Bone Marrow Biopsy Procedure Guide

[Dr. Aaron Fritts]
For the audience…I just wanted to let you know to really communicate with the cytotech before you get started because sometimes that gets dropped. The last thing you want is your needles out and then they're like, “Wait a minute, I need more.” That's a key thing. Next step is, what imaging are you using? Are you doing a CT-guided or fluoroscopic guided?

[Dr. Chris Beck]
This is a sticking point for some people. I'm not dogmatic. Our workflow is very much CT. 98% of the time I'm in CT and if I'm not in CT, it's usually because CT is so booked up and it's an add-on situation, and I accept the patient, and we're not going to be able to get into CT for whoever knows, like maybe it's down or something. I will take them over to fluoro and do it in fluoro, and I don't have a problem with that. In fact, I'm on the record saying with a lot of my partners I think that I can do, with certain patient body habitus, I'm pretty certain I could do it blind safely. I always use some imaging, and 98% of the time it'll be CT.

[Dr. Aaron Fritts]
Now, once you've done like hundreds of them, you can visualize what the imaging looks like and your angle and then there's tactile feel. Between those three things, you're right. I think once you've done enough–

[Dr. Chris Beck]
Everyone else is doing them without imaging. It's not like you're so off base.

[Dr. Aaron Fritts]
I know, and they're not even radiologists.

[Dr. Chris Beck]
Right, exactly. It's just not like-- Yes, once you do enough of them, and then also with the information that everyone else is doing them without imaging, it's just not like such a stretch before you're like, all right, I can do these without pictures.

[Dr. Aaron Fritts]
I agree. My workflow has always been CT guided because that's just the way it was been done. Now there's one hospital where they have a cone beam CT available. You could do it under fluoro, and then confirm your needle positioning under cone beam CT. They just do like a real quick spin. The downside is you're wearing fluoro or you're wearing lead, which I don't like to do. I like to not have to do that. Then the other thing is sometimes getting that confirmatory cone beam CT can be clumsy if you got a new tech that day or something like that. To me, it just works faster in CT, and that's probably just familiarity and so forth.

[Dr. Chris Beck]
Hold on. If you're using fluoro, I suspect that a lot of people who are using fluoro are not going to do cone beam.

[Dr. Aaron Fritts]
I mentioned that because that's the reason why some of the docs in my group use the fluoro. They're like, I can just confirm my position with the cone beam. Now, granted they might just be comfortable doing it just under fluoro. That's really fine too. Again, I haven't looked at the difference in radiation, but to me, it's faster in CT, just the setup and everything. Pretty fast. It's pretty fast. I imagine that's just a number of reps, right? If I started doing it in fluoro, I'd probably be just as fast.

[Dr. Chris Beck]
I think that it's just a fast procedure in general. That being said, so this gets into-- well, I don't want to jump too far ahead, but I'm interested to see how you do them and like how many CT pictures you're taking and how many fluoro pictures you take if you do fluoro.

[Dr. Aaron Fritts]
Let's talk a little bit about the needles on the market, because when we first discussed this on episode one, we were talking about Jamshidi versus the OnControl. I know that you switched to the OnControl, which has been-- that was six years ago. It's pretty much dominated I think the market. Once everybody got it in their hands, they realized, okay, this is taking better samples. This is not sponsored by Teleflex or OnControl, but I still love that needle.

[Dr. Chris Beck]
We should send this to Teleflex or OnControl. Maybe they would sponsor.

[Dr. Aaron Fritts]
Look, I bring it up because there's actually a competitor out there now in terms of powered versus non-powered. When we talk about Jamshidi or the SnareCoil, which is, I think, Mermaid Medical now. Some of these other ones that you just brute force. Those don't use a drill or a power drill, and those are non-powered, right? I don't know anybody still using those, at least in my group or people I talk to. I feel like Jamshidi, it's cheap, that's good. Maybe it probably is still around at small community hospitals who don't want to invest in the powered. I feel like once pathologists, interventional radiologists, and even diagnostic radiologists got their hands on OnControl, saw what great samples it takes. I think the conversion's been pretty widespread.

BD, who actually makes the Jamshidi, just came out with their own powered version. It's called the Trek. It's very similar to the OnControl. I got to try it on like a sample bone,. The sales rep came by. It feels just like OnControl. I don't know if there's any real advantages over OnControl other than maybe it's price. I don't know. Just to let everybody know, like there's another version by BD in addition to Teleflex. These needles are crazy sharp. That's the other thing that I do with that pre-procedure imaging. Is I look at what the bones look like. If it's a young patient, they're 25, and their bones are dense, I'm definitely going to be using the drill, because that does improve the patient experience. Don't you think?

[Dr. Chris Beck]
I don't know. Maybe a little. Maybe a little.

[Dr. Aaron Fritts]
Because it just makes it faster. You're not like grinding that bone in. It's just like vshoom, and it's much faster. Now, that can have an effect if the patient hears that drill. That's the challenging part, and that's why I use it sparingly, because them hearing that drill can because some anxiety.

[Dr. Chris Beck]
Okay. Let me talk a little bit about that. I've been a convert, like I was using the Jamshidi system, and now I use the OnControl and the drill. I think both of them still very much get the job done. One of the main reasons I switched over, was I getting a better sample? Maybe a little bit better. That's hard to deny, I think the samples were better for me with the OnControl. At the same time the Jamshidi samples were totally adequate. It's like, okay, you're getting a better sample, but does that really move the needle? You're getting good samples out of both, at least in my experience.

A couple of the reasons I like the OnControl better is, or like a powered system better, it's just way more fun, like drilling, and I use the drill 100% of the time. I just find for me, the drill was just a more fun way to do the procedure, it almost just spice it up a little bit. I'm a power tool guy, and so I got that drill and I just gravitated towards it immediately. What I would say is like the Jamshidi was still getting the job done, and I wasn't unsatisfied with it. It's just a lot more fun to using the drill. There are some patients, like I found younger patients with sclerotic bone diseases, like mastocytosis or something, it's very nice to have that drill to get a nice sample like that. That's such a small percentage of patients, but at the same time, it was nice to have that in my back pocket.

I know I've read on the SIR forum about how people are-- You have a strong right arm, and you can get the Jamshidi everywhere. I don't necessarily disagree with that, but for me, what I would rather-- and I'm a hobbyist woodworker by nature, and so like I think it's slightly dangerous, and I want to preface that, in different hands. I don't like using a lot of my force to grind a needle into an iliac bone. To me, like if that slips off, that's whenever you can have like a major problem where like that needle goes somewhere you're not expecting it to go.

[Dr. Aaron Fritts]
Right, or breaks.

[Dr. Chris Beck]
Yes, or it breaks off. For me, I feel very in control with the drill. I can just apply a little bit of forward pressure and it still drills through that bone. When I was using the Jamshidi, I was very much a fan of the mallet. I think a mallet is a way to deliver a lot of controlled taps into a bone. That's like the woodworker in me. You don't want to be leaning your body weight on this stuff. That to me is like you're creating a bad situation. A nice mallet with the Jamshidi I think still gets the job done.

[Dr. Aaron Fritts]
Yes. I totally agree with you. To go back to me, the most significant update was the sharpness of the needle and the robustness that really allowed for-- Even if you're applying your own force, it made it less force. That's why for that control with the demineralization, because what worries me, and is exactly in the same lines of what you're just saying, is when you get those little old ladies that are demineralized, who their pelvic bone is not terribly big to begin with, they're demineralized. That's when the power tool to me is a little bit scary. I just use my own gentle force to get it in.

For me, it's all about patient selection in terms of whether or not I'm going to. I use the exact same needle. The OnControl needle is fantastic.

[Dr. Chris Beck]
It's a sharp needle.

[Dr. Aaron Fritts]
It's a very sharp needle.

[Dr. Chris Beck]
It's a good needle.

[Dr. Aaron Fritts]
Whether you use the drill or not, it takes very good samples, robust samples. The other thing that I found compared to the Jamshidi, I may have mentioned this on the first one, was, I just found myself having to go in less. Like, I only have to go in once. That's it. Whereas with the Jamshidi, sometimes the sample or the SnareCoil sometimes would be really bad. I'd have to go in two or three times because what I would get out, the cytotech would look at it and be like, this isn't enough. Can you go in again? That to me is super frustrating when a procedure that should be 5 minutes ends up being 10, 15 minutes long. That to me is the advantage. I imagine the BD Trek is very similar. I may get to try it depending on, if one of these hospitals gets it in. That's why I'm a fan of these newer needles. I'm glad that they've evolved and updated over time.

[Dr. Chris Beck]
I agree. I'm a fan of the OnControl. I don't fault people for wanting to use like a manual system at all. I was using that for a long time, and I still think I got me totally adequate results. Just given the option, for me, it's way more fun. Even in osteoporotic patients, I don't find the power drill component of it. It's all about the forward pressure. For me, I just really dial back that forward pressure. Even though the drill is spinning, without the forward pressure, it's not going to go any, or at least in my hands, I feel like it's not going anywhere I don't want it to go. I feel very comfortable with it.

I agree, it gives you very nice samples. I think it is a little bit less fussy in terms of positioning, like getting an aspirate back. That has also been an experience that I've had between the Jamshidi and the OnControl. I've also used the OnControl needle to-- This is a little bit off topic, but like sometimes like there's a lymph node, like a retroperitoneal lymph node or like a pre-sternal lesion that like you can get to it a couple different ways, but I've actually drilled through bone on both ends. I'll drill cortex to cortex to go through a bone. Then like I use that as like an introducer to get like my BioPince or whatever, like Temno needle to like the target location.

[Dr. Aaron Fritts]
That's fantastic, man. That's a great tip.

[Dr. Chris Beck]
It's something. Depending on where you are, like people have probably heard me mention the sternum and this probably like makes it a little bit queasy, depending on how people feel about mediastinal biopsies. I feel in controlled hands, very patient selection, sometimes that can be a safe way to get to where you want to go.

[Dr. Aaron Fritts]
Yes. If you have like a pelvic node, that's like an obturator node or something.

[Dr. Chris Beck]
Yes, exactly.

[Dr. Aaron Fritts]
Yes. That's interesting.

[Dr. Chris Beck]
If you have to like-- I don't know if you've ever had like those psoas abscesses that are difficult to get to. I'm not saying you're going to put a drill through or you're going to like put a drain through this or anything. You've just got to get a couple CCs or a sample for like cultures or something. You said that.

[Dr. Aaron Fritts]
That would be incredible to have a drain through that.

[Dr. Chris Beck]
Yes. Right.

[Dr. Aaron Fritts]
Oh my God. Don't do that folks. Please don't do that. Because I can imagine it-

[Dr. Chris Beck]
Yes, don't do that.

[Dr. Aaron Fritts]
-it snapping off.

[Dr. Chris Beck]
Somebody will do it.

[Dr. Aaron Fritts]
Yes.