cancer, for example).
Assessing the effectiveness of treatment and monitoring the condition of hematological patients.
Research and procurement of the resulting stem cells for transplantation to a donor or the punctured patient himself after courses of chemotherapy or radiation.
Intraosseous administration of drugs.

Contraindications for sternal puncture there are also:

Severe bleeding disorders.
Old age in cases where sternal puncture is not the only possible diagnostic method.
Acute inflammatory and infectious lesions at the site of the intended skin puncture.
Patient refusal to study.
Severe concomitant diseases in the stage of decompensation (the question of the advisability of a puncture is decided individually).

Preparation and technique for performing sternal puncture

The patient undergoes a blood clotting test and a general analysis no more than 5 days before the planned procedure;
Two hours before the puncture, the last meal and water is possible;
Before the procedure, the bladder and intestines are emptied;
All medications are canceled, except those that are vital;
On the day of the puncture, no other procedures are prescribed.

Before the manipulation, the patient must inform the doctor about all the medications he is taking, especially for anticoagulants and other blood-thinning agents, which should be discontinued due to the greatly increasing risk of bleeding while taking them.

The technique of performing sternal puncture includes several stages:

Features of sternum puncture in children:

Sternal puncture is possible only from two years of age;
Special needles of smaller diameter than for adults are used;
General anesthesia is possible.

The results of a sternal puncture can be obtained on the same day if a cytological examination of a bone marrow smear is expected. With histological analysis and other more technically complex studies, the diagnosis is extended for a period of 7-10 days.

Video: sternal puncture technique

Complications and features of the postoperative period

The bone marrow collection procedure lasts approximately 20 minutes. After it, the patient is under observation for about an hour, general health, pulse and blood pressure are monitored. You can leave the hospital the same day, but it is highly undesirable to drive, as there is a risk of fainting.

The puncture site does not require any treatment at home, however, for the first three days it is recommended to exclude water procedures so as not to introduce an infection into the puncture hole. Sternal puncture does not imply any restrictions on diet and nutrition. If there is severe pain at the puncture site, the patient can take a painkiller.

Through puncture (in a child or patient with osteoporosis);
Bleeding from the puncture site;
Infection of the puncture site (extremely rare);
Fainting states in emotionally labile persons, hypotensive persons, with insufficiently thorough psychological preparation of the patient for manipulation;
Shock in case of severe pathology of the cardiovascular system in elderly people.

Interpretation of sternal puncture results

Analysis of bone marrow obtained through sternal puncture shows the number of cellular elements in it, their ratio and degree of maturity. The myelogram characterizes the qualitative and quantitative indicators of the white germ of hematopoiesis:

Myelokaryocytes (the total number of blood cells containing nuclei) are 50-250x10 9 per liter of blood;
Megakaryocytes (precursors of platelets) - 0.054-0.074x10 6 per liter;
Reticulocytes (precursors of red blood cells) make up 20-30% and increase with blood loss and hemolytic anemia;
Blast cells - 0.1-1.1%, myeloblasts - 0.2-1.7%, promyelocytes - 0.5-8.0% of all elements of the white lineage of the bone marrow, lymphocytes - 1.2-1.5 %, monocytes - 0.25-2.0%, plasma cells - no more than 1%.

A decrease in the number of myelokaryo- and megakaryocytes is possible due to errors in the puncture, when the bone marrow is diluted with liquid blood.

Bone marrow indices

To assess the quantitative content of each type of bone marrow cells, their ratio in 500 cells is calculated. An important indicator is bone marrow neutrophil maturation index, which is calculated by dividing the total number of white lineage precursor cells by the total number of band and segmented neutrophils. Normally, the indicator is 0.6-0.8.

Along with the assessment of the white sprout, the characteristics of erythropoiesis are also important. Erythroid element maturation index calculated by the content of erythroblasts and normocytes and is 0.8-0.9. This indicator characterizes iron metabolism, the degree of saturation of red cells with hemoglobin, and increased erythropoiesis in anemia.

After calculating the number of granulocytes and the total number of red germ cells containing nuclei, their ratio is calculated, which is normally 3-4: 1 - leuko-erythroblastic ratio.

Bone marrow indices make it possible to objectify data on absolute numbers and percentages of specific cell populations. So, increase in leuko-erythroblastic index characteristic of hyperplasia of the white germ of hematopoiesis, which is observed in chronic lympho- and myeloblastic leukemia, infectious diseases, intoxications, and it can also indicate hypoplastic anemia with a general depletion of bone marrow tissue.

Decrease in leuko-erythroblastic index is indicative of hemolytic, posthemorrhagic and megaloblastic anemia (with normal bone marrow cellularity), and in the case of bone marrow depletion, it indicates agranulocytosis (decreased leukocyte count).

Neutrophil Maturation Index with sufficient cellularity of the punctate, it increases in case of tumors of the hematopoietic tissue (leukemia), drug poisoning, and its decrease is usually characterized by bone marrow dilution due to errors during puncture.

The described myelogram criteria make it possible to assess hematopoiesis as a whole, but the specialist’s conclusion should not be categorical. It is important to correlate the results of the study of sternal puncture with the characteristics of the clinical picture and the data of peripheral blood analysis.