How to Perform the Perfect Bone Marrow Biopsy

Cyrus Khan, MD, and Casey Moffa, DO
Published: Monday, Oct 31, 2011
“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.

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