1 Introduction

Bone marrow examination is useful in the diagnosis and staging of haematological diseases, as well as in the assessment of overall bone marrow cellularity. Because of easy accessibility, aspiration, biopsy and culture of the bone marrow may also play a role in the assessment of patients with fever of undetermined origin as well as in the diagnosis of various storage and infiltrative disorders – malignancies, evaluation of cytopenia. BMB should be executed by trained individuals who are aware of the indications, contraindications and hazards of the procedure.

The iliac crest is the only site at which both aspiration and biopsy may be safely performed in the adult. The posterior superior iliac crest and spine (PSIS) is the favoured site of examination in the adult, as well as in the child and in most infants. This site also provides the least discomfort to the patient compared with other sites. Haemorrhage was the most common documented complication following diagnostic bone marrow aspiration and biopsy in an analysis by representatives of British Society of Haematology.⁵ The dominance of other complications like haemorrhage, infections and being an infrequent complication might be the probable reasons for scarce literature on needle breakage during such procedures. Here, we present a case of young female with pancytopenia, for whom needle biopsy was performed from PSIS for evaluation of the cause and inadvertently the needle broke inside leaving approximately 4–5 cm embedded in the bone.

2 Case report

A 22 year-old-female was admitted under General Medicine department of our hospital for past 10 days for evaluation of etiology accountable for pancytopenia. BMB from posterior iliac crest was planned for assessment and diagnosis of the definitive cause. All aseptic measures were taken and right lateral position was given. Mild sedation was given with 2 ​cc of Injection midazolam. Sterile autoclaved biopsy needle of unknown make was used for the procedure. Due to excessive unbalanced force by the resident doctor to change the course of the needle, while it was in the bone, part of the needle got stuck in the biopsy tract. Despite of multiple local manoeuvres, the broken needle could not be retrieved. So, for expert management in the background of jammed foreign body at the biopsy site, the Orthopaedic Surgeons were consulted. Patient was hemodynamically stable. There was a puncture wound in left posterosuperior gluteal region. Routine blood investigations were representative of pancytopenia. Anteroposterior radiograph of pelvis and computed tomography (CT) was advised to locate the exact position of the broken needle. X-ray revealed metallic foreign body over the sacrum near the left sacroiliac joint (Fig. 1). CT bony cuts and reporting confirmed the biopsy needle tract extending from left iliac crest with its tip in ala of left sacrum- S1 vertebra (Figs. 2 and 3). The patient was counselled about the complications of the needle in the joint and was planned for removal of needle operatively after proper consent. The patient was transfused with 3 units of blood to improve her haematological profile before the surgical procedure.

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Fig. 1 Plain radiograph anteroposterior view of pelvis with both hips demonstrating metallic foreign body (broken biopsy needle) over left sacrum near left sacroiliac joint.

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Fig. 2 CT scan axial cuts confirming the location of needle with a part of it embedded in left sacroiliac joint.

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Fig. 3 CT sagittal image showing exact length and position of the broken needle.

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Patient was induced by spinal anaesthesia and the procedure was performed in prone position under all aseptic conditions. Needle was again localized under C- arm (Fig. 4). Skin incision of around 3 cm was given over Posterior Superior Iliac Crest and soft tissue dissection was done (Fig. 5). Needle tip was visible after clearing the soft tissue with electrocautery. 2 mm burr tip over burr machine was used to clear out the surrounding cortical bone. The tip of broken needle was clearly visualised and extracted with the help of a nose plier under direct vision. Confirmation done with fluoroscopy and on table the broken needle was measured using a sterile ruler (Fig. 6). Blood loss of around 50 ml was noticed during the procedure. Haemostasis achieved and wound closure was done in layers with sterile dressing. Patient was transferred to medicine side for further management of pancytopenia.

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Fig. 4 Intra-operative fluoroscopic marking to confirm the site of incision.

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Fig. 5 Skin incision of 3 cm over left posterior superior iliac spine.

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Fig. 6 Retrieved broken biopsy needle of 5 cm after removal.

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3 Discussion

Bone marrow biopsy procedures which are frequently done for haematological diseases and malignancies are generally considered safe. Erroneous and inexperienced techniques and failure to take appropriate precautions during the procedure may land up in different complications like haemorrhage, infections, tumour seedings etc that can lead to significant morbidity and mortality. Iliac crest, usually PSIS, is the preferred site for aspiration if there is a need for trephine biopsy. The iliac crest is safer but it is often preferable to use sternum in very obese or immobile patients.⁸

Breakage of biopsy needle is rare. In developing countries, may be due to financial constraints, reusable needles are used, which are utilized multiple times after cleaning and autoclaving and that may lead to corrosion and compromise in durability of the needles. Pre-sterilised disposable needle must always be preferred over an autoclavable and reusable one to prevent transmission of diseases and avoid the risk associated with cleaning the needle which leads to corrosion and affect the hardness and the tensile strength of the needle. Bain.et al. reported a survey of complications as well as morbidity and mortality following bone marrow aspiration and trephine biopsy, of British Society of Haematology, in which they found only two cases of trephine biopsy needle breakage in 13,506 cases.⁶ In our setup, reusable stainless steel needle was used due to economic constraints and use of such needles are associated with higher chances of needle breakage. Furthermore, technical difficulties during the procedure should be anticipated priorly and associated pain reduction measures should be taken for the ease of the procedure.^6,1 Shaikh et al. demonstrated needle in needle technique for retrieval of broken biopsy needle. They have used a large bore Murphy M2 needle which was advanced over the distal portion of broken needle under CT-guided fluoroscopy and captured the broken bonopty needle along with core specimen.³ Navigation-guided extraction of foreign bodies have been utilized by maxillofacial surgeons particularly for complex areas in proximity to vital neurovascular structures.⁹ As there is no literature till date on utility of navigation-assisted system for retrieval of such broken needle, the authors would illuminate the fact pertaining to the role of navigation in modern times for retrieval of such small metallic foreign bodies from complex peri-articular areas or areas nearby vital structures.

Given below is a list of various articles published till date which had iatrogenic needle breakage as a complication of BMB Table 1. Considering this, needle breakage occurring during BMB could be rare and the involvement sacroiliac joint with the corresponding vertebra is even rarer.

4 Conclusion

Rarity of our case would be the penetration of the needle in the left S1 vertebra, partly into the left SI joint. A number of extraction methods of broken needle in the bone have been documented like needle in needle technique, broken screw removal set or even a cannulated drill bit typically used for internal fixation of femoral neck fractures performed under moderate conscious sedation. In our case, high speed burr along with nose plier was used.

Proper prior information should be available about the quality of the needle to be used in the procedure as well as it should be performed under supervision of experts with all precautionary measures, to avoid erroneous techniques and catastrophic consequences of needle breakage during the procedure. This unusual and arduous complication of a usual procedure can be dealt with meticulous pre-operative planning with radiological imaging and appropriate armamentarium for surgical extraction.

Funding/sponsorship

This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.

Informed consent

Written informed consent in the language well understood by the patient was taken for documentation of clinical history and relevant images.

Author's contribution

SP - Writing original draft/Formal analysis, SKG– Conceptualization/Supervision, AKY - Visualization/Validation, TM- Data curation/Revision and editing.