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BackTable / MSK / Podcast / Transcript #39
Podcast Transcript: Bone Marrow Biopsy Tools & Techniques
with Dr. Christopher Beck
In this episode of the Back Table MSK podcast, co-hosts and interventional radiologists Dr. Aaron Fritts and Dr. Chris Beck have an in-depth discussion about bone marrow biopsies, including their preferred techniques and devices, potential complications, and management of patient expectations. You can read the full transcript below and listen to this episode here on BackTable.com.
Table of Contents
(1) Bone Marrow Biopsy Indications
(2) Discussing Bone Marrow Biopsy with the Patient
(3) Communicating with the Cytotechnologist & Preparing the Sample
(4) CT-Guided vs. Fluoroscopic-Guided Bone Marrow Biopsy
(5) CT-Guided Bone Marrow Biopsy: Step-by-Step Guide
(6) Choosing Your Biopsy Needle: Powered vs. Non-Powered Approaches
(7) Bone Marrow Biopsy Potential Pitfalls & Complications
(8) Bone Marrow Biopsy Post-Procedure Care
(9) Sedation Pearls for Bone Marrow Biopsy
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[Dr. Aaron Fritts]
Hello, everyone, and welcome to The BackTable MSK Podcast. Your source for all things musculoskeletal. You can find all previous episodes of our show on Spotify, Apple Podcasts, and on BackTable.com.
Today, I've got another special episode. These are some of my favorites. Just me and Dr. Chris Beck geeking out on basic topics. Those of you who may remember, we've covered even going back to episode one. Actually, this was episode one.
[Dr. Chris Beck]
This was episode one. Exactly.
[Dr. Aaron Fritts]
- Of BackTable was bone marrow biopsies. We are going to do a redux, a part two, I guess, or an evolution over the last five years. That was 2017, so it's six years.
[Dr. Chris Beck]
Yes, well, definitely needed. To go back and listen to episode one, it's a little bit painful. I'd rather just rerecord something about bone marrow biopsies.
[Dr. Aaron Fritts]
Please do not go back and listen to that episode. In fact, we need to strip it from the record.
[Dr. Chris Beck]
Yes. Also, I'll say, I feel like I've changed my tune a little bit about bone marrow biopsies. Happy to re-state.
[Dr. Aaron Fritts]
Exactly. I'm excited to hear about that. Also, I don't think we did this on the first one, which was just walking through how you do the procedure. We were mostly at that time focused on the actual device aspect and the pros and cons. That's the way we did things in the beginning. We do want to get more procedural information out there for people who, for example, and I think I said this on the very first episode. I didn't do one bone marrow biopsy until I started practice. Not one, in training, in residency, in fellowship.
Then day one of practice, of course, there's like three of them on the schedule. One of the more senior partners in the practice was like, come on, let me show you. See one, do one, teach one, was the principle back then. I don't think we can get away with that anymore. I think you have to be proctored a little bit more on even the basic stuff, right? This is about as basic as it gets. Other than maybe a thyroid nodule biopsy. What do you think?
[Dr. Chris Beck]
I think this is more basic than a thyroid nodule biopsy. I think this is the bottom of the talent stack of IR.
[Dr. Aaron Fritts]
Maybe that's why it's my favorite. It's so mindless.
[Dr. Chris Beck]
To me, this is as mindless as it gets.
[Dr. Aaron Fritts]
Yes. I get so excited to get a nice big chunk of bone out. That, I think, is the game. That's winning the game. You just get a nice big piece robust sample that's got mealworm.
[Dr. Chris Beck]
Reluctantly, I have to say, that's a little bit satisfying, to drive down, get a really nice core.
[Dr. Aaron Fritts]
You get that ooh from the cytotech where they're like, oh, that's better than your partner.
[Dr. Chris Beck]
This is true. This is true. Yes.
(1) Bone Marrow Biopsy Indications
[Dr. Aaron Fritts]
Anyway, let's jump into it. First off, Dr. Chris Beck, why are we doing this? What's the most common indications that come across our plate when we're getting a consult to do a bone marrow biopsy?
[Dr. Chris Beck]
For me, in my practice, it's anemia. A majority of our bone marrow biopsies are outpatient. Not that we don't have some inpatients, but it's usually an anemia workup. Honestly, I know there's a big drive to make interventionalists more clinical, and I totally agree with that. This is not one of the spaces in which I really thrive in terms of knowing all the ins and outs. Basically, if the oncologist refers me a patient for a bone marrow biopsy, I'm going to do the bone marrow biopsy.
I don't see these patients in clinic beforehand. I don't see them afterwards. These are just like one-off procedures where I'm very much like a technician. Although I do look at the indication, I want to make sure that jives with why the patient is being referred over. Most commonly, I see some form of anemias or leukemia lymphoma workups.
[Dr. Aaron Fritts]
Yes, or like thrombocytopenia, something hematologic. The hematologic abnormality or concern for hematologic malignancy, and we're just obtaining hematopoietic cells basically from the source. I guess rarely, I think, that we've gotten it for stem cells for the purpose of tissue reconstruction, but that's very few and far between.
[Dr. Chris Beck]
I've never done that. If I'm doing that, I don't even. What they put on the referral sheet sometimes isn't always what they're working up, but I've never seen like obtain stem cells.
[Dr. Aaron Fritts]
You're right. I've known friends and relatives who've had it done for that reason.
[Dr. Chris Beck]
Cool.
[Dr. Aaron Fritts]
For me, it's more like, just like you said, anemia, workup for leukemia lymphoma sort of thing. Most often coming from the Hemonc docs for the most part.
[Dr. Chris Beck]
I think all mine are from Hemonc. I can't think of-- maybe nephrology every now and then. Maybe nephrology. Maybe.
(2) Discussing Bone Marrow Biopsy with the Patient
[Dr. Aaron Fritts]
Yes, they're working up some sort of systemic process, right? Okay. Then where are you most? Before we get into where, let's talk about what's the conversation like with the patient because you'll see the patient. Usually, they're waiting outside the CT or they're waiting outside. Rarely you have to maybe go up and talk to them, the family before, or especially when they're outpatient, you go talk to them in the waiting room to get consent. What's that conversation like?
[Dr. Chris Beck]
One, it just seems like such a terrible setup to have to go talk to the patients out in the waiting room. Is that where you have to talk to your patients?
[Dr. Aaron Fritts]
Sometimes. When it's an outpatient. There's a rule at one of our hospitals where, if they're getting sedation, you have to see them in their pre-op waiting area.
[Dr. Chris Beck]
Oh, okay. It's like a pre-op area, like there's a bay or something.
[Dr. Aaron Fritts]
Pre-op. Yes, it's a bay. Exactly. Yes.
[Dr. Chris Beck]
Okay. Nevermind. That seems okay.
[Dr. Aaron Fritts]
It used to be, they just wheel them back and talk to them right at the bed, before they jump on the table. A lot of that's changed now. They want to make sure that they're properly talked to, all questions are answered. It's not like a speedy, get them on the table and get them done.
[Dr. Chris Beck]
I actually like that. I like that. I was thinking for some reason you're out in the waiting area, where before they get called in. You have, a dedicated area where they're on the monitor or something, or a nurse has already seen them.
[Dr. Aaron Fritts]
Yes. These are pretty much 100% of the time getting sedation in my practice.
[Dr. Chris Beck]
Same. We also see them back, I think we just call it, pre-op holding. I'll go do a brief H&P, and I'm just checking for labs, sedation, basically risk stratification for sedation, which we also use sedation, not always, but maybe 90% of the cases and checking for allergies. Just a basic, very standard H&P and a brief physical exam. The conversation that informs consent is what takes up the majority of the time. What I really try and do is briefly talk about the risks. I think the risks are low, so I don't want to oversell it, but I do give a nice informed consent.
Then I spend a fair amount of time talking about the sedation and just managing expectations about what that's like, only because, at least in my experience, that there are certain patients that are expecting, zero pain. Sometimes that can be a little bit difficult due to the speed of this procedure. You don't have all the time in the world to get the anesthetic on board to where it's an absolutely painless, you're totally out procedure. I just do a little bit of expectation management in that regard. A lot of the conversation, a little bit of-- not a little bit. Full informed consent, brief, but then a lot of time talking about, how this procedure is going to feel, how it's going to go, how much time it's going to take, and recovery afterwards.
[Dr. Aaron Fritts]
Totally agree. I think that is the key. A key piece of doing this procedure is managing those expectations, because some people think, oh, I'm getting anesthesia, I'm going to be out, I'm not going to feel any pain. You're exactly right. That's why I tell the patient, I say, "Look, the advantage of doing this here with us and not in the office with the Hemonc doc is that you're going to get sedation. Which means that you're going to be much more comfortable than just local anesthetic in the office." Because that's the way they do them. That's the way they do them in the office.
They might give them a little bit of an anxiolytic, but that's it. They're not doing sedation in the office. What I like to tell them is, hey, show them where we're going. You can feel that big posterior iliac spine in the back. I said, "That's a nice big chunk of bone, and it's very superficial so we can get to it easily, but we do use imaging guidance, right? That helps speed things along. Because of how fast the procedure is, it is challenging to get you completely asleep. The goal is for you to just feel pressure. If you can feel pressure while we're doing the procedure, you'll hear us talking, but before you know it, we'll be done and we'll be getting you back in your room." I think that people like that. It's like offering one thing over another. It's like, "Okay, I'm not going to be fully asleep, but at least it's fast and I'll be getting out of here fast." They seem to like that.
[Dr. Chris Beck]
You must be just a better negotiator of people than me. I feel like in my practice, we're a little bit teed up for failure, and that the oncologists almost universally tell the patients that they were going to be completely asleep. Also because like in where I'm at, in the suburbs of New Orleans, a majority of these are still done by oncology and maybe some pathologists who aren't using sedation. There's this small referral of oncologists who were like, "Oh, you don't want to have it. You want it to be painless. Here, let me send you to interventional radiology where they're going to put you to sleep." These patients come with an expectation that it's going to be lights out.
I just find that that's a little bit hard to unwind. I do my best. I think these patients, ultimately just want to get this biopsy and move on. There's a fair amount of conversation around that. I really do. We try to get on top of it. I'll sometimes give a cocktail pre-procedurally. I'm sure you have a cocktail too, which you use for like the pre-op holding area for some super anxious patients.
[Dr. Aaron Fritts]
Yes. It's called Benadryl.
[Dr. Chris Beck]
Yes. I do that.
[Dr. Aaron Fritts]
I like to make them sleepy with the Benadryl. We talked about that one with Vishal, another episode I recommend people go and listen to, because we're talking about a lot of the same things.
[Dr. Chris Beck]
Right. Yes, exactly.
[Dr. Aaron Fritts]
Throw a little Benadryl in there, and a lot of times, they do just fall asleep, and then they just wake up when you're getting that core, and they're like, "Oh, okay, well that wasn't that bad."
[Dr. Chris Beck]
Yes. I like the Benadryl, Ativan/Valium and Zofran combo.
[Dr. Aaron Fritts]
Okay. Yes. Zofran is always good too. Right. Yes, man, I think that is one of the most challenging parts of it. Because it's technically-- we're going to talk through that technically. It's not a very challenging procedure. It depends on what tool you're using, but in terms of getting a good sample. The pain thing, I think, is key. What's nice, what you were just talking about is how sometimes these patients have already had one done in the office, and they have that to compare to. That's fantastic, because then you're like, "Well, this is going to be better than that. I can guarantee that."
[Dr. Chris Beck]
Yes, exactly. This is better than that. Yes. Exactly.
[Dr. Aaron Fritts]
That usually makes them happy. Even if they were expecting to be lights out, it's just like, look, I can make you lights out, but that's going to keep you here another hour afterwards. What would you rather?
[Dr. Chris Beck]
If I could make people lights out, I would. It's not that I don't have the patience to do it, but I just found that the hardest patients to get to fall asleep are the patients who want to be asleep and are very, very wound up about it. That's just my experience in my patient population. Those are the patients that tend to fight it, and they're like, they'll keep telling you, they're like, "I'm not asleep. I'm not asleep. I'm not asleep." We do a lot of tricks.
Sometimes I'll do what's called the silent procedure, where there's minimal talking throughout the staff. Just like, there's no external stimuli for them to anchor onto. We'll put a washcloth over their eyes, dim the lights, like a lot of things. Try and keep the room very quiet and subdued. Sometimes that works. These are all just little anesthesia tricks.
[Dr. Aaron Fritts]
That's a good idea. I go the opposite sometimes where I'm like, look, "I'm here, I'm going to talk you through every step. I'm going to let you know when you can expect a sting and when--." That way there's no surprises, because they are face down, remember. That adds some anxiety. You're right, I try to minimize chat, like people talking about what they're going to have for lunch or stuff like that.
[Dr. Chris Beck]
Exactly. Yes.
[Dr. Aaron Fritts]
I think that walking them through it, being like, " Here, I'm putting the light away now." "Okay. Here, you're going to feel some pressure here." That to me seems to help a little bit if they are still awake.
[Dr. Chris Beck]
I think you're right. I think there's some patients-- I'll just say that there's some patients that want to hear it, and there's some patients that don't, but I agree with you. I think there's definitely some patients, as long as you're talking them through it, and they know all this is expected, then they're very okay with that. Absolutely.
[Dr. Aaron Fritts]
They just want things to go as expected. According to plan.
[Dr. Chris Beck]
You're exactly right. For sure.
(3) Communicating with the Cytotechnologist & Preparing the Sample
[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.
(4) CT-Guided vs. Fluoroscopic-Guided Bone Marrow Biopsy
[Dr. Aaron Fritts]
Perfect. For the audience, I didn't mean to jump ahead. 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.
(5) CT-Guided Bone Marrow Biopsy: Step-by-Step Guide
[Dr. Aaron Fritts]
Let's proceed with this doing under CT, because that's what you and I do. I think it's probably what most people do. The needle placement is the same. It's just like, how are you confirming your position with imaging? Walk through your CT guided bone marrow biopsy.
[Dr. Chris Beck]
Patients are prone, although they don't have to be prone. I will say that, it's not unreasonable to do a patient supine, and you can come at a different angle to the iliac crest. It's, I think, a little bit more challenging. I think you have more real estate to land that needle from prone position. I go prone. I usually go from inside to outside. I'm like the needle follows along the trajectory of the iliac crest. I'll numb the patients up. This is something I do that I think like helps me, one, keep my patients more comfortable, and two, gives me a feel for where that iliac crest is.
Basically, I do one CT picture-- not one CT picture, but one scan with the grid on. Then I mark my positioning on the skin and numb that up. Then also we'll use a 22 spinal needle to basically walk that spinal needle along the cortex and numb that cortex really well. Use a lot of lidocaine for this. Also what I'll do is, I'll walk that spinal needle off the lateral edge of the iliac crest. I'm like, all right, that's a safe area, because lateral, you're just in soft tissue. I have a good idea of the trajectory from the 22 gauge spinal needle. Then dermatotomy. Then, with your biopsy device, I go in and land it on the cortex.
I don't just go right in and, all right, I'm there. I'll walk it along the edge there and try and find where it slips off the edge. I'm like, all right, that's too lateral. Then I walk it back medial, and then I'll seat it. I'm actually not taking additional pictures after that. I'll seat it. Then I use the OnControl, the drill. I'll drill it in, take my aspirates, boom, take my bone marrow core, and then I come out. I don't actually get a CT picture with the needle, with the Jamshidi or the OnControl or whatever bone marrow biopsy device. I don't ever actually have that confirmation picture. I do just that one pre-picture and that's it.
[Dr. Aaron Fritts]
That's great. It was ingrained in me at some point early on that you should always have-- Like if you're doing a biopsy or something where somebody could question whether or not you were actually in a lesion, to always have that confirmatory picture. That goes more for, I think, lesions than a bone marrow biopsy. I don't think anybody's going to-- Look, it was like your pathology was saying, but the lesion's not in the biopsy, right? Is that what he was saying? I know the needle is in the lesion, but the lesion is not in the needle.
[Dr. Chris Beck]
Exactly, yes. In reference to when I was interviewing a pathologist, like an old episode.
[Dr. Aaron Fritts]
That episode is coming out soon so people can catch that. That is so true. It doesn't really matter what your image shows, because if there's not adequate tissue, that's game over. You got to do it over again.
[Dr. Chris Beck]
Exactly. What I will say is, I think it is absolutely solid IR advice that you need to-- Especially when it's targeted lesions or really like basically everything that we do except bone marrow biopsies. My advice to trainees, younger IRs, older IRs or anybody is like, you need to have a picture of you in the lesion or within very much striking distance. That is my standard operating procedure. I do pre-pictures. I have pictures leading up to the biopsy, like as the needle is inching along. I usually have one or two seated in it. Then, a post-picture. That for me, goes out the window with bone marrow biopsies, just because it's like, okay, I know I'm in bone. I don't know. It's just silly to think like, what else would you be in? You can feel that you're in the bone, and then you're getting a bone out. That's pretty confirmation for me. That's enough confirmation for me.
[Dr. Aaron Fritts]
I tell you what, when I was green, when I was first doing these, and before I had that sort of tactile sixth sense from having done them. Not sixth sense, but tactile sense.
[Dr. Chris Beck]
Seventh sense.
[Dr. Aaron Fritts]
Seventh sense, yes. Sometimes I would scan and I was in the SI joint, right? Because you can slip. Like you said, you can slip down and then you're like, whoa, that felt like bone. Especially in demineralized old ladies. Sometimes bone, it just feels like hot knife through butter. It just goes right through and you're like, I don't know if I'm in bone or not. That's part of the reason why I do a confirmatory. That's why.
[Dr. Chris Beck]
I don't fault anyone who does that. I don't disagree with that sentiment. Also should walk that back a little bit. If there's ever a time where I feel like something is not right, of course I'll take a picture. Of course I'll treat it more like a targeted biopsy. If for some reason I'm having trouble, my game is a little bit off, or maybe it's just a long throw or whatever. The way that I do it is I basically find that lateral edge of the iliac bone. I'm cheating towards the lateral margin. I'm less likely to end up in the SI joint or like somewhere in the sacrum.
Also, there's a depth difference. I think you have to have a decent feel. Once you do enough of these, you have a pretty good idea of, all right, I'm hitting bone at this time. This makes sense. Rather than if you're hubbing a nine centimeter spinal needle and you're like, "Wow, I'm only barely touching the cortex," and you look at your pictures. All those things have to make sense. There's just a lot of built-in knowledge to understanding distances and where your safe zones are. That's why I was trying to lay that out a little bit. Then I really figure out that trajectory with the spinal needle, very quickly. I'm not like futzing around with this for too long. Understand where that lateral cortex is. That way I have an idea of how much distance I need. Then when I lay in that, the bigger biopsy device on the cortex, I have a pretty good idea that I'm on iliac bone and not so much like in the SI joint or something. Certainly I will take pictures if needed.
[Dr. Aaron Fritts]
Yes, and that's the whole thing. So just to go back to how many pictures. I think that's fantastic that you just do one at the beginning. That's what typically everybody does. One at the beginning to map out, plan out your trajectory, and then get the needle seated. Once it's seated, I'll even just push in maybe just a centimeter, so I'm just past the cortex. That's when I take my confirmatory picture to show, look, I was in the bone, and then I proceed to do the rest of the procedure, get my aspirates and get your sample.
(6) Choosing Your Biopsy Needle: Powered vs. Non-Powered Approaches
[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.
(7) Bone Marrow Biopsy Potential Pitfalls & Complications
[Dr. Chris Beck]
I wanted to back up and talk about real quick. What do you do in terms of like 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.
(8) Bone Marrow Biopsy Post-Procedure Care
[Dr. Aaron Fritts]
Then 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.
(9) Sedation Pearls for Bone Marrow Biopsy
(9) Sedation Pearls for Bone Marrow Biopsy
[Dr. Aaron Fritts]
It totally could. Now what throws a wrench in those gears is the sedation, because A, you got to do a timeout before you start the sedation. A lot of times in the hospitals I work at, the CT tech wants to do the timeout before they scan the patient. That means you got to be there. Because I agree with you, it'd be amazing. Because then you could basically walk in, confirm that they marked in the right spot, do the timeout real quick, and then scrub and put the lidocaine in and by five minutes the sedation should have started having effect within a couple minutes really. Then you're ready to go. It's just that whole timeout sedation, making sure there's sedated enough before you stick the needle in is the challenging part to speed it up.
[Dr. Chris Beck]
Absolutely. Totally agree. Every now and then you have somebody who either is getting done under local or doesn't care that much because they have these done all the time. We have some patients that have had five or six bone marrow biopsies, and they want the sedation, but they're not overly worried about it. I give them a little cocktail beforehand, and then when they're getting in the room, as soon as I walk in the room, we're doing the timeout. All of it is happening concurrently.
[Dr. Aaron Fritts]
I think if you give them a cocktail beforehand and they're already pretty sleepy then that definitely, you could knock it out. That's great.
[Dr. Chris Beck]
Yes. I agree that the slow part of the procedure is the sedation. No doubt.
[Dr. Aaron Fritts]
I thought it would be a good extension of this conversation, which we do a lot of our bone lesions, but more specifically spinal bone lesions. Either it'd be a disc space for discitis or osteomyelitis. Usually it's an aspiration plus biopsy for that thing, or just spine lesions for metastatic disease. We should do that conversation. It's not going to be a whole. It has its own nuances and different needles that you can use and so forth. I think that would be a good second conversation beyond. Those can be challenging because of the anatomy.
[Dr. Chris Beck]
Yes. Actually I think that could be a really robust podcast. Only because my approach to discitis osteomyelitis, I do actually do those under fluoro. Jacob, I bet he was taught to do his disc biopsies with fluoro. It'll change. It's life changing. I've loved it. Because getting into especially a collapsed disc space under CT can be a little bit frustrating-
[Dr. Aaron Fritts]
Totally.
[Dr. Chris Beck]
And a little bit fussy, but doing it under fluoro, it’s beautiful.
[Dr. Aaron Fritts]
Oh, yes. You can see it.
[Dr. Aaron Fritts]
It's probably like, “This is so easy compared to doing it under CT”
[Dr. Chris Beck]
Oh, you should see. Exactly. You're exactly right. Yes. So easy.
[Dr. Aaron Fritts]
Okay. Awesome. Let's do that. We will mark it.
[Dr. Chris Beck]
Okay, cool.
[Dr. Aaron Fritts]
Maybe Jacob would want to join us.
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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