Bone Marrow Biopsy

"Pmb" <[email hidden]> wrote in message
"]news:[email hidden]...

Quoted message said:

Does anyone know of ways to lessen the pain of a bone
marrow biopsy?

Thanks

Pete

Good technique. My haematopathologist is known as
"Painless Brian"!

Yu need :
1) Plenty of local anaesthetic
2) Plenty of time for it to work
3) Someone who knows the anatomy

Steph is right. Amount of pain is directly proportional to
the practitioner's technique and experience (and patient's
pain threshold). Mine even at one point said as he inserted
the biopsy needle "are you feeling this?". When I said yes
... he backed out and put more local anesthesia in. It is
not something I would go out of my way to experience again,
but the pain is tolerable.

Another thing you can do is to request "conscious sedation"
(Versed). It is a drug administered via IV (same as for
Colonoscopy). You will wake up and not ever remember it.
However, not many doc's offices have the facilities
(requires training in anesthesiology or an
anesthesiologist).

Larry E.

Pmb said:

Does anyone know of ways to lessen the pain of a bone
marrow biopsy?

Thanks

Pete

Pmb said:

Does anyone know of ways to lessen the pain of a bone
marrow biopsy?

Thanks

Pete

I've noticed some confusion with this expression...

There are two different things:

-- A bone marrow ASPIRATION used for marrow smears for
cytology, for cytometry, for cytogenetics. It's a
fundamental step in leukemia, myelodisplastic syndromes and
pernicious anemia where histology is poor and cytolgy
reigns. The best place for this is the sternum at the level
of the second intercostal space. I use a 18G spinal needle
for this. Paramedics and dumb people use much thicker
needles with an arrest plate so that they can't go wrong
even with bad technique... This is painless (with proper
local anest.) till the moment of the aspiration. The vacuum
inside the bone hurts and nothing can be done about it. If
you aspirate slowly it doesn't hurt but you're only catching
blood filtered by the marrow and not real marrow.

-- An osteo-medular BIOPSY when you want a 2cm long bone
cilinder for histology. It's essential for staging of
lymphomas, and diagnosing marrow invasion, aplasia or
fibrosis. The best place is the postero-superior iliac
spine. Here you use a much thicker needle and you have to
twist and brake the fragment so that it comes out inside the
needle. This hurts a little, like pulling out a tooth at the
dentist. Same way, inserting the needle is painless (with
proper anest) and you can remove it gently and painless
also... but empty, leaving the bone fragment in place...

Neither of these procedures justifies the risk of a general
anesthesia for light it may be.

"_PT_" <[email hidden]> wrote in message
"]news:[email hidden]...

Quoted message said:

Pmb said:

Does anyone know of ways to lessen the pain of a bone
marrow biopsy?

Thanks

Pete

I've noticed some confusion with this expression...

There are two different things:

-- A bone marrow ASPIRATION used for marrow smears for
cytology, for cytometry, for cytogenetics. It's a
fundamental step in leukemia, myelodisplastic syndromes
and pernicious anemia where histology is poor and cytolgy
reigns. The best place for this is the sternum at the
level of the second intercostal space. I use a 18G spinal
needle for this. Paramedics and dumb people use much
thicker needles with an arrest plate so that they can't go
wrong even with bad technique... This is painless (with
proper local anest.) till the moment of the aspiration.
The vacuum inside the bone hurts and nothing can be done
about it. If you aspirate slowly it doesn't hurt but
you're only catching blood filtered by the marrow and not
real marrow.

-- An osteo-medular BIOPSY when you want a 2cm long bone
cilinder for histology. It's essential for staging of
lymphomas, and diagnosing marrow invasion, aplasia or
fibrosis. The best place is the postero-superior iliac
spine. Here you use a much thicker needle and you have to
twist and brake the fragment so that it comes out inside
the needle. This hurts a little, like pulling out a tooth
at the dentist. Same way, inserting the needle is painless
(with proper anest) and you can remove it gently and
painless also... but empty, leaving the bone fragment in
place...

Neither of these procedures justifies the risk of a
general anesthesia for light it may be.

I had 8 of them and I'd have given good money not to have to
be awake for them.

Pmb

Interesting. I find the biopsy virtually painless, with most
of the pain occurring during the aspiration. And you're
right, there's no way to avoid this without conscious
sedation ... which some people do insist on.

Larry E.

Pmb said:

"_PT_" <[email hidden]> wrote in message
"]news:[email hidden]...

Quoted message said:

Pmb said:

Does anyone know of ways to lessen the pain of a bone
marrow biopsy?

Thanks

Pete

I've noticed some confusion with this expression...

There are two different things:

-- A bone marrow ASPIRATION used for marrow smears for
cytology, for cytometry, for cytogenetics. It's a
fundamental step in leukemia, myelodisplastic syndromes
and pernicious anemia where histology is poor and cytolgy
reigns. The best place for this is the sternum at the
level of the second intercostal space. I use a 18G spinal
needle for this. Paramedics and dumb people use much
thicker needles with an arrest plate so that they can't go
wrong even with bad technique... This is painless (with
proper local anest.) till the moment of the aspiration.
The vacuum inside the bone hurts and nothing can be done
about it. If you aspirate slowly it doesn't hurt but
you're only catching blood filtered by the marrow and not
real marrow.

-- An osteo-medular BIOPSY when you want a 2cm long bone
cilinder for histology. It's essential for staging of
lymphomas, and diagnosing marrow invasion, aplasia or
fibrosis. The best place is the postero-superior iliac
spine. Here you use a much thicker needle and you have to
twist and brake the fragment so that it comes out inside
the needle. This hurts a little, like pulling out a tooth
at the dentist. Same way, inserting the needle is painless
(with proper anest) and you can remove it gently and
painless also... but empty, leaving the bone fragment in
place...

Neither of these procedures justifies the risk of a
general anesthesia for light it may be.

I had 8 of them and I'd have given good money not to have
to be awake for them.

Pmb

"Larry" <[email hidden]> wrote in message
"]news:[email hidden]...

Quoted message said:

Interesting. I find the biopsy virtually painless, with
most of the pain occurring during the aspiration. And
you're right, there's no way to avoid this without
conscious sedation ... which some people do insist on.

Larry E.

I hear some people don't feel that much pain while others
experience the most grueling pain imaginable, me being in
the later group. Most people are in that later group as a
matter of fact.

Pmb

I would respecfully disagree. I think the pain (for the
people who have a low pain threshhold is with the aspiration
and not the biopsy).

Larry E.

Pmb said:

"Larry" <[email hidden]> wrote in message
"]news:[email hidden]...

Quoted message said:

Interesting. I find the biopsy virtually painless, with
most of the pain occurring during the aspiration. And
you're right, there's no way to avoid this without
conscious sedation ... which some people do insist on.

Larry E.

I hear some people don't feel that much pain while others
experience the most grueling pain imaginable, me being in
the later group. Most people are in that later group as a
matter of fact.

Pmb

.

Quoted message said:

I hear some people don't feel that much pain while others
experience the most grueling pain imaginable, me being in
the later group. Most people

are

Quoted message said:

in that later group as a matter of fact.

Pmb

There are lots of differences in the way people feel/express
pain. Doctors will give analgesia or sedation according to
the accepted norm but there will always be people who feel
the pain anyway whether because of their physiology or fear
(the pain is still real to them). The answer is for them to
discuss the problem with the doctor who may use more local
anaesthetic or sedation or maybe suggest an adjuvant therapy
like hypnotherapy to lessen the pain/stress of the
procedure. MIKE

Larry said:

I would respecfully disagree. I think the pain (for the
people who have a low pain threshhold is with the
aspiration and not the biopsy).

Larry E.

Could explain why none of my patients reported pain during
BM biopsy. I only had to cut through bone, never aspirate.
Sedation with midazolam (Versed/Dormicum) was standard.

--
madiba

"Larry" <[email hidden]> wrote in message
"]news:[email hidden]...

Quoted message said:

I would respecfully disagree. I think the pain (for the
people who have a low pain threshhold is with the
aspiration and not the biopsy).

I speak to people all the time who have had many bone marrow
biopsies. I've had 8 of them myself. I know of only one
person who said it wasn't bad. As far as "threshold" goes -
How did you measure their pain threshold? If you never
measured their pain threshold then why do you think it has
to do with something you call a "pain threshold"?

Unless you can actually and objectively measure a pain
threshold then its just a guess. And its only a guess based
on what pain they show. Not on what pain they experience.
Its very unreasonable and unscientific to claim that because
someone else experiences more pain that they have a low pain
threshold. To make such a claim you'd literally have to be
two different people at the same time and that is literally
impossible. Bone marrow biopsies are famous for being
extremly painful. In fact the Goldenberg SNARECOILTM Needle
was invented to save the patient the agony of the biopsy.
And no. I'm not refering to the aspiration. I'm refering to
the pain of the drilling and core extraction.

Pmb

"Larry" <[email hidden]> wrote in message
"]news:[email hidden]...

Quoted message said:

I would respecfully disagree. I think the pain (for the
people who have a low pain threshhold is with the
aspiration and not the biopsy).

Larry E.

A few questions if you don't mind: Are you a doctor who has
given bone marrow biopsies (BMB)? What meds did you give the
patients before giving them the BMBs? Have you ever actually
had one done to yourself? Did all the patients you gave them
to respond identically to all the other patients you gave
them to with respect to the pain. Please define "Pain
threshold." Ddo you mean that the physical sensation is the
same and that people react differently to the same pain
levels? Are do you mean that people who have a lower
threshold to pain have a greater nerve density and therefore
physically experience more pain?

Thanks

Pmb

"Mike Radcliffe" <[email hidden]> wrote in message
"]news:[email hidden]...

Quoted message said:

.

Quoted message said:

I hear some people don't feel that much pain while
others experience the most grueling pain imaginable, me
being in the later group. Most people

are

Quoted message said:

in that later group as a matter of fact.

Pmb

There are lots of differences in the way people
feel/express pain. Doctors will give analgesia or sedation
according to the accepted norm but there will always be
people who feel the pain anyway whether because of their
physiology or fear (the pain is still real to them). The
answer is for them to discuss the problem with the doctor
who may use more local anaesthetic or sedation or maybe
suggest an adjuvant therapy

like

Quoted message said:

hypnotherapy to lessen the pain/stress of the
procedure. MIKE

And like any other test............... Is the potential
benefit from the result larger than the distress from the
procedure? If not, don't do it!

"madiba" <[email hidden]> wrote in message
"]news:[email hidden]...

Quoted message said:

Larry said:

I would respecfully disagree. I think the pain (for the
people who have a low pain threshhold is with the
aspiration and not the biopsy).

Larry E.

Could explain why none of my patients reported pain during
BM biopsy. I only had to cut through bone, never aspirate.
Sedation with midazolam (Versed/Dormicum) was standard.

That doesn't explain anything. If the patient is sedated
then you're comparing apples and oranges. Some oncologists
don't use anything more than a shot of lidocaine. Some use
stronger drugs.

Next time give them only a shot of lidocaine and see how
they respond.

Pmb

"Pmb" <[email hidden]> wrote in message
"]news:[email hidden]...

Quoted message said:

"Larry" <[email hidden]> wrote in message
"]news:[email hidden]...

Quoted message said:

I would respecfully disagree. I think the pain (for the
people who have a low pain threshhold is with the
aspiration and not the biopsy).

I speak to people all the time who have had many bone
marrow biopsies.

I've

Quoted message said:

had 8 of them myself. I know of only one person who said
it wasn't bad. As far as "threshold" goes - How did you
measure their pain threshold? If you never measured their
pain threshold then why do you think it has to do

with

Quoted message said:

something you call a "pain threshold"?

Unless you can actually and objectively measure a pain
threshold then its just a guess. And its only a guess
based on what pain they show. Not on

what

Quoted message said:

pain they experience. Its very unreasonable and
unscientific to claim that because someone else
experiences more pain that they have a low pain threshold.

Correction - I meant to say that just because some people
don't outwardly show more pain than others that it means
they have a lower threshold. In fact some may people
suppress any outward signs of pain. It doesn't mean they
don't experience it.

Pmb

I am not a doctor, but a patient that has had 5 (sorry I can't compete
with your 8, but close enough :-)).

I'm afraid that I really do have to disagree with you on
this (respectfully, of course). I have had many discussions
with other patients on this topic, and have also read many
discussions on the topic at the Multiple Myeloma Listserver.
Please understand that I didn't record the level of pain
that each person experienced and I don't have a tally ... I
am basing my conclusions on my memory of these discussions
over the years ... and, of course, upon my own experience.
It really does have a lot to do with the practictioner's
technique and upon the individual's threshold for pain
tolerance. Yes ... it is absolutely true ... some people
just have more tolerance or are more sensitive to pain than
others. My Dad has actually had a tooth filled without
anesthesia ... even without a local ... and has claimed to
me that it wasn't that bad (although I will never do this).

You are welcome to your opinion, but it certainly isn't
accurate (IMHO) to say "Bone marrow biopsies are famous for
being extremly painful." That just isn't true. I wouldn't go
out of my way to have one :-), but there are some people who
feel that they aren't much more painful than a blood test. I
personally feel that if the pain from a blood test was a 2
or 3 on a scale of 1 to 10, then the pain from a BMB would
be about a
7. I have had much worse pain in my life from things like a
bad sunburn and by accidentally catching my finger in a
door while it closed.

Take a look at
cancernetwork.comn0004p.htmOpen ↗

This is a study of an analgesic where patients were surveyed
on their experience during BMBs before and after using it.
Note the average "pain" score of 3.97 (scale 1 to 5) across
26 patients with no meds.

"Current pain scores were significantly lower than past pain
scores. On a pain scale of 0 (no pain) to 5 (worst pain
imaginable), patients who received 200 µg of Actiq scored
the current procedure 1.75, compared to
8. for previous procedures. Those who received 400 µg,
scored the current procedure 1.59, compared to 3.97 for
previous procedures. The previous procedures were
sometimes conducted with analgesics, sometimes without."

I would venture to say that I have found that the ratio
is more like
9/50 of people who find it tolerable, vs. those that find it
"extremely painful".

And I also feel that the aspiration is the more
painful part.

Take a look at
nlm.nih.gov003934.htmOpen ↗ :

"How the test will feel

There will be a sharp stinging from the anesthetic
injection. As the aspirate is withdrawn, there may be a
brief, sharp pain. The biopsy needle may also produce a
brief pain, usually more dull. Since the interior of
the bone cannot be anesthetized, this test may cause
some discomfort. Not all patients experience these
symptoms, however."

and medicinenet.comarticle.htmOpen ↗ :

"Typically, only a local anesthetic is required to numb the
skin and tissue down to the surface of the bone. A small
cut (less than one-quarter inch) is then made in the skin.
A special needle is used to penetrate through the dense
outer shell of bone. Once inside the bone, the center
portion of this needle (the trochar) is removed and a
syringe is attached. The bone marrow is withdrawn by
pulling back on the plunger of the syringe and collecting
the liquid. This sample is known as the marrow aspirate.
This part of the procedure only lasts a few seconds but is
usually the most painful due to the sudden stimulation of
small nerves inside the bone.

A biopsy may also be obtained in addition to the marrow
aspirate or when an aspirate cannot be obtained. The same
needle is used but without the center portion in place. As
the needle is twisted through the bone it cuts a core which
is trapped inside the needle. Once the needle is removed,
this core can be extracted from the needle barrel."

Certainly, you are entitled to your opinion. Just curious
... have you had all 8 done by the same person?

Larry

Pmb said:

"Larry" <[email hidden]> wrote in message
"]news:[email hidden]...

Quoted message said:

I would respecfully disagree. I think the pain (for the
people who have a low pain threshhold is with the
aspiration and not the biopsy).

Larry E.

A few questions if you don't mind: Are you a doctor who
has given bone marrow biopsies (BMB)? What meds did you
give the patients before giving them the BMBs? Have you
ever actually had one done to yourself? Did all the
patients you gave them to respond identically to all the
other patients you gave them to with respect to the
pain. Please define "Pain threshold." Ddo you mean that
the physical sensation is the same and that people react
differently to the same pain levels? Are do you mean
that people who have a lower threshold to pain have a
greater nerve density and therefore physically
experience more pain?

Thanks

Pmb

"Pmb" <[email hidden]> wrote in message
"]news:[email hidden]...

Quoted message said:

"Larry" <[email hidden]> wrote in message
"]news:[email hidden]...

Quoted message said:

I would respecfully disagree. I think the pain (for the
people who have a low pain threshhold is with the
aspiration and not the biopsy).

Larry E.

A few questions if you don't mind: Are you a doctor who
has given bone marrow biopsies (BMB)?

I am

Quoted message said:

What meds did you give the patients before giving them
the BMBs?

Local anaesthesia only

Quoted message said:

Have you ever actually had one done to yourself?

No. I haven't had a laparotomy or an MRI scan either.....

Quoted message said:

Did all the patients you gave them to respond identically
to all the other patients

you

Quoted message said:

gave them to with respect to the pain. Please define "Pain
threshold." Ddo you mean that the physical sensation is
the same and that people react differently to the same
pain levels? Are do you mean that people who have

a

Quoted message said:

lower threshold to pain have a greater nerve density and
therefore physically experience more pain?

Thanks

Pmb

I'm not really into existentialist questions. I don't do BM
biopsies any more, because I have a very slick
haematopathologist who does them very well, and painlessly

Quoted message said:

Quoted message said:

There are lots of differences in the way people
feel/express pain.

Doctors

Quoted message said:

Quoted message said:

will give analgesia or sedation according to the
accepted norm but there will always be people who feel
the pain anyway whether because of their physiology or
fear (the pain is still real to them). The answer is for
them to discuss the problem with the doctor who may

use

Quoted message said:

Quoted message said:

more local anaesthetic or sedation or maybe suggest an
adjuvant therapy

like

Quoted message said:

hypnotherapy to lessen the pain/stress of the
procedure. MIKE

And like any other test............... Is the potential
benefit from the result larger than the distress from the
procedure? If not, don't do it!

The most poignant point of all! Like I tell my patients,
there is no way on earth I would go through
chemotherapy........but , then, nobody has diagnosed me with
cancer...yet. MIKE

Larry <[email hidden]> wrote in message news:<[email hidden]>...

Quoted message said:

I am not a doctor, but a patient that has had 5 (sorry I
can't compete with your 8, but close enough :-)).

I'm afraid that I really do have to disagree with you on
this (respectfully, of course). I have had many
discussions with other patients on this topic, and have
also read many discussions on the topic at the Multiple
Myeloma Listserver. Please understand that I didn't record
the level of pain that each person experienced and I don't
have a tally ... I am basing my conclusions on my memory
of these discussions over the years ... and, of course,
upon my own experience.

Did you have medication before this or did the doc simply
walk into the room and start drilling? What makes you
think that when you're comparing yourself to everyone else
that you're holding all other variables constant. E.g. a
dab of EMLA cream on the area before adding lidocaine and
demerol before the procedure starts can drop the pain from
a 10 to a 5.

Quoted message said:

It really does have a lot to do with the practictioner's
technique and upon the individual's threshold for pain
tolerance.

The term "pain threshold" is pretty much meaningless until
it is actually define and a procedure is devised to actually
measure it. Perhaps there are a few people who have a low
density of nerves in the place where the drilling is done.
Perhaps anestesia helps some and not others. Anticipation
anxiety plays a large role in how much pain the patient
experiences too.

Quoted message said:

You are welcome to your opinion, but it certainly isn't
accurate (IMHO) to say "Bone marrow biopsies are famous
for being extremly painful."

I;m not basing this on opinion. I'm basing this on numerical
fact. Go the the Leukemia and Lymphoma Societies discussion
board and look around. You'll notice that everyone there who
had a BMB has experienced large levels of pain.

Quoted message said:

Take a look at
cancernetwork.comn0004p.htmOpen ↗

This is a study of an analgesic where patients were
surveyed on their experience during BMBs before and after
using it. Note the average "pain" score of 3.97 (scale 1
to 5) across 26 patients with no meds.

It says

" 3.97 for previous procedures. The previous procedures were
sometimes conducted with ------->analgesics,<----------
sometimes without."

By the way, 3.97 is nothing to sneeze at since that is a 7.1
on a scale from 1 to 10. Not to mention that people can't
accurately gauge pain with numbers in a non-subjective
fashion. And that's a 7 out of 10 with pain meds. Pain meds
don't work the same on everyone.

Quoted message said:

Just curious ... have you had all 8 done by the same
person?

The first was done by a an oncologist from my home town. He
just gave me a shot of lidocaine and started drilling. It
was a nightmare. I can tolerate pain pretty well but that
was overwhelming. It was the first time I ever screamed from
pain in the last 25 years. I had to have anotherone the next
day at Dana Farber. I begged them to give me as much drugs
as theyu could. They gave me demerol. That was a different
doc. The next six were done by the same person with
differing levels of pain, ranging from 7 to 9. I did some
research during this time to learn how to lesson the pain. I
learned that anxiety increases the pain. I also learned that
EMLA cream can kill a lot of the pain. The last one was a
piece of cake. The third one was kind of funny since the
doctor said "Uh oh!" It was his first one and he thought he
didn't hit the bone. He actually did but he didn't know it
right off, hence the "Uh oh!" And, of course, I remind him
of that occasionaly. :-)

Pmb

Pmb said:

"madiba" <[email hidden]> wrote in message
"]news:[email hidden]...

Quoted message said:

Larry said:

I would respecfully disagree. I think the pain (for
the people who have a low pain threshhold is with the
aspiration and not the biopsy).

Larry E.

Could explain why none of my patients reported pain
during BM biopsy. I only had to cut through bone, never
aspirate. Sedation with midazolam (Versed/Dormicum) was
standard.

That doesn't explain anything. If the patient is sedated
then you're comparing apples and oranges. Some oncologists
don't use anything more than a shot of lidocaine. Some use
stronger drugs.

Next time give them only a shot of lidocaine and see how
they respond.

Afraid you're the one mixing up apples with oranges, a
midazolam sedation is just sedation and not analgesia. Of
course they got lidocaine locally from skin to periostium as
well. Anyway, nowdays I leave BM biopsies to the youngsters.

--
madiba