Original Research

An MRI Analysis of the Pelvis to Determine the Ideal Method for Ultrasound-Guided Bone Marrow Aspiration from the Iliac Crest

Publish date: May 30, 2018

TAKE-HOME POINTS

There is an ideal angle and distance for optimization of a bone marrow harvest from the iliac crest.
Ultrasound is a reliable technology that allows clinicians to accurately and consistently identify the PSIS and avoid neurovascular structures.
This safe, reliable bone marrow aspiration technique can lower the risk of serious potential complications.
The ideal angle does not differ significantly between sexes, but the safe distance a clinician can advance does.
The PSIS should be considered a “table” as opposed to a protuberance.

References

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ABSTRACT

Use of mesenchymal stem cells from bone marrow has gained significant popularity. The iliac crest has been determined to be an effective site for harvesting mesenchymal stem cells. Review of the literature reveals that multiple techniques are used to harvest bone marrow aspirate from the iliac crest, but the descriptions are based on the experience of various authors as opposed to studied anatomy. A safe, reliable, and reproducible method for aspiration has yet to be studied and described. We hypothesized that there would be an ideal angle and distance for aspiration that would be the safest, most consistent, and most reliable. Using magnetic resonance imaging (MRI), we reviewed 26 total lumbar spine MRI scans (13 males, 13 females) and found that an angle of 24° should be used when entering the most medial aspect of the posterior superior iliac spine (PSIS) and that this angle did not differ between the sexes. The distance that the trocar can advance after entry before hitting the anterior ilium wall varied significantly between males and females, being 7.53 cm in males and 6.74 cm in females. In addition, the size of the PSIS table was significantly different between males and females (1.20 cm and 0.96 cm, respectively). No other significant differences in the measurements gathered were found. Using the data gleaned from this study, we developed an aspiration technique. This method uses ultrasound to determine the location of the PSIS and the entry point on the PSIS. This contrasts with most techniques that use landmark palpation, which is known to be unreliable and inaccurate. The described technique for aspiration from the PSIS is safe, reliable, reproducible, and substantiated by data.

The iliac crest is an effective site for harvesting bone marrow stem cells. It allows for easy access and is superficial in most individuals, allowing for a relatively quick and simple procedure. Use of mesenchymal stem cells (MSCs) for treatment of orthopedic injuries has grown recently. Whereas overall use has increased, review of the literature reveals very few techniques for iliac crest aspiration,¹ but these are not based on anatomic relationships or studies. Hernigou and colleagues^2,3attempted to quantitatively evaluate potential “sectors” allowing for safe aspiration using cadaver and computed tomographic reconstruction imaging. We used magnetic resonance imaging (MRI) to analyze aspiration parameters. Owing to the ilium’s anatomy, improper positioning or aspiration technique during aspiration can result in serious injury.^2,4-6 We hypothesized that there is an ideal angle and positioning for bone marrow aspiration from the posterior superior iliac spine (PSIS) that is safe, consistent, and reproducible. Although most aspiration techniques use landmark palpation, this is unreliable and inaccurate, especially when compared with ultrasound-guided injections^7-16and procedures.^9,12,17-19 We describe our technique using ultrasound to visualize patient anatomy and accurately determine anatomic entry with the trocar.

METHODS

MRI scans of 26 patients (13 males, 13 females) were reviewed to determine average angles and distances. Axial T2-weighted views of the lumbar spine were used in all analyses. The sacroiliac (SI) joint angle was defined as the angle formed between the vector through the midline of the pelvis and the vector that is parallel to the SI joint. The approach angle was defined as the angle formed between the vector of the most medial aspect of the PSIS through the ilium to the anterior wall and the vector through the midline of the pelvis (Figure 1).

The distance, in centimeters, of the PSIS to the anterior ilium wall was measured to determine the maximum distance the trocar can advance without puncturing the anterior ilium wall. The perpendicular distance from the PSIS table to the anterior aspect of the ilium was measured to determine the average depth the trocar could advance if the clinician entered it perpendicular to the patient’s coronal plane (Figure 2).

The PSIS table width was defined as the width, in centimeters, of the PSIS posteriorly. The minimum width, in centimeters, of the ilium was measured at the thinnest region of the ilium to determine the degree of variation if the trocar were entered too far laterally and advanced to the anterior ilium wall (Figure 3).

Means and standard deviations were calculated by sex and as a total. Student’s t test was used to determine statistical significance (P < .05).

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