Bone marrow biopsy Information | Mount Sinai

Biopsy – bone marrow

A bone marrow biopsy is the removal of marrow from inside bone. Bone marrow is the soft tissue inside bones that helps form blood cells. It is found in the hollow part of most bones.

Bone marrow biopsy is not the same as bone marrow aspiration. An aspiration removes a small amount of marrow in liquid form for examination.

A small amount of bone marrow is removed during a bone marrow aspiration. The procedure is uncomfortable, but can be tolerated by both children and adults. The marrow can be studied to determine the cause of anemia, the presence of leukemia or other malignancy, or the presence of some storage diseases, in which abnormal metabolic products are stored in certain bone marrow cells.

A bone biopsy is performed by making a small incision into the skin. A biopsy needle retrieves a sample of bone and it is sent for examination. The most common reasons for bone lesion biopsy are to distinguish between benign and malignant bone tumors, and to identify other bone abnormalities. Bone biopsy may also be performed to determine the cause of bone pain and tenderness.

How the Test is Performed

A bone marrow biopsy may be done in the health care provider’s office or in a hospital. The sample may be taken from the pelvic or breast bone. Sometimes, another area is used.

Marrow is removed in the following steps:

• If needed, you are given medicine to help you relax.
• The provider cleans the skin and injects numbing medicine into the area and surface of the bone.
• A biopsy needle is inserted into the bone. The center of the needle is removed and the hollowed needle is moved deeper into the bone. This captures a tiny sample, or core, of bone marrow within the needle.
• The sample and needle are removed.
• Pressure and then a bandage are applied to the skin.

A bone marrow aspiration may also be done, usually before the biopsy is taken. After the skin is numbed, the needle is inserted into the bone, and a syringe is used to withdraw the liquid bone marrow. If this is done, the needle will be removed and repositioned. Or, another needle may be used for the biopsy.

How to Prepare for the Test

Tell the provider:

• If you are allergic to any medicines
• What medicines you are taking
• If you have bleeding problems
• If you are pregnant

How the Test will Feel

You will feel a sharp sting when the numbing medicine is injected. The biopsy needle may also cause a brief, usually dull, pain. Since the inside of the bone cannot be numbed, this test may cause some discomfort.

If a bone marrow aspiration is also done, you may feel a brief, sharp pain as the bone marrow liquid is removed.

Why the Test is Performed

Your provider may order this test if you have abnormal types or numbers of red or white blood cells or platelets on a complete blood count (CBC).

This test is used to diagnose:

• Anemia (some types)
• Infections
• Leukemia
• Other blood cancers and disorders

It may also be used to help determine if a cancer has spread or responded to treatment.

Normal Results

A normal result means the bone marrow contains the proper number and types of blood-forming (hematopoietic) cells, fat cells, and connective tissues.

What Abnormal Results Mean

Abnormal results may be due to cancers of the bone marrow (leukemia, lymphoma, multiple myeloma, or other cancers).

The results may detect the cause of anemia (too few red blood cells), abnormal white blood cells, or thrombocytopenia (too few platelets).

Specific conditions for which the test may be performed:

• A body-wide fungal infection (for example, disseminated coccidioidomycosis)
• A white blood cell cancer called hairy cell leukemia
• Cancer of the lymph tissue (Hodgkin or non-Hodgkin lymphoma)
• Bone marrow doesn’t make enough blood cells (aplastic anemia)
• Blood cancer called multiple myeloma
• Group of disorders in which not enough healthy blood cells are made (myelodysplastic syndrome; MDS)
• A nerve tissue tumor called neuroblastoma
• Bone marrow disease that leads to an abnormal increase in blood cells (polycythemia vera)
• Abnormal protein buildup in tissues and organs (amyloidosis)
• Bone marrow disorder in which the marrow is replaced by fibrous scar tissue (myelofibrosis)
• Bone marrow produces too many platelets (thrombocythemia)
• White blood cell cancer called Waldenström macroglobulinemia
• Unexplained anemia, thrombocytopenia (low platelet count) or leukopenia (low WBC count)

Risks

There may be some bleeding at the puncture site. More serious risks, such as serious bleeding or infection, are very rare.

Bates I, Burthem J. Bone marrow biopsy. In: Bain BJ, Bates I, Laffan MA, eds. Dacie and Lewis Practical Haematology. 12th ed. Philadelphia, PA: Elsevier; 2017:chap 7.

Chernecky CC, Berger BJ. Bone marrow aspiration analysis-specimen (biopsy, bone marrow iron stain, iron stain, bone marrow). In: Chernecky CC, Berger BJ, eds. Laboratory Tests and Diagnostic Procedures. 6th ed. St Louis, MO: Elsevier Saunders; 2013:241-244.

Choby BA. Bone marrow aspiration and biopsy. In: Fowler GC, ed. Pfenninger and Fowler’s Procedures for Primary Care. 4th ed. Philadelphia, PA: Elsevier; 2020:chap 220.

Vajpayee N, Graham SS, Bem S. Basic examination of blood and bone marrow. In: McPherson RA, Pincus MR, eds. Henry’s Clinical Diagnosis and Management by Laboratory Methods. 24th ed. Philadelphia, PA: Elsevier; 2022:chap 31.

Last reviewed on: 4/29/2022

Reviewed by: Todd Gersten, MD, Hematology/Oncology, Florida Cancer Specialists & Research Institute, Wellington, FL. Review provided by VeriMed Healthcare Network. Also reviewed by David C. Dugdale, MD, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.

This Is Going to Hurt: Revisiting the Patient Experience of Bone Marrow Biopsies

Hemasphere. 2022 Apr; 6(4): e710.

Published online 2022 Mar 25. doi: 10.1097/HS9.0000000000000710

¹

Author information Copyright and License information Disclaimer

I am starting to feel a pattern is emerging, of acceding to a request on the basis of partial information and then not being able to pull out when the beans are fully spilled

-Claire Gilbert, writing about her bone marrow biopsy during myeloma diagnosis in her collection of letters “Miles to go before I sleep”¹

Bone marrow aspirate and trephine (BMAT) is a common procedure for the diagnosis and response assessment of many hematological conditions. As a hematology registrar, I commonly consent patients for BMAT, perform the procedure, and hear patients’ reflections on their experience. I have listened to senior colleagues set expectations for the procedure—“it will just take five minutes”; “it is safe and generally well-tolerated”; or “it can be a little uncomfortable but it’s over quickly”—expectations that often do not reflect my observations of patients’ experiences. One conversation stands out: a patient in his 30s in remission from acute myeloid leukemia who required intensive chemotherapy, reinduction with chemotherapy postrelapse, and an allogeneic stem cell transplant. He told me that of the entirety of his healthcare experiences, his diagnostic bone marrow biopsy was the worst of them all. He had subsequently required a further 14 bone marrow procedures for response assessment or surveillance.

How common is pain in bone marrow procedures? Relatively few studies have sought to answer this question. A Swiss group prospectively surveyed 700 adult bone marrow procedures at a single centre, with patients reporting “bearable pain” in 59. 6% and “unbearable pain” in 3.7% of cases.² Another prospective study surveyed immediate and postprocedural pain in 235 hemato-oncology adult patients at a Swedish centre. A total of 70% of patients reported pain: of these, 56% was moderate, 32% severe, and 3% the worst possible. Pain was present in 42% of patients at 3 days post-procedure, and 12% after 1 week.³ There is inadequate evidence of pain incidence beyond this timeframe. However, one provocative study of patients reviewed in the pain clinic at the MD Anderson Cancer Center demonstrated a significant incidence of sacro-iliac joint (SIJ) pain in 4.95% of patients who had undergone bone marrow biopsy during the 1-year study period. The median time from BMAT to SIJ pain of 3.5 weeks in this study is beyond what would be usual for immediate post-procedure pain.⁴

It is worth noting that some of the most widely cited literature on BMAT morbidity (a series of UK surveys led by Professor Bain) was based on reporting from clinicians rather than patients. These surveys reported five incidents of persistent pain across 2 years of data collection with a denominator of 39,852 procedures (0.01% incidence).^5,6 This could reflect a very low incidence of persistent pain, or more likely reflects clinicians’ lack of enquiry about severe or persistent pain, or a perception that it is not noteworthy enough to report. Underestimation of pain in BMAT is common: one study reported that both doctors and nurses recognized pain to be severe in only one-third of cases where patients self-reported severe pain during BMAT.⁷

Pain is not distributed equally. Younger patients and those with higher body mass index experience more pain during BMAT.⁸ Patients who have experienced severe pain in previous BMAT experience more pain in subsequent procedures.² The observation that unemployed patients experience higher levels of pain hints at the impact of social factors and power dynamics.³

Given that pain is reported by most patients during BMAT, why do clinicians commonly use euphemisms like “uncomfortable” or “mostly well-tolerated,” rather than directly acknowledging the likelihood of pain, which can be severe or persistent? There are likely to be several reasons. The first is amnesia: senior clinicians who set patients’ initial expectations of the BMAT may not have performed or even witnessed one for many years and may genuinely not know or remember how painful they are. Alternatively, clinicians may underemphasize pain with the aim to minimize a patients’ anxiety pre-procedure: while this may help patients who encounter minimal pain, others may be shocked by their experience and could lose confidence in the trustworthiness of their clinicians. We may be motivated by fear that the patient will refuse a crucial BMAT which is in their best interests, if we emphasize the painfulness of the procedure. Finally, there is likely to be a subconscious element of “not wanting to be the bad guy”: during a positive and affirming encounter with a patient, we do not want to be tarnished by the prospect of causing them pain.

Can anything be done to reduce the pain experienced during and after BMAT procedures? Pediatric practitioners make use of pre-medications, deep sedation/general anesthesia, and modalities such as art therapy to help develop coping techniques through. In contrast, for adults undergoing BMAT in institutions I have worked with, pain relief is limited to local anesthesia, and if a patient is anxious, they may be offered a low dose oral benzodiazepine. The difference in practice is partly explained by the inverse correlation of pain and age, and partly from the increase of complications from sedation with increasing age, but also reflects different service provision limitations and clinician attitudes towards pain in adult and pediatric settings.

We can do better: many studies have demonstrated the value of pharmacological and non-pharmacological approaches to reduce pain in BMAT in adults. Three examples of effective interventions are music, buffered lidocaine, and tramadol. Music can reduce pain and anxiety experienced during BMAT^9,10 and can be easily offered to all patients. Buffering lidocaine with bicarbonate reduces pain during instillation of the anesthetic^11,12 and in one study reduced the overall pain experienced throughout the BMAT procedure. ¹² A 50 mg dose of tramadol given 1 hour prior to procedure reduced the incidence of moderate or severe pain to 20% compared to 40% in patients receiving placebo, with no toxicities from tramadol seen. Tramadol has been shown to be safe and effective in reducing pain in other procedural settings such as dressing changes in burns patients¹³ and during hysteroscopy.¹⁴ In contrast, the effectiveness of inhalational nitrous oxide has not been consistently shown, although may still be helpful in some patient groups.^15,16

There is surprisingly little research into how to train practitioners who perform BMAT. There is no published research in how to train doctors for BMAT, and only one published guideline for training and assessing the competency of nurse practitioners in carrying out the procedure.¹⁷ It is informed by educational theory and provides a structure to procedural training, which improves upon the “see one, do one, teach one” approach and could be used for training doctors and other staff. Further work is needed on the effectiveness of simulation-based training,¹⁸ and on the best approaches clinicians can take to patient education and communication.

In summary, we need to aspire towards “well-tolerated” and “slightly uncomfortable” BMATs by the deployment of pharmacological and non-pharmacological analgesic methods, and by better methods of practitioner training. For the time being, we need to be honest about the likelihood and potential severity of procedural pain and allow patients to take this into account when deciding whether to go ahead with the procedure.

1. Claire G. Miles To Go Before I Sleep. London: Hodder & Stoughton; 2021. [Google Scholar]

2. Degen C, Christen S, Rovo A, et al.. Bone marrow examination: a prospective survey on factors associated with pain.
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3. Lidén Y, Landgren O, Arnér S, et al.. Procedure-related pain among adult patients with hematologic malignancies.
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4. Roldan CJ, Huh BK, Chai T, et al.. Sacroiliac joint pain following iliac-bone marrow aspiration and biopsy: a cohort study.
Pain Manag. 2019;9:251–258. [PMC free article] [PubMed] [Google Scholar]

5. Bain BJ. Bone marrow biopsy morbidity: review of 2003.
J Clin Pathol. 2005;58:406–408. [PMC free article] [PubMed] [Google Scholar]

6. Bain BJ. Morbidity associated with bone marrow aspiration and trephine biopsy – a review of UK data for 2004.
Haematologica. 2006;91:1293–1294. [PubMed] [Google Scholar]

7. Lidén Y, Olofsson N, Landgren O, et al.. Pain and anxiety during bone marrow aspiration/biopsy: comparison of ratings among patients versus health-care professionals.
Eur J Oncol Nurs. 2012;16:323–329. [PMC free article] [PubMed] [Google Scholar]

8. Valebjørg T, Spahic B, Bremtun F, et al.. Pain and bleeding associated with trephine biopsy.
Eur J Haematol. 2014;93:267–272. [PubMed] [Google Scholar]

9. Schandert LC, Affronti ML, Prince MS, et al.. Music intervention: nonpharmacologic method to reduce pain and anxiety in adult patients undergoing bone marrow procedures.
Clin J Oncol Nurs. 2021;25:314–320. [PubMed] [Google Scholar]

10. Shabanloei R, Golchin M, Esfahani A, et al.. Effects of music therapy on pain and anxiety in patients undergoing bone marrow biopsy and aspiration.
AORN J. 2010;91:746–751. [PubMed] [Google Scholar]

11. Kuivalainen AM, Ebeling F, Rosenberg P. Warmed and buffered lidocaine for pain relief during bone marrow aspiration and biopsy. A randomized and controlled trial.
Scand J Pain. 2014;5:43–47. [PubMed] [Google Scholar]

12. Ruegg TA, Curran CR, Lamb T. Use of buffered lidocaine in bone marrow biopsies: a randomized, controlled trial.
Oncol Nurs Forum. 2009;36:52–60. [PubMed] [Google Scholar]

13. Zhang XH, Gao XX, Wu WW, et al.. Impact of orally administered tramadol combined with self-selected music on adult outpatients with burns undergoing dressing change: a randomized controlled trial.
Burns. 2020;46:850–859. [PubMed] [Google Scholar]

14. Samy A, Nabil H, Abdelhakim AM, et al.. Pain management during diagnostic office hysteroscopy in postmenopausal women: a randomized study.
Climacteric. 2020;23:397–403. [PubMed] [Google Scholar]

15. Kuivalainen AM, Ebeling F, Poikonen E, et al.. Nitrous oxide analgesia for bone marrow aspiration and biopsy – A randomized, controlled and patient blinded study.
Scand J Pain. 2015;7:28–34. [PubMed] [Google Scholar]

16. Johnson H, Burke D, Plews C, et al.. Improving the patient’s experience of a bone marrow biopsy – an RCT.
J Clin Nurs. 2008;17:717–725. [PubMed] [Google Scholar]

17. Jackson K, Guinigundo A, Waterhouse D. Bone marrow aspiration and biopsy: a guideline for procedural training and competency assessment.
J Adv Pract Oncol. 2012;3:260–265. [PMC free article] [PubMed] [Google Scholar]

18. Yap ES, Koh PL, Ng CH, et al.. A bone marrow aspirate and trephine simulator.
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Biopsy and bone marrow aspiration

Azarova Ksenia Olegovna

Reproductologist

Clinic “Mother and Child” Yaroslavl

How the examination is performed

Puncture (aspiration) of the bone marrow in patients is usually done from the posterior iliac crest of the pelvis, while the patient lies on his stomach. The procedure area is disinfected. The puncture is performed with a special puncture needle. For the study, disposable imported needles are used.

In a bone marrow biopsy, a sample of the hard part is taken with a larger needle. Usually, with a bone marrow biopsy, it is done simultaneously with aspiration.

When puncturing the posterior iliac crest of the pelvis, local anesthesia is performed with novocaine or lidocaine, as well as with trephine biopsy. If you are allergic to these medicines, be sure to tell your doctor before starting the procedure!

Do not confuse a bone marrow puncture from the ilium with a spinal puncture of the spinal canal, in which cerebrospinal fluid is taken for analysis. They are completely different procedures!

Preparation for examination

Bone marrow sampling is often performed on an outpatient basis and usually does not require special preparation. Taking bone marrow is often painless and the procedure requires little time: biopsy usually takes about 20 minutes, aspiration – 5-10 minutes.

Before the procedure

For most people, local anesthesia is all that is needed for a comfortable examination. It is possible to conduct research under anesthesia.

After the procedure

After taking the bone marrow, a sterile bandage is applied to this area. You can then go home and return to your daily activities.

Wound care

The bandage in the area of ​​bone marrow sampling must remain dry for 24 hours.

Bone marrow analysis

Bone marrow analysis (myelogram count and trephine biopsy assessment) is carried out by a laboratory diagnostics doctor and a pathomorphologist who issues an appropriate conclusion.

The conclusion of the bone marrow analysis is necessary for your hematologist or oncologist to make the correct diagnosis.

The test results are prepared within a few days. Check with your doctor when you can get them. In some cases, multiple analyzes may need to be performed over time.

Risks and complications during examination

Complications of bone marrow aspiration or biopsy are rare, but some patients may experience bleeding from the bone marrow site.

Make an appointment

to the doctor – Azarova Ksenia Olegovna

Clinic “Mother and Child” Yaroslavl

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Biopsy: does it hurt?

Biopsy: does it hurt?

When faced with a doctor’s referral for a biopsy, many patients wonder if it hurts. But the doctors immediately give their answer – modern medical equipment, which you can buy from us, new methods for taking a biopath and the experience of doctors will allow us to talk about its painlessness. Especially if high-quality medical equipment is used, in particular, the MAX-CORE automatic disposable biopsy instrument.

Types of punctures and their implementation

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If we talk about whether it is painful to undergo a biopsy, it all depends on the characteristics of the body, the level of the pain threshold and the type of the most prescribed manipulation.

1. Bone marrow examination – biopath sampling is carried out using a special Kassirsky needle. Most often, such biopsy sampling is carried out on the sternum or calcaneus, one of the bones of the small pelvis
2. From the cavity of the peritoneum, the fluid of the walls themselves is taken, and if gynecological pathologies are suspected, the fluid is taken from the retrouterine space or through the posterior fornix of the vagina

Carrying out a puncture – it all depends on its type, taking into account the organ being examined.

• If a pleural puncture is prescribed, doctors use local anesthesia. The patient is seated with his back to the doctor, and the injection site itself is treated with a local anesthetic. Previously, the doctor conducts an ultrasound scan and determines the exact location of the focus of the pathological process, thereby simplifying and facilitating the biopath sampling. If there is a need to pump out excess liquid, a special container is attached to the needle and it is collected there
• If bone marrow sampling is performed, surgery is also performed using a local type of anesthesia. The patient is laid on his back, the needle insertion site is treated with a special composition and the needle is inserted – the Kassirsky needle by scrolling it. So it is introduced into the middle of the sternum and then the spinal cord is pumped out into the cavity of the syringe
• If the biopath is taken from the peritoneal cavity, the instrument is inserted through the wall of the abdominal cavity, and in case of gynecological diseases, the anus of the vagina or the anus.