Feature Story

Sure-handed sampling

Easing the trauma of bone marrow collection

March 2004
Mark Alberhasky, MD

Advances in technology eventually may circumvent the need to directly sample bone marrow in evaluating hematologic disease. But today, this procedure remains high on the list of dreaded tests for most patients and many pathologists. This need not be the case, however.

Using proper technique, bone marrow sampling can be performed with minimal psychological and physical trauma. My favorite response from a patient is: "Wow, that wasn”t bad at all. I have been dreading this all day."

Presented below are tips to augment the standard bone marrow technique that may raise the comfort level for pathologists and patients.

Setting the tone

Bedside manner gets far too little attention in today”s fast-paced, volume-driven "business" of medicine. But in the "art" of medicine, how you engage and prepare your patient can make a world of difference. In the first 30 seconds after you enter a patient”s room, you can create an atmosphere that will contribute to your chances for success. Enter slowly, smile, and introduce yourself. The patient knows you are about to perform a procedure that will inflict pain or discomfort. While this can”t be changed, everyone feels more at ease with a smiling face and warm, caring introduction.

Your day may be frantic, but the patient needs you to go slowly. Introduce yourself not only to the patient but also to any family members or friends in the room. Make them feel important. Explain to guests that the procedure typically takes 15 to 20 minutes and they can return shortly. If a spouse or other caregiver asks to stay, allow them to do so. Encourage them to take a position on the side opposite from your work so they can face and comfort the patient. Offering this option empowers the patient and the family with choice, granting them some control in a situation where they feel they have none, and, more importantly, demonstrates your self-confidence. It says, in effect, "Your presence will not bother me because I know what I am doing."

Having set a relaxed tone, continue to build a rapport with the patient. Many medical facilities have a nurse explain the procedure to the patient and secure the proper signature on the procedure permit. Do not make the mistake of accepting this as a bonus timesaver. This is the moment where you can redefine your patients” expectations. They are either uninformed about what to expect, in which case they will imagine the worst, or they have already been told by someone that this is an awful, painful procedure.

First I explain why the test is important, and that I will personally interpret the biopsy. I also outline the timetable for processing the different portions of the specimen, since the availability of special study results may influence when the final diagnosis is reported. Then I explain how the procedure is performed. I stress that 95 percent of the procedure does not hurt. "We numb the skin, the soft tissues around your hip bone, and the surface of the bone itself. Most of the procedure will be painless. The only area we can”t numb is the inside of the bone. This means that in two instances, for about five to 10 seconds each, you may experience some discomfort, but I will tell you each time so you will be ready, can take a deep breath, and relax. Most of my patients tell me when I”m finished that it was not as uncomfortable as they expected."

I specifically replace such words as pain and hurt with "some discomfort." No one expects it to be painless when a needle is placed into their hip bone. Bear in mind that pain tolerance varies widely. Some patients hardly flinch as you take the core. Others flinch as you apply Betadine to the skin. Don”t prejudice a patient”s expectation to any higher level than "discomfort." Both of you may be pleasantly surprised at the result.

When placing patients in position, ask them if they are comfortable. This shows you are concerned with their well-being. Talk, talk, talk. Discuss the weather, ask them about their family, comment on the TV show they were watching when you arrived. Conversation is distracting. It makes them think about something else besides what you are doing. Keep them informed at each step, before you proceed. "Here comes a little mosquito bite with some numbing medicine." I keep two percent Lidocaine on the marrow tray and use it instead of the one percent often included in the kit. I also explain (more talking) that Novocaine takes away the sensation of pain but not touch. "You may still feel me moving a needle around back here, but it shouldn”t hurt."

Numbing with the right needle

Anesthetizing the periosteum with the 1.5-inch 22-gauge needle that is standard on the tray should be satisfactory for the average patient. With heavier patients, however, localizing the thumb-width ridge on the posterior iliac crest can be difficult, if not impossible. Usually you can guesstimate its orientation, but it can be deceptively deep when you start trying to reach it with a 1.5-inch 22-gauge needle. Pushing deep against tense skin looking for the crest is not the way to go, particularly if you end up searching with the Jamshidi needle. This is especially true since once you find the crest, you want to apply Lidocaine in a specific fashion.

Keep three-inch 22-gauge spinal needles on your marrow tray. If the crest doesn”t feel close to the skin, use a three-inch spinal needle to inject Lidocaine and find the crest without tenting the skin. (For the thinner patient, complete the same steps using a 1.5-inch 22-gauge needle.) Once at the periosteum, apply a central aliquot and then "walk" the needle tip around, anesthetizing an area the size of a nickel. I usually remark at this juncture, "You can probably feel the needle touching your bone now, but it doesn”t sting, right?" Then I realign the needle perpendicular to the skin and embed the tip into the periosteum, in the center of the Lidocaine zone. Detach the syringe and leave the needle in place. This defines the exact point of properly anesthetized bone surface.

At this point I make sure the Jamshidi needle is close at hand, the cap screws on and off easily, the stylet slides in and out, and the tip is ground correctly. An assistant should have collection tubes and vials ready. This 30- to 60-second equipment check provides additional opportunity for the anesthetic to take effect.

Performing the procedure

Once the patient is properly anesthetized, take a narrow tip scalpel blade from the tray and make a puncture incision of adequate depth to traverse the full thickness of the dermis and enter the subcutis, extending radially from the shaft of the spinal needle. Incise directly from the spinal needle shaft, cutting an adequate width to allow easy introduction and removal of the Jamshidi. Having to punch the large-gauge needle through unincised tissue not only is unpleasant for the patient but also forms a glove-tight fit on the needle shaft which makes it difficult to manipulate the needle subtly.

Introduce the Jamshidi, "feeling" the metal sensation of the spinal guide needle along the way. Up to this point the patient will have experienced little pain or discomfort. If you have properly anesthetized the periosteum, you can be comfortable moving the Jamshidi tip to find a point of firm resistance, which marks solid iliac crest. Once identified, you should be able to walk the Jamshidi tip medial and lateral and superior and inferior at least several millimeters in each direction. If you can”t do so, you may be on the edge of the crest. If you apply pressure here, the needle may slip off the crest and across unanesthetized periosteum, which is quite painful. Feeling around the crest to ensure a stable solid surface is good insurance. Once identified, talk to the patient again. "Okay, we are now at the point where I am going to push firmly against your hip. You may feel some discomfort but just count with me. Concentrate on breathing deeply, in and out, and relaxing."

With experience, you will recognize the distinctive "gritty" sensation that begins when the needle passes through the cortical bone into the fine marrow bone trabeculae. When the needle feels firmly set in the bone, you should advance the needle one to 1.5 inches over four to five seconds. Distract the patient by talking as you advance the needle. Offer encouraging words, such as, "You are doing great, just a second more."

With the needle in place at the maximum depth of advancement, firmly grasp the hub and rotate it in a circle of approximately one-inch diameter. This should be done with enough force to shake the patient gently for several seconds. I preface this with, "Are you ready for a little rock ”n roll?" The rocking motion helps break loose the bone core to recover as long a segment as possible. This does not have to be a drastic motion and will not break the needle or cause discomfort.

During my first two years in practice, I grew frustrated with obtaining short cores while one oncologist on staff always had long, beautiful cores. One day I asked him if I could observe his technique. The only thing he did differently was the "rock ”n roll" gyration before removing the needle. It does help.

Acquiring the aspirate

After extracting the core from the needle, go back for your aspirate. I prefer to take the core first, concerned that the aspirate process may artifactually distort the marrow architecture if taken as the first sample. When re-introducing the needle, "feel" through the skin and adipose tissue the path of least resistance created initially. If you have to apply force, you probably are not following the track of your initial needle placement and may not end up back in the "numb" zone of periosteum. Ideally, you should be able to identify the ostium from which you took your core. Make one of the three-mm moves within your "Novocaine nickel" to choose another site of needle placement for the aspirate. With the Jamshidi stylet in place, the needle will pierce the bone with somewhat less pressure, so go a little easier. Again, preface this move by telling the patient you are going to push against the hip once more. Advance until you feel that same familiar soft gritty sensation, which tells you the tip is in the marrow. As you remove the stylet and attach the syringe, inform the patient: "You may feel some warm pressure or discomfort for about five to six seconds. Breath deeply, relax, and count with me." I slowly count out loud to six. As you turn to fill the EDTA and other tubes, let the patient know you are finished. Smoothly and gently remove the needle as you tell the patient, "I”m easing the needle out now." Just as the needle is removed, announce in a positive tone: "All done. You did great."

If you encounter a "dry" tap, recovering no aspirate, it is good practice to obtain a second core sample. This core can be submitted in flow cytometry transport media and is an acceptable and desirable substitute when an aspirate is unavailable. The flow laboratory is able to work with the core and procure cellular material suitable for the flow analysis, which may be relevant in explaining the dry tap.

Assisting in problem sampling situations

Pathologists are sometimes asked to assist nonpathologist clinicians who are having trouble obtaining a bone marrow specimen. This can be a difficult situation. The patient is undoubtedly already upset, afraid, and possibly has experienced pain in the sampling attempts made thus far. The clinician is probably also distressed by how the procedure has unfolded and may be chagrined at having to request your assistance.

Even if you have reservations about playing the role of bone marrow expert, play it close to your chest. You likely have performed more marrow samplings than this doctor and have a greater level of technical expertise. What has been a difficult marrow for the other clinician may be routine for you.

Start by introducing yourself to the patient face-to-face in a calming fashion. Establish rapport using the techniques discussed earlier. They are even more important in this scenario. Acknowledge that everyone occasionally has trouble with marrows so the patient understands it is not necessarily a poor reflection on the doctor.

How to proceed technically can be problematic. The patient is already under a sterile field and presumably is anesthetized. I say presumably because this is an assumption. My first step is to make sure a new bone marrow needle is available. When I biopsy, I want to start with a new edge, not one dulled from the unsuccessful attempts. Before inserting the Jamshidi, however, I take a 22-gauge spinal needle and establish my own posterior iliac crest landmark, finding the broad solid crest face and determining from the patient that the area is numbed adequately. I then proceed as usual.

A word of caution: If the clinician has not made the skin incision at an optimal location in relation to the iliac crest bone, the needle approach may not be at an angle perpendicular to the bone surface. This may result in the needle slipping off when you apply cutting force pressure or be of a trajectory that prevents sampling a suitable length of marrow core. Because the skin and soft tissue have an anchoring effect on the needle shaft, it is nearly impossible to change this trajectory. If you try once or twice and are unsuccessful, consider breaking down the sterile field and starting from scratch, palpating the hip to find a new skin entry point. A bad angle based on a poor location may have caused the earlier failure. As you progress, continually praise the patient for his or her patience and understanding.

Working with obese patients

The obese patient is always a challenge for practitioners collecting bone marrow. To alleviate some of the anxiety that arises from working with obese patients, be up front with such patients about their physical condition and how it may affect your technique. I usually comment as I am palpating the hip, "You have some extra padding here which makes it difficult to feel your hip bone, so be patient with me as we go along." This honestly states the situation and prepares the patient for a little extra probing. Here again, having the three-inch 22-gauge spinal needle on the tray is invaluable. Never go hunting for the iliac crest with the Jamshidi. It can be difficult to push the needle through the fibrous septae within the subcutis, and repeated placement can be traumatic. The thin 22-gauge needle makes it a cinch to find the bone, and you needn”t be timid about searching for it. Collecting sternal aspirate is also an excellent alternative to posterior iliac sampling.

Perfecting your practice

It is good practice to educate your surgeons and oncologists about the advantages of collecting an intraoperative specimen whenever possible. Your patient will like nothing better than being asleep, and you get the luxury of performing a collection under general anesthesia. Take advantage of these rare "two-for-one" opportunities.

The key to an atraumatic marrow is a positive attitude. If you feel comfortable, the patient will feel comfortable. If you feel uncomfortable and communicate this with a rushed, insecure, or uncompassionate manner, the patient will be uncomfortable. A tense, fearful patient is likely to perceive greater pain than a relaxed patient in the hands of a confident practitioner.

The other day a leukemic patient I had previously biopsied for an original diagnosis was back for another marrow to evaluate treatment results. With everything else that could be on her mind, imagine my satisfaction when she said: "I was so relieved when they told me you would be doing the procedure. I was so worried." When you get that kind of feedback, you”ll know you”re on the right track.

Dr. Alberhasky is laboratory director, Greenview Regional Hospital Partner, Associated Pathologists, PLC, Brentwood, Tenn. He can be reached at malberhasky@pathgroup.com.