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BackTable / MSK / Article
Bone Marrow Biopsy Sample Prep, Complications & Post-Procedure Care
Sara Stewart • Updated May 12, 2024 • 84 hits
Image-guided bone marrow biopsy, while a relatively basic procedure in interventional radiology, can be optimized for efficiency and effectiveness with the proper preparation.
This article provides essential insights into effective communication with cytotechnologists and adherence to standardized bone marrow biopsy sample protocols, citing the experiences of Dr. Aaron Fritts and Dr. Christopher Beck. It also covers potential bone marrow biopsy complications and emphasizes the importance of proper technique and awareness of anatomical structures. Finally, the doctors share their post-procedural considerations, including sedation management and discharge protocols, offering strategies to optimize efficiency in the procedure room through coordinated teamwork.
This article features excerpts from the BackTable MSK Podcast. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.
The BackTable MSK Brief
• Effective communication with the cytotechnologist is paramount for a successful bone marrow biopsy, as standard procedures for sample preparation may vary and need confirmation before the procedure.
• A bone marrow biopsy sample typically consists of three components: a non-heparinized blood aspirate, a heparinized blood aspirate, and a bone sample, with a goal volume of 5cc to 10cc for creating the necessary smears for pathology.
• During the procedure, interventional radiologists must be vigilant for potential complications such as dry taps. Techniques like needle repositioning or attempting the procedure on the opposite side may aid in obtaining samples, while avoiding complications such as inadvertent entry into the sacroiliac joint or pelvis.
• Post-procedurally, complete recovery from sedation is crucial before patient discharge. While the biopsy itself does not delay discharge, sedation prolongs post-procedural monitoring. Immediate discharge is feasible for patients managed solely with local anesthetic.
• To optimize efficiency and minimize post-procedural observation time, it is essential to have a well-coordinated support team of technologists and nurses. Their roles include properly positioning the patient, obtaining pre-procedure CT scans, selecting the entry site, and preparing the lidocaine before the interventional radiologist enters the room.
Table of Contents
(1) Bone Marrow Biopsy Sample Preparation
(2) Pitfalls & Potential Bone Marrow Biopsy Complications
(3) Bone Marrow Biopsy Post-Procedure Care
Bone Marrow Biopsy Sample Preparation
Effective communication with the cytotechnologist is crucial for ensuring a successful bone marrow biopsy procedure. Standard protocols for sample preparation exist in most hospitals, yet it is essential to confirm these protocols with the recipient cytotechnologist beforehand. Typically, a bone marrow biopsy sample comprises three parts: a non-heparinized blood aspirate, a heparinized blood aspirate, and a bone sample. For the aspirates, varying volumes may be required, but a goal of 5cc to 10cc is usually enough to create the smears needed for pathology.
[Dr. Aaron Fritts]
I think that is a good tip. You've talked to the patient, you got them consented, they're ready to go. You got them on the table. You did the timeout, giving them some Benadryl. I usually start with 1 and 50, and then 25 of fentanyl, and then one of versed and 50, depending on the size of the patient. If it's a big patient, I'll start with 2 and 50, especially since they're prone. Then I always check with the cytotech because at our, at our hospital-- I'm rotating different hospitals. I think you do too. You probably know the cytotechs really well because you're at a lot of the same hospitals.
It seems like even post-COVID there has been a lot of turnover. I always want to make sure that I'm getting what they need instead of assuming what they need. Because some places they'll be like, "Oh, yes, I just need two of a non-heparinized aspirated blood, and then give me 10 with the heparin. Then others, they're like 1 in 5. I always ask them ahead of time. I don't know if that's something that you have to deal with.
[Dr. Chris Beck]
I think we have a pretty steady stable of cytotechs, so I know what they need, but I think that's a good idea. For some reason, if I didn't recognize the cytotech, then I would definitely check with them ahead of time. We have a standard operating procedure and I just assume that's the case unless they said otherwise.
[Dr. Aaron Fritts]
That's good. For anybody who's new to this out there who's maybe never done this before and they're listening to this before they do it. One, the reason I mentioned that is because for every procedure, what they need is usually an aspirate. One, some volume of aspirate of blood, once you get the needle in that's non-heparinized and then some volume of blood that is heparinized. Then you need the actual bone marrow biopsy sample itself, the actual bone. Those are like the three components of your sample. Right?
[Dr. Chris Beck]
Agreed. Years ago, we actually gave up doing the heparinized aspirate. It was per pathology. This is one of those procedures where I take a lot of advice and guidance from my colleagues. If pathology tells me they need heparinized, non-heparinized, whatever, I'm like, sure, whatever you want. I don't question it. Now we just do two aspirates. Whatever they need. We do two aspirates, but non-heparinized.
[Dr. Aaron Fritts]
Those are for the smears, right?
[Dr. Chris Beck]
Yes, exactly.
[Dr. Aaron Fritts]
I guess they just need enough to make five or six smears. I guess it just depends on the cytotech, how much volume they like.
[Dr. Chris Beck]
Mine's usually between like 5cc and 10cc. I've definitely read on the SIR forum some people have really gotten deep into the weeds on this. They're very specific with all the amounts that they need. For me, if it's free-flowing and I'm just getting like-- I can get whatever I want. I usually do between 5 and 10 CCs to two syringes and give that over the cytotech. Now, sometimes whenever you're doing the bone marrow biopsy, people's aspirate can be a little stingy. I think what's important though, is you don't spend 20 minutes trying to get to 5 CCs. You want to get it out of the bone into the syringe and into the hands of the cytotech pretty quickly.
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Pitfalls & Potential Bone Marrow Biopsy Complications
During a bone marrow biopsy procedure, interventional radiologists must be aware of potential complications. While infrequent, one complication is a dry tap, particularly observed in patients with densely sclerotic bones or significant metastatic disease. Repositioning the needle or attempting the procedure on the opposite side may aid in obtaining a sample. Other complications include inadvertently entering the sacroiliac (SI) joint, leading to pain or bleeding, and the most severe, drilling into the pelvis. These scenarios underscore the importance of proper technique and awareness of adjacent anatomical structures during the procedure.
[Dr. Chris Beck]
I wanted to back up and talk about real quick. What do you do in terms of when you get a dry tap?
[Dr. Aaron Fritts]
Then I have a conversation with the cytotech. It totally happens. If I get a dry tap, I just say, "Hey, look, I'm going to go ahead and get the bone marrow sample." I get the bone marrow sample. Then sometimes they're just-- And then I might just go a little bit deeper. That's where you have to reimagine and be like, "Okay, where am I?"
[Dr. Chris Beck]
Sure. Sure. Make sure you're really, really in the right spot.
[Dr. Aaron Fritts]
Make sure you're really in the right spot. I might try and go deeper. Then what sometimes I'll do is I'll come back and I'll re angle it and just try and maybe just get a different angle because for whatever reason I'm in a dry area. Sometimes it's when it's dry right down the middle. If you go along the inner assert of the cortex, you don't want to collect cortex, but you want to get just deep to the cortex. Sometimes that's a little bit-- you can get an aspirate there. It's really just re-angling, maybe going deeper. Usually that's the case. Then I just try and get as much out as I can. If it's one CC or two CC, a lot of times they cytotech is like, "Hey, we got what we got."
[Dr. Chris Beck]
Absolutely. If you get one or two CCs, and sometimes it's, I was going to say blood from a stone, blood from a bone in this situation. For us, and I think my partners handle it differently, but I agree with you. I like a little bit of like needle repositioning. Sometimes you can tell, like there's some bones that are like densely sclerotic that you have like an idea ahead of time that this could be potentially a dry tap, but I'll take that biopsy. You take the actual biopsy without the aspirate. I think our pathologist has always asked us to get two cores.
I'll do a core from the right. Then I'll also take a core from the left and try and aspirate from like the different iliac bone. I'll just tell people that I've never had a situation in which I was not able to get one from the right and then I was able to get it from the left. I always thought like, you know, maybe trying something different, who knows maybe. I've never had a situation where it actually yielded me some aspirate. That's what I do. I always think like you've tried everything at that point.
[Dr. Aaron Fritts]
A dry has only happened to me maybe twice in the last like eight, nine years.
[Dr. Chris Beck]
That's it?
[Dr. Aaron Fritts]
Yes. Not very often. Very rare.
[Dr. Chris Beck] That's pretty good.
[Dr. Aaron Fritts]
Yes. That's actually a great thing to do, is just go to the other side.
[Dr. Chris Beck]
Because I can take an inside to outside approach. I basically go from midline lateral. It's not all that hard. Sometimes like you're bringing the needle towards you and that's not always ideal.
[Dr. Aaron Fritts]
It's uncomfortable.
[Dr. Chris Beck]
Yes, it's a little bit uncomfortable, but it's still very doable. Especially if you've got the drill.
[Dr. Aaron Fritts]
No problem. There's some people in my group that that's how they do their bone marrows, like angled towards them. I'm always like, that's just so weird.
[Dr. Chris Beck]
Bizarre.
[Dr. Aaron Fritts]
Yes. It's bizarre. Those listening, you know who you are.
[Dr. Chris Beck]
Yes.
[Dr. Aaron Fritts]
I'm just letting you know, that is weird to me. Why you would go?
[Dr. Chris Beck] Totally agree.
[Dr. Aaron Fritts]
Anyway, Okay. Great point. Never had. That's, I guess, a pseudo complication is just not getting sample.
[Dr. Chris Beck]
I don't know. To me, this just can happen. Especially if you have densely sclerotic bones, sometimes you'll-- I don't know, for some reason, I think I'd one time did this. I had a dry tap on a patient who was diffusely ridden with metastatic disease, like sclerotic metastatic disease. I think I had a dry tap. I've probably had, just a little bit under double digits. I would say like 8 to 10 in a eight year career. Not common, but it was common enough to where like I have an approach for it.
[Dr. Aaron Fritts]
You know what I just realized? When we were talking about the angle, we didn't really talk about what side we stand on and where we go. If the patient is prone, I'm standing on their left side and I'm going into the right posterior iliac spine. That's just like my standard. Unless I see something on the CT they've had like a prior bone harvest.
[Dr. Chris Beck]
Totally agree.
[Dr. Aaron Fritts]
Bone graft.
[Dr. Chris Beck]
If they've bone graft harvested.
[Dr. Aaron Fritts]
If they've been harvested for bone graft before, they might have a chunk missing or something like that, or one side is super demineralized, the other one is all right. Or like you said, if it's metastatic disease or something like that, one side looks better than the other, and then I decide. If it's just a run-of-the-mill standard anemia bone marrow biopsy, I'm staying on the left, going to the right. That's what we were talking about. Some people will stand on the left and go into the left so that they're angling towards them.
[Dr. Chris Beck]
Towards them?
[Dr. Aaron Fritts]
Yes.
[Dr. Chris Beck]
I'm sure if I did enough like that I would get used to it, but that just feels like exactly the opposite of what I want to do.
[Dr. Aaron Fritts]
Yes. Especially if you're grinding manually, that's ergonomically awkward.
[Dr. Chris Beck]
It's a terrible way to do things.
[Dr. Aaron Fritts]
Okay. Anyway. All right. Any other complications? Look, you could slip into the SI joint which might cause some pain. It's pretty benign procedure. You could have excessive bleeding afterwards but you just hold pressure. Anything else that could go awry with a bone marrow biopsy that you can think of?
[Dr. Chris Beck]
Yes. I think like you named it. I think you can get into the SI joint. Maybe you can get into the sacral foramina. I think the worst thing that you can do is blow through some bone, some osteoporotic bone, and then end up in the pelvis.
[Dr. Aaron Fritts]
You should be pretty reckless.
[Dr. Chris Beck]
I think that’s the doomsday scenario for this. I know with my approach, I'm pretty, I wouldn't say aggressive, but I consider my safe zone the lateral side, but in the back of my mind you know that there's some arteries that live back there that you could tag. I just think of adjacent structures. You're pretty good but you have some arteries in there. You have some neural foraminal around the sacrum. Then the real bad one I think is you blow through osteoporotic bone and then you're in the pelvis, and that is a terrible area to be in with a lot of high value real estate.
Bone Marrow Biopsy Post-Procedure Care
Following a bone marrow biopsy procedure, several steps must be taken before the patient can be discharged. The most crucial step is ensuring complete recovery from sedation before release, with the duration varying based on individual patient response and the level of sedation administered. While the biopsy itself does not delay discharge, sedation prolongs post-procedural monitoring. For patients managed solely with local anesthetic, immediate discharge is feasible. To expedite the procedure and minimize post-procedural observation time, it is important to have an excellent support team of technologists and nurses who properly position the patient, obtain pre-procedure CT scan, select the entry site, and prepare the lidocaine before the interventional radiologist enters the room.
[Dr. Aaron Fritts]
The procedure is over, you got a good sample, no complications. What's your post-procedure care when you send them?
[Dr. Chris Beck]
We keep them for just about an hour, but basically as soon as the anesthesia wears off, we get them out the door. Some people that's quicker than others, and some people it holds on a little bit longer. Just as long as it takes them to meet the nursing criteria for our standard modern sedation, then they can leave. What I stress to people, it's not the bone marrow biopsy that keeps you here. If we just did the bone marrow biopsy, I think I'd turn them loose right out the door. The people who use local, we just let them go. If you have moderate sedation, then we hold onto you just until you meet our standard criteria. Which I don't know off the top of my head, but basically it's they're seeing assessment and they're like, "All right, you can go."
I think about how to do the fastest bone marrow biopsy. Okay. This has gotten me to where this is as streamlined as we ever got our system. This is before I'm in the room. The patient is prone, the grid is on. The CT tech will scan the patient, your pre-scan is done. I have the CT tech, and you have to work with these CT techs a lot. They will take the grid off. They will mark the patient up the expected area that I'm going to go. They'll pick the entry site, and they show it to me. I walk in, they show it to me. If they're a little bit off by a centimeter, I don't remark it, I'm just like, "All right. I might start a little bit more lateral ,or I might start a little bit more medial."
CT techs, they see us do these all the time. It's not beyond them to find a nice trajectory. Then the tray is already out, the lidocaine is already drawn up, and it's boom, boom, boom. Then I just do that one scan, which I'm not even in the room for. Then the bone marrow biopsy, it can be under five minutes, just two or three minutes.
Podcast Contributors
Dr. Christopher Beck
Dr. Chris Beck is a practicing interventional radiologist with Regional Radiology Group in New Orleans.
Dr. Aaron Fritts
Dr. Aaron Fritts is a Co-Founder of BackTable and a practicing interventional radiologist in Dallas, Texas.
Cite This Podcast
BackTable, LLC (Producer). (2024, January 17). Ep. 39 – Bone Marrow Biopsy Tools & Techniques [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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