How painful is a bone marrow biopsy?

Bone marrow biopsies are a common diagnostic procedure used to assess blood disorders if your blood tests show your levels of platelets, white or red blood cells are too high or too low. A bone marrow biopsy is also used to help diagnose and evaluate certain types of blood cancers, such as multiple myeloma, leukaemia, and lymphoma. While these tests provide invaluable insights, they are often associated with significant discomfort and pain for patients. In this article, we will delve into the painful realities of bone marrow tests, explore strategies to reduce the discomfort and discuss the importance of patient-centred care in this context.

Understanding bone marrow and its significance

Bone marrow is the soft, spongy tissue found within the hollow centres of our larger bones. This remarkable tissue is responsible for the production of the three main types of blood cells: red blood cells, white blood cells, and platelets. Red blood cells carry oxygen throughout the body, white blood cells defend against infections, and platelets help with blood clotting.

The liquid portion of bone marrow contains stem cells, which are the precursors to these various blood cells. The solid, tissue-like portion of bone marrow is where the maturation and differentiation of these cells occurs. By examining a sample of this bone marrow, healthcare providers can gain valuable insights into the overall health and function of this vital hematopoietic system.

Why do I need a bone marrow biopsy?

A bone marrow biopsy may be recommended by a healthcare provider for a variety of reasons, including:

• Diagnosing blood disorders: Conditions such as anaemia, aplastic anaemia, leukopenia, leukocytosis, thrombocytopenia, thrombocytosis, and polycythemia vera can be evaluated through a bone marrow biopsy
• Detecting cancers: Cancers affecting the blood and bone marrow, such as leukaemia, lymphoma, and multiple myeloma, can be diagnosed and monitored using this procedure
• Identifying metastatic cancers: Bone marrow biopsies can detect the presence of cancers that have spread from other parts of the body, such as breast or lung cancer
• Investigating unexplained fevers: In cases where the cause of a persistent fever is unclear, a bone marrow biopsy may provide valuable insights
• Evaluating treatment effectiveness: Patients undergoing treatment for blood or bone marrow disorders may undergo regular bone marrow biopsies to monitor the progress and efficacy of their therapy
• Determining stem cell transplant compatibility: Bone marrow biopsies can help assess the suitability of a donor for an allogeneic stem cell transplant, a procedure used to treat certain blood and bone marrow diseases

The bone marrow biopsy procedure

The bone marrow biopsy procedure typically involves the following steps:

Preparation

• Medical history and medication review: Your healthcare provider will thoroughly review your medical history and any medications you are currently taking, as certain conditions or medications may affect the procedure or recovery
• Fasting and sedation: Depending on the protocol, you may be asked to fast for some time before the procedure, and you may be provided with a sedative to help you relax during the process
• Skin preparation: The area where the biopsy will be performed, usually the back of the hip bone (posterior iliac crest), will be thoroughly cleaned with an antiseptic solution

The biopsy process

• Local anesthesia: A local anaesthetic will be administered to numb the area where the biopsy will be taken, helping to minimise any discomfort during the procedure
• Bone marrow aspiration: A thin, hollow needle will be inserted into the bone, and a small sample of the liquid portion of the bone marrow will be withdrawn using a syringe
• Bone marrow biopsy: A slightly larger, specialised biopsy needle will then be used to extract bone marrow tissue
• Sample collection: The collected bone marrow cells will be carefully labelled and sent to a laboratory for analysis to haematology

Post-procedure care

• Bandage application: Pressure will be applied to the biopsy site to stop any bleeding, and a bandage will be placed over the area
• Recovery and observation: Depending on the sedation used, you may be asked to rest for some time before being discharged. If a sedative was administered, you will need to arrange for someone to drive you home
• Aftercare instructions: Your healthcare provider will provide you with specific instructions on caring for the biopsy site, managing any discomfort, and when to contact them if you experience any concerning symptoms

Understanding bone marrow biopsies

A bone marrow biopsy is a medical procedure that involves the removal of a small sample of bone marrow, typically from the hip or breastbone, for analysis. This tissue is then examined under a microscope to diagnose or monitor various conditions, including blood disorders, cancers, and infections. The procedure is often performed in conjunction with a bone marrow aspiration, which collects a liquid sample of the marrow.

The pain factor

Contrary to the often-downplayed descriptions of bone marrow biopsies as merely “uncomfortable,” research has shown that a significant proportion of patients experience moderate to severe pain during and after the procedure. A Swiss study found that 59.6% of patients reported “bearable pain,” while 3.7% experienced “unbearable pain.” Another study conducted in Sweden revealed that 70% of patients reported pain, with 56% experiencing moderate pain, 32% severe pain, and 3% the worst possible pain.

Factors influencing pain levels

Several factors have been identified as contributors to the varying levels of pain experienced during bone marrow biopsies. Younger patients and those with a higher body mass index tend to report more discomfort. Patients who have undergone previous bone marrow biopsies and experienced severe pain are also more likely to have a similar or even worse experience in subsequent procedures.

Interestingly, social factors and power dynamics may also play a role, as evidenced by the observation that unemployed patients tend to report higher levels of pain. This suggests that the patient’s overall well-being and support system can influence their pain perception and tolerance.

Underestimating and underreporting pain

One of the most concerning aspects of the bone marrow biopsy experience is the apparent disconnect between patients’ reported pain and the perceptions of healthcare providers. Studies have shown that clinicians and nurses recognise severe pain in only one-third of cases where patients self-report experiencing it. Downplaying the discomfort to minimise patient anxiety and increase the likelihood of the procedure being performed, which they believe to be in the patient’s best interests. However, this approach can backfire, as patients who encounter severe pain may feel betrayed by the clinician’s initial reassurances, potentially eroding trust and confidence in the healthcare team. It is crucial to find a balance between managing patient anxiety and setting realistic expectations.

Medication for pain relief

Fortunately, to reduce the pain and discomfort associated with bone marrow biopsies pain relief medication such as the use of buffered lidocaine, tramadol, and nitrous oxide, are effective in reducing pain during the procedure.

Non-pharmacological approaches, such as the use of music therapy, can also play a significant role in reducing anxiety and discomfort. Studies have demonstrated that the incorporation of music during bone marrow biopsies can have a positive impact on the patient’s overall experience.

Conclusion

The painful reality of bone marrow biopsies is a topic that deserves greater attention and action within the healthcare community. By acknowledging the severity of pain experienced by patients, and offering pain management, clinicians can work towards a future where these essential diagnostic procedures are truly well-tolerated.

Sources

• Bone Marrow Biopsy: What It Is, Procedure & Results
• Bone marrow biopsy and aspiration – Mayo Clinic
• This Is Going to Hurt: Revisiting the Patient Experience of Bone Marrow Biopsies – PMC
• Bone Marrow Biopsy – Johns Hopkins Medicine
• Bone marrow biopsy Information – Mount Sinai – New York