How to Perform the Perfect Bone Marrow Biopsy

“The bone marrow aspirate is dilute and cell morphology cannot be adequately determined. The biopsy specimen is inadequate to determine cellularity.” This is not the kind of result you’re looking forward to after putting your patient through an ordeal that’s best described by his comment: “Doc, this is the closest I’ll ever come to experiencing the pain of childbirth as a 45-year-old man.”

A successful bone marrow aspirate and biopsy require not only experience and good technique, but also patience and perseverance. The procedure can be challenging for you and the patient, but being cognizant of some important issues can lead to better-quality biopsies and make the experience more tolerable for the patient. The intent of this article is not to provide an expansive review of how to perform a bone marrow biopsy, as this can be found in many texts, but rather to emphasize some important tips in order to successfully perform the perfect bone marrow biopsy.

Plan Ahead

In Alan Lakein’s words, “Failing to plan is planning to fail.” As with any medical procedure, being well prepared cannot be overemphasized. Realizing that some important equipment is missing during the procedure or that the patient is not in the proper position can be very unsettling. It is also crucial that you determine in advance whether the biopsy will be taken from the more common and easily accessible posterior superior iliac spine, or from the sternum when there is difficulty in getting samples from the iliac spine (eg, such as in an obese patient or one with anatomical deformities).

Know the Indications for the Biopsy

It is important to be familiar with the patient’s history and understand why the biopsy is necessary. Just as important as the biopsy itself is ensuring that you order the correct studies on the specimen, which in turn depends on what diagnosis is being entertained. It is also equally imperative to know when not to do a biopsy. There are a few circumstances that are considered absolute contraindications, such as hemophilia, severe disseminated intravascular coagulation (DIC), and other bleeding disorders. Thrombocytopenia is usually not a contraindication. Also, remember that while a sternal aspirate is possible, a biopsy should never be attempted in this case due to the close proximity to vital structures of the thorax and the fact that only a thin bony plate is separating your needle from these structures.

Choose the Right Time and Place

It is generally understood that fellowship training is exceptionally busy and finding adequate time for the biopsy can be very challenging. It is important to choose a block of time in which you can carry out the procedure in an unrushed fashion. It is counterproductive to schedule a biopsy half an hour before an important conference or another important task; it is typically recommended to allocate at least 45 minutes for the procedure. The time it will take you to do a biopsy can be unpredictable. Some will be only 20 minutes while others may require an hour if complications arise. Make sure you give advance notice to the patient and their nurse and ensure that they are not scheduled for any other procedures during the dedicated time. Ideally, the biopsy should be done in a private patient room where there is more space and privacy; however, this may not always be possible in the hospital setting. Check that the patient’s bed is in working order and see that enough personnel are available to help in order to keep interruptions to a minimum.

Bring the Correct Equipment

Familiarize yourself with the specific biopsy kit that is used at your institution and gather any other necessary material that is not provided with the kit. Make a checklist. In general, the following equipment is needed: aspirate and biopsy needles, syringes with needles, sterile gloves, antiseptic swabs, gauze material, lidocaine, heparin, collection tubes and pathology specimen cups to send off the required samples (usually, these are aspirates for morphology, immunohistochemistry, flow cytometry, and cytogenetics, as well as a biopsy specimen for pathology), slides, and the necessary request forms. This list is a general guideline and should be modified to meet specific institutional needs.

Prepare the Patient

Many patients cringe at the notion of having to go through a bone marrow biopsy, as they have inadvertently heard that it is a “horrible” procedure. It is important that you prepare the patient for the procedure to help ease his or her preconceived ideas. A conscious effort should be made to not trivialize the procedure, since it is probably the patient’s first experience.

Appropriately counsel the patient beforehand and go through each planned step in detail. Explain why the biopsy is necessary and what to expect during each step. Never say that the biopsy is painless, as this is typically not the case. Tactfully reiterate that you will do your best to minimize pain and discomfort and that the procedure is generally well tolerated with adequate use of local anesthesia. Obtain informed consent and be sure that you describe the possible complications, which are generally very rare.¹ Prepare the patient for what to expect afterward, such as pain and discomfort in the area and how to care for the biopsy site. Tell the patient how long it usually takes for test results to become available at your institution. Ensure that the patient understands your instructions completely, will be able to cooperate during the procedure, and will answer any questions.

Minimize Pain and Anxiety

It is virtually impossible to completely eliminate pain from the biopsy procedure, but certain measures can help reduce the discomfort or at least the perception of pain. People have different pain thresholds, which is illustrated by the very different comments made by various patients postprocedure. One patient may feel very little pain (“I must be one of the lucky ones. I didn’t feel much pain (maybe a 4 or 5), mostly just a lot of pressure”), while another may have a completely different experience (“That was the most pain I have ever experienced in my life. When they broke through the bone into the marrow, a pain shot down my legs that caused me to break a sweat and curse like a drunken sailor”). In a study of 235 patients undergoing a bone marrow biopsy, 56% reported moderate pain while 32% reported severe pain.² Another factor that may augment a patient’s perception of pain is the anxiety associated with the procedure. Up to 75% of patients in 1 study reported moderate to severe procedural anxiety.³ It is important that you are mindful of these facts and that you make an effort to individualize each patient’s pain and anxiety management. It cannot be overemphasized that the specimen obtained may be of much better quality if the patient is comfortable and cooperative.

Most patients do well with only local anesthesia but there may be some who need premedications, usually narcotic analgesia, anxiolytics, or even conscious sedation. If only local anesthesia is used, an adequate amount should be given. Anesthetize a wide area and don’t hesitate to use additional anesthetic if the adequacy of pain control is not optimal. Do not continue to poke and prod while trying to comfort the patient with words like “It’s going to be over soon” while the patient cries in pain. There is no reason why more local anesthetic cannot be given.

The choice and dose of the premedication may vary based on personal experience, but generally an IV or oral morphine derivative and lorazepam can be used to both provide some sedation and help with pain. If possible, the premedications should be given at least 30 minutes before the planned time of the procedure. A study of 138 patients undergoing a bone marrow biopsy reported that using 1 mg of lorazepam preprocedure did not reduce pain significantly but enhanced cooperation of the patient and his or her willingness to undergo another procedure.⁴ Another study evaluated 84 patients who had either 10 mg of oral oxycodone and 2 mg of lorazepam or placebo administered 30 minutes prior to the procedure. Compared with placebo, the combination regimen provided a 14% decrease in the perception of pain (P ≤.05).⁵

There is no conclusive evidence that premedicating a patient necessarily reduces procedural pain, but it may be helpful under certain conditions and help get the actual procedure done more effectively and efficiently.

Know the Correct Technique

It is important that you learn correct biopsy technique early in your fellowship, because it is difficult to unlearn poor technique later on in your career. Before beginning to perform biopsies under supervision, observe attending physicians or other senior fellows who have developed a good technique. Once you have advanced to performing biopsies on your own, have them observe you until you have become proficient. There is a lot of variation among each procedure and while the first 10 biopsies may go smoothly, the 11th one may be challenging and require the help of a more experienced colleague. Another good way to learn is to watch a video (available to subscribers) at the New England Journal of Medicine Website.⁶

Another testament to a good overall procedure is the quality of the sample provided. If you’re sending the aspirate specimen directly to the lab instead of preparing slides at the bedside, ensure that spicules are present. Getting a good-quality aspirate may not be possible under certain circumstances. When this situation is encountered a touch imprint can be provided to the pathologist to assist with the diagnosis. It is also critical to get a good-length biopsy specimen; it is generally accepted that a 2-cm specimen has greater diagnostic yield.⁷ Remember to collect adequate specimens for the various studies that will be ordered. In the situation where you cannot get good, adequate samples or find the correct location, try to switch sides, obtain a sternal aspirate, or even consult radiology to perform the procedure under radiological guidance. Toward the end, apply a pressure dressing and instruct the patient to lay supine for 20 to 30 minutes to allow for adequate hemostasis.

Dealing With Complications

Take comfort in the fact that complications are quite rare. In a report published in 2003, there were only 26 adverse events out of a total of 55,000 procedures.¹ In the event that a complication does occur, you will need to be prepared. Some common complications are bleeding from the biopsy site and local infections. Bleeding can generally be controlled with adequate and prolonged pressure to the site. Infections can be prevented by good antiseptic technique and are usually limited to the skin. Other complications are even rarer and can include needle breakage, transient neuropathy, or fracture due to underlying osteoporosis.

At the conclusion of the procedure, ensure that all sharps are discarded properly. Thank the patient and clean up behind yourself. You don’t want to be known as the notoriously sloppy fellow in nursing-gossip circles. Doublecheck that all samples are labeled correctly and sent to the correct departments. Hopefully, by following these general guidelines you will become more comfortable at performing bone marrow biopsies and every one of them will be perfect.

References

1. Bain BJ. Bone marrow biopsy morbidity and mortality. Br J Haematol. 2003;121(6):949-951.

2. Liden Y, Landgren O, Arner S, Sjolund KF, Johansson E. Procedurerelated pain among adult patients with hematologic malignancies. Acta Anaesthesiol Scand. 2009;53(3):354-363.

3. Brunetti GA, Tendas A, Meloni E, et al. Pain and anxiety associated with bone marrow aspiration and biopsy: a prospective study on 152 Italian patients with hematological malignancies [published online ahead of print February 2, 2011]. Ann Hematol. DOI:10.1007/s00277-011-1166-7.

4. Park SH, Bang SM, Nam E, et al. A randomized double-blind placebocontrolled study of low-dose intravenous Lorazepam to reduce procedural pain during bone marrow aspiration and biopsy. Pain Med. 2008;9(2):249-252.

5. Talamo G, Liao J, Bayerl MG, Claxton DF, Zangari M. Oral administration of analgesia and anxiolysis for pain associated with bone marrow biopsy. Support Care Cancer. 2010;18(3):301-305.

6. Malempati S, Joshi S, Lai S, Braner DA, Tegtmeyer K. Videos in clinical medicine: bone marrow aspiration and biopsy. N Engl J Med. 2009;361(15):e28.

7. Campbell JK, Matthews JP, Seymour JF, Wolf MM, Juneja SK. Optimum trephine length in the assessment of bone marrow involvement in patients with diffuse large cell lymphoma. Annals Oncol. 2003;14(2):273-276.

Cyrus Khan, MD, is a third-year hematology/oncology fellow at the West Penn Allegheny Health System in Pittsburgh, Pennsylvania. He is planning a career in hematopoietic stem cell transplantation. Casey Moffa, DO, is a graduate of the Philadelphia College of Osteopathic Medicine and is currently a third-year hematology/oncology fellow for the West Penn Allegheny Health System in Pittsburgh, Pennsylvania. She is planning a career in community oncology.