Powered Device Hailed as Advance for Bone Marrow Biopsy

Zosia Chustecka

December 22, 2011

December 22, 2011 (San Diego, California) ( UPDATED December 29, 2011 ) — Using a new powered device (OnControl, Vidacare Corp) for obtaining bone marrow biopsy specimens should now be considered a standard of care for adult hematology patients, say researchers who compared it with the traditional manual method. The device made the procedure quicker and resulted in better-quality biopsy samples, they reported here at the annual meeting of the American Society of Hematology.

Patients with leukemias and lymphomas often undergo multiple bone marrow biopsies during the course of treatment. Traditionally, these have been obtained by using the Jamshidi (CareFusion) needle, which involves manual rotary insertion into the posterior aspect of the iliac bone. This involves thrusting and pulling on the needle by hand, and can require quiet a bit of force, especially in adults with hard bones, explained lead author Louis Juden Reed, MD, from the Department of Hematology/Oncology at the Jacobi Medical Center, Bronx, New York.

Dr. Reed and colleagues reported a study from their teaching hospital, in which 11 hematologists-in-training alternated between using the traditional manual technique (for 26 bone marrow biopsies) and the powered device (used for 28 procedures). The fellows worked under the supervision of 3 attending hematologists and 1 research technologist.

OnControl bone marrow device

The primary endpoint was the length of the biopsy specimen, which is a surrogate for quality, Dr. Reed explained. This was assessed by pathologists who were working in a blinded manner, and the results showed that the biopsy specimens obtained by using the powered device were significantly longer than those obtained manually (15.3 mm vs 9.8 mm; P < .003).

A secondary endpoint was the time taken to complete the procedure, skin-to-skin, which was timed with a stop-watch. This also favored the powered drill, Dr. Reed commented: The mean procedure time was 175 seconds with the device vs 292 seconds with the manual technique (P < .007).

In addition, a questionnaire completed by the patients suggested a trend toward less pain being associated with the powered device, although this finding did not reach significance. Also, more patients who underwent the procedure with the powered device said they would agree to another biopsy if it was medically indicated, and this result did reach statistical significance (P = .003).

"Refusal by the patient to undergo bone marrow biopsy procedures, especially in diseases like myeloma, leukemia and lymphoma, leads to delays in the diagnosis and treatment, which may have fatal consequences," the researchers commented in their poster presentation. "Any device which promotes greater patient acceptance of a painful, but necessary, procedure, may be anticipated to improve quality of care and to enhance favorable clinical outcomes," they added.

Bone marrow biopsy is rather a "crude messy procedure," and relatively few improvements have been made over the last 40 years, Dr. Reed commented in an interview with Medscape Medical News. "I think that the powered device represents a significant advance that gives better specimens and reduces the discomfort for the patients.... I would certainly recommend it."

Another hematologist who has been using the new device for the past 18 months is Parameswaran Hari, MD, from the Medical College of Wisconsin in Milwaukee.

"The most important advantage, in my opinion, is that it is fast," Dr. Hari commented in an interview with Medscape Medical News. With the traditional manual device, "you can be drilling for 5-10 minutes, especially in a young person with strong bones, and then there is twisting and turning to pull it out of the bone — it can be like a difficult tooth extraction," he said. With the powered device, in contrast, the needle goes straight in, so you are in and out within a minute, he said.

"I would say that 90-95% of patients say they would prefer the powered device, once they have experienced it," Dr. Hari said.

There is a perception that the powered device makes the procedure less painful, but because the needle passes through the same amount of tissue, Dr. Hari believes that the perception is due mainly to the speed with which the procedure is performed. "The sensation is different because the needle goes quickly in and out, like a knife," he added.

From an operator point of view, of the 10 hematologists who regularly perform bone marrow biopsies within his department, Dr. Hari estimates that 6 or 7 clinicians use the powered device exclusively, and the others use it in selected patients, particularly for young patients.

The manual procedure can be physically demanding. "It's a lot of effort on your wrist and your shoulders, and you are pressing down on the patient's back," Dr. Hari explained, whereas with the powered device, that strength is no longer needed.

Performing the procedure manually can cause physical problems for the clinicians: Some have developed repetitive strain injury. One physician who had developed a problem and then changed over to OnControl is Kelly McCaul, MD, from Avera Hematology and Transplant in Sioux Falls, South Dakota. He recalled his experience in a prepared statement: "As a physician who performs bone marrow procedures regularly, I know how physically hard it can be. For nearly 3 years, I've suffered from pain in my right (dominant) hand, and doing procedures exacerbated that pain. I have had a great relief with my wrist pain using the OnControl system. After months of unhelpful pain management measures, I was able to get my hands on the OnControl system, and it helped immediately, just by taking the strain off of my injured/damaged tendon. Now, just a few months later, the pain is virtually gone, and it has made a huge difference in my life."

Better Technique Needed

On reading this article, Dawson Lim, MD, from the Monongahela Valley Hospital, Pennsylvania, wrote to Medscape Medical News to say that "using an electric drill should not substitute for manual bone marrow procedure done with good technique."

"I have been doing bone marrows since medical school (in the late 1970s), and I was taught very well the best technique for doing a bone marrow. I am afraid that many oncologists and hematologists have not been taught well. I know from my staff and from observation, many bone marrows are done poorly by many very good oncologists," Dr. Lim commented.

"It is upsetting to read that the drilling may take 10 minutes," he continued. No marrow should take '5 to 10 minutes of drilling.' In my experience, it takes about 20 to 30 seconds of drilling."

Dr. Lim suggests that if drilling is taking a long time, then maybe there are flaws in technique that the oncologist or hematologist doing a marrow may not realize they have, and their imperfect technique is consistently repeated. "It is likely these physicians pass on their poor bone marrow technique to the next generation of physicians, and unfortunately many oncologists and hematologists in 2011 have poor technique.

"It also upset me to read an article that depicts the traditional bone marrow as messy and clumsy. If not done properly, a bone marrow procedure can be a rather tortuous procedure, but it is because the procedure was done poorly, and not because the typical marrow is messy or tortuous. We need to teach better techniques to medical students, residents, fellows, and attending staff to ensure a good bone marrow is not a rare event," Dr. Lim concluded.

American Society of Hematology (ASH) 53rd Annual Meeting: Abstract 3133. Presented December 11, 2011.

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