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Bone Marrow Biopsy Procedure Guide

Author Sara Stewart covers Bone Marrow Biopsy Procedure Guide on BackTable MSK

Sara Stewart • May 7, 2024 • 38 hits

Image-guided bone marrow biopsy is a foundational procedure for interventional radiologists. This article provides a comprehensive guide to navigating the image-guided bone marrow biopsy procedure, covering key considerations such as the choice between CT-guided and fluoroscopic-guided procedures, patient positioning, needle insertion techniques, and the debate over confirmatory imaging during the procedure.

This article also explores the selection of biopsy needles, comparing powered systems like OnControl and Trek with manual options like the Jamshidi needle. Ultimately, it offers insights into the factors influencing the choice between powered and non-powered needles for bone marrow biopsies, including provider preference, patient characteristics, and equipment availability.

This article features excerpts from the BackTable MSK Podcast. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.

The BackTable MSK Brief

• Interventional radiologists primarily choose between CT-guided and fluoroscopic-guided approaches for bone marrow biopsies, often opting for CT guidance due to its speed and familiarity, with fluoroscopic guidance serving as an alternative when CT is unavailable.

• Prior to bone marrow biopsy, patients are positioned prone or supine, with a CT scan performed initially to confirm landmarks and positioning. Needle insertion follows the iliac crest trajectory, with thorough numbing of the skin and cortex before obtaining aspirates and marrow cores.

• While there's debate over the necessity of additional CT scans for confirming needle placement, it's generally considered unnecessary due to inherent confirmation through obtained samples. However, additional imaging may be warranted in certain situations, such as biopsies in elderly patients with demineralized bone.

• Interventional radiologists must weigh the benefits and drawbacks of powered (OnControl, Trek) versus non-powered (Jamshidi) biopsy systems. Powered systems offer sharper needles and greater satisfaction, particularly in cases of dense bone, but may be costlier and present challenges in certain patient populations.

• Pre-procedural imaging plays a critical role in patient selection, especially in cases of sclerotic bone, where powered tools may be preferable. However, manual approaches like the Jamshidi needle still provide satisfactory results, particularly in experienced hands, with the choice ultimately dependent on operator preferences, patient characteristics, and equipment availability.

Bone Marrow Biopsy Procedure Guide

Table of Contents

(1) CT-Guided vs Fluoroscopic-Guided Bone Marrow Biopsy

(2) Step-by-Step Guide to CT-Guided Bone Marrow Biopsy

(3) Choosing Your Bone Marrow Biopsy Needle: Powered vs Non-Powered Approaches

CT-Guided vs Fluoroscopic-Guided Bone Marrow Biopsy

When selecting the imaging modality for bone marrow biopsy procedures, interventional radiologists often consider two primary options: CT-guided and fluoroscopic-guided. While the choice typically hinges on provider preference, many interventional radiologists opt for CT-guidance due to its procedural speed and their familiarity with the modality. An alternative approach, particularly for those preferring CT-guidance when it's unavailable, involves performing fluoroscopic-guided bone marrow biopsy with cone beam CT confirmation of needle positioning.

It's worth noting that other physicians, such as hematologist-oncologists conducting in-office biopsies, often perform these procedures without image guidance. Accordingly, interventional radiologists can confidently select the imaging modality they are most accustomed to and comfortable with, depending on its availability.

[Dr. Aaron Fritts]
For the audience…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.

Listen to the Full Podcast

Bone Marrow Biopsy Tools & Techniques with Dr. Christopher Beck on the BackTable MSK Podcast)
Ep 39 Bone Marrow Biopsy Tools & Techniques with Dr. Christopher Beck
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Step-by-Step Guide to CT-Guided Bone Marrow Biopsy

Prior to beginning a CT-guided bone marrow biopsy, patients are typically positioned prone, although a supine position is feasible with adjusted angles. A CT scan is taken at the beginning of the procedure to confirm landmarks and positioning. Then, following the trajectory of the iliac crest, a needle is used to thoroughly numb the skin and cortex using lidocaine.

Utilizing the lateral edge of the iliac crest as a guide, the needle is directed to the desired biopsy site. A skin incision is made, and the biopsy device is prepared and guided to the bone cortex. Aspirates and bone marrow cores are obtained before needle removal. While there's debate over the necessity of another CT scan for confirming needle placement, it's often deemed unnecessary due to the procedure's inherent confirmation through obtained samples. However, in cases involving elderly patients with demineralized bone, additional imaging may be warranted.

[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.

Choosing Your Bone Marrow Biopsy Needle: Powered vs Non-Powered Approaches

When considering biopsy needles for bone marrow procedures, operators must weigh the choice between powered and non-powered options. The prevailing systems in the market are the OnControl and the newer Trek bone marrow biopsy system for powered drill-based procedures, and the Jamshidi needle for manual biopsies. Each approach has its merits and drawbacks.

Powered systems like OnControl and Trek offer sharper needles, facilitating superior sample collection, and tend to yield higher satisfaction among providers and patients, particularly in cases of dense bone. Manual systems like the Jamshidi needle are cost-effective but may be more prone to user error due to the force required during the procedure. The introduction of the Trek needle by BD as a powered alternative provides practitioners with another option, although its advantages over the OnControl system are unclear.

Pre-procedural imaging plays a crucial role in patient selection, especially in cases of demineralized bone, where powered tools may present challenges. Despite the appeal of powered systems, manual approaches like the Jamshidi needle still offer satisfactory results, particularly in the hands of experienced physicians. Ultimately, the choice between powered and non-powered needles hinges on factors such as procedural preferences, patient characteristics, and equipment availability.

[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.

Podcast Contributors

Dr. Christopher Beck discusses Bone Marrow Biopsy Tools & Techniques on the BackTable 39 Podcast

Dr. Christopher Beck

Dr. Chris Beck is a practicing interventional radiologist with Regional Radiology Group in New Orleans.

Dr. Aaron Fritts discusses Bone Marrow Biopsy Tools & Techniques on the BackTable 39 Podcast

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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