Iliac Crest Bone Marrow Aspiration: Ultrasound Guidance




Keywords

BMAC, bone marrow aspirate, iliac crest, regenerative, stem cells, ultrasound

 



Note: Please see pages ii , iii for a list of anatomic terms/abbreviations used throughout this book.


Ultrasound can be used for imaging guidance to access the medullary cavity of the iliac crest while avoiding neurovascular structures and excess radiation exposure. A technique perpendicular to the tables of the ilium can be used in-plane to the ultrasound transducer. This allows for aspiration from multiple cortical sites to maximize yield of nucleated cells. An alternative technique (not described in this text) can be used that is a similar parallel approach as the described fluoroscopic technique. This alternative parallel approach would be out-of-plane to the transducer, or would use ultrasound identification of the intended target and then completion of the procedure without live guidance.




In-Plane Technique ( Fig. 36B.1 )





  • Patient is prone.



  • Interventionalist is on the patient’s ipsilateral side.



  • Ultrasound image contralateral to the interventionalist and in line with transducer ( Fig. 36B.1A , see Chapter 4 ).






    Fig. 36B.1


    A, Typical room, interventionalist, US transducer, and US unit setup for hybrid procedure with with fluoroscopic and ultrasound guidance. B, Ultrasound image of trocar placement within the iliac crest in short axis. C, The relevant radiolucent structures. Yellow dashed line represents borders of the image seen on ultrasound in B. D, Skeleton with transducer placement. Opaque transducer represents the starting point at the superior aspect of the posterior superior iliac spine. Semi-opaque probes represent additional trocar trajectories into the iliac crest.



  • Curvilinear ultrasound transducer positioned so the palpated ipsilateral iliac crest is in the short axis.



  • Scan caudad/cephalad to identify the most peaked aspect of the iliac crest. This is the cephalad aspect of the posterior superior iliac spine (PSIS).



  • Mark the intended needle entry point in-plane to the transducer so that the intended needle trajectory is perpendicular to the iliac crest 1 to 2 cm below the most superficial peak ( Fig. 36B.1B,C ).



  • Pivot from the marked entry point obliquely caudad/cephalad to identify additional intended targets on the iliac crest ( Fig. 36B.1D ). When pivoting caudad, the peak of the iliac crest will start to flatten at the level of the PSIS (see Fig. 36B.3A ). When pivoting cephalad, the peak of the iliac crest will start to thin at the superior aspect (see Fig. 36.3 C).



  • Identify any neurovascular structures lateral to the iliac crest in the needle guidance track.



  • Insert needle/trocar and advance in-plane to the transducer from lateral to medial.



  • Advance trocar into subcortical medullary cavity.



  • Once the trocar is advanced into the medullary cavity, it cannot be visualized with ultrasound.



  • After advancing the trocar into the medullary cavity, fluoroscopic image may be taken with the C-arm in an identical setup as the above described contralateral oblique trajectory view ( Fig. 36B.2 ).


Jan 27, 2019 | Posted by in RHEUMATOLOGY | Comments Off on Iliac Crest Bone Marrow Aspiration: Ultrasound Guidance
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