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Medical Forum / Diseases and Disorders / Cancer / June 2004Bone Marrow Biopsy
Does anyone know of ways to lessen the pain of a bone marrow biopsy? Thanks Pete > 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. > Does anyone know of ways to lessen the pain of a bone marrow biopsy? > > Thanks > > Pete >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. > >Does anyone know of ways to lessen the pain of a bone marrow biopsy? > > [quoted text clipped - 34 lines] > 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. >>>Does anyone know of ways to lessen the pain of a bone marrow biopsy? >>> [quoted text clipped - 39 lines] > > 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. 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. >>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 [quoted text clipped - 7 lines] > > 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. 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.  Signaturemadiba > > 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). [quoted text clipped - 4 lines] > 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 > > > 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). [quoted text clipped - 10 lines] > > 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. Signaturemadiba > 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 > > 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). [quoted text clipped - 10 lines] > 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 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 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 http://www.cancernetwork.com/journals/oncnews/n0004p.htm 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 3.0 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 50/50 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 http://www.nlm.nih.gov/medlineplus/ency/article/003934.htm : "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 http://www.medicinenet.com/Bone_Marrow/article.htm : "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 >>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). [quoted text clipped - 14 lines] > > Pmb > I am not a doctor, but a patient that has had 5 (sorry I can't compete > with your 8, but close enough :-)). [quoted text clipped - 6 lines] > 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. > 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. > 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. > Take a look at http://www.cancernetwork.com/journals/oncnews/n0004p.htm > > 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. > 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 >>I am not a doctor, but a patient that has had 5 (sorry I can't compete >>with your 8, but close enough :-)). [quoted text clipped - 14 lines] > from a 10 to a 5. > No meds at all. Just Lidocaine, and lot's of it. >>It really >>does have a lot to do with the practictioner's technique and upon the [quoted text clipped - 16 lines] > >>Take a look at http://www.cancernetwork.com/journals/oncnews/n0004p.htm Well then I'm basing my statements on numerical fact also. Take a look at http://listserv.acor.org/archives/myeloma.html , search on "BMB" "Bone Marrow Biopsy", and "Bone Marrow" and I think you will find almost as many people who feel the pain is tolerable as those that feel it isn't. And I don't think you'll find very many who describe it as excruciating ... some will say "very painful" or something like that. >>This is a study of an analgesic where patients were surveyed on their >>experience during BMBs before and after using it. Note the average [quoted text clipped - 9 lines] > 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. Never said it was pain-free or that it was something to sneeze at. But 3.97 is an average across 26 patients. Seems reasonable to me. >>Just curious ... have you >>had all 8 done by the same person? [quoted text clipped - 15 lines] > > Pmb I have had nothing more than lidocaine every time I've had one. Like I said, it's not something I'd volunteer to do or go out of my way to do, but I find it tolerable. I've never had to scream or yell ... the most I've done is wince. I have more pain when the lidocaine wears off and I roll over on it that night while sleeping. As I said, this has a lot to do with the practitioner's technique and I think someone else said it has a lot to do with the amount of lidocaine used. It's a very interesting procedure as it results in a wide variety of experiences. Larry Larry <Larry@nospam.net> wrote > Well then I'm basing my statements on numerical fact also. Question: What is your point? I said that BMBs were not painful to some people but some people experience a lot of pain where most fall into this later group. Is it the "most" that you disagree with or do you claim that most people feel no pain at all? I based that on my personal experience speaking with fellow leukemia patients over the last few years at the LLS forum. However, using personal experiences is not an accurate method of collecting accurate information. I don't recall many people who said they didn't feel much discomfort and I do recall many people stating that it was terribly painful. They may have used different adverbs than I do to describe the same thing but that is another story all together. Because they didn't use the adverbs I use is of little importance. I say "Terribly painful." Many of the women I speak to say that childbirth was less painful. To me that means terribly painful even if they didn't use that term. Is this all about ratios (pain to no pain) and adverbs (painful/horribly painful)? If you hold that BMBs are not considered painful then that seems quite incorrect to me. Bone Marrow Biopsies are well know for being painful. E.g. From the "Southern Medical Associates" -- http://www.sma.org/smj1999/maysmj99/dunlop.pdf "Bone marrow aspirate and biopsy is universally recognized as being painful" > I have had nothing more than lidocaine every time I've had one. Like I > said, it's not something I'd volunteer to do or go out of my way to do, > but I find it tolerable. I've never had to scream or yell ... the most > I've done is wince. I have more pain when the lidocaine wears off and I > roll over on it that night while sleeping. That tells me is that you didn't experience the same pain I did. It does not automatically hold that you have a higher tolerance of pain. The phrase "higher tolerance" is quite vauge. If by this phrase you mean "I experience the exact same pain you do but I don't let it bother me" then that is very difference than "I don't experience the exact pain that you do under identical circumstances" - Tolerance means to experience and to put up with. Anybody can have a high tolerate pain if they don't feel it. But its quite impossible for anyone on Earth to claim that they know what the pain I experience is like. Just because they have the same procedure it doesn't mean they have the same pain. Pmb > Larry <Larry@nospam.net> wrote > [quoted text clipped - 4 lines] > into this later group. Is it the "most" that you disagree with or do > you claim that most people feel no pain at all? My point is that I agree that BMBs were "not painful to some people". Your earlier statement was "I know of only one person who said it wasn't bad". Big difference. Sounds like we're in agreement now. > I based that on my personal experience speaking with fellow leukemia > patients over the last few years at the LLS forum. However, using [quoted text clipped - 7 lines] > painful. To me that means terribly painful even if they didn't use > that term. I agree on the subjectivity of people. Can't imagine how someone could think a BMB is worse than childbirth. Only possible explanation is a botched up BMB or bad technique. > Is this all about ratios (pain to no pain) and adverbs > (painful/horribly painful)? > > If you hold that BMBs are not considered painful then that seems quite > incorrect to me. Bone Marrow Biopsies are well know for being painful. > E.g. Never said that. > From the "Southern Medical Associates" -- > http://www.sma.org/smj1999/maysmj99/dunlop.pdf > > "Bone marrow aspirate and biopsy is universally recognized as being > painful" I agree. Never said it wasn't. >>I have had nothing more than lidocaine every time I've had one. Like I >>said, it's not something I'd volunteer to do or go out of my way to do, [quoted text clipped - 15 lines] > > Pmb Larry > > Well then I'm basing my statements on numerical fact also. > [quoted text clipped - 27 lines] > "Bone marrow aspirate and biopsy is universally recognized as being > painful" But that's untrue. I'm part of the Universe, I have lots of patients who have bone marrows, and I ask them all.........some find it painful, most do not. >But that's untrue. I'm part of the Universe, I have lots of patients who >have bone marrows, and I ask them all.........some find it painful, most do >not. But people must be very tough to survive in that snow covered piece of nowhere you live on! :) > >But that's untrue. I'm part of the Universe, I have lots of patients who > >have bone marrows, and I ask them all.........some find it painful, most do [quoted text clipped - 3 lines] > nowhere you live on! > :) If you knew anything about Vancouver Island, _PT_, you would realise how stupid that comment is. But you don't, so you don't. It doesn't surprise me. You seem to be an expert in many areas in which you haven't bothered with the facts. There, I've done the work for you http://www.islands.bc.ca/general/climate.html >> >But that's untrue. I'm part of the Universe, I have lots of patients who >> >have bone marrows, and I ask them all.........some find it painful, most [quoted text clipped - 12 lines] >There, I've done the work for you >http://www.islands.bc.ca/general/climate.html Know the internet convention of the smile? That's what the :) is doing just below my message! Your sense of humor and your bad manners don't improve with time... Have considered testosterone patches? :) :) :) But there is a FACT beneath my humorous comment! Emigrants are usualy tougher and boulder people compared with their starving contryman that had no courage/drive to seek a better life away from home. You should acknowledge that and feel proud about it instead of being rude and insulting! There was another intention when changing to humor in replying you in this thread -- making you realize that you don't have to persist in having the last word in a subject you aren't an expert in. I've done thousands of aspirations and biopsies and still do some almost everyday. You don't (unless radiotherpy is very odd in your place). And Vancouver Island IS a piece of nowhere, as any other place away from Europe (25 and growing!) :) > But there is a FACT beneath my humorous comment! > Emigrants are usualy tougher and boulder people compared with their > starving contryman that had no courage/drive to seek a better life > away from home. > You should acknowledge that and feel proud about it instead of being > rude and insulting! Well, I admit you are an expert on rude and insulting, true. > There was another intention when changing to humor in replying you in > this thread -- making you realize that you don't have to persist in > having the last word in a subject you aren't an expert in. > I've done thousands of aspirations and biopsies and still do some > almost everyday. You don't (unless radiotherpy is very odd in your > place). I've done hundreds, not thousands, but I don't do them now because I have a very slick pathologist who does them better. I guess the real issue is how many of your thousands were indicated.... It's your place which seems to have odd "radiotherapy". We have radiation oncology here. > And Vancouver Island IS a piece of nowhere, as any other place away > from Europe (25 and growing!) > :) As a European, I am ashamed of your parochialism > > 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). [quoted text clipped - 3 lines] > A few questions if you don't mind: Are you a doctor who has given bone > marrow biopsies (BMB)? I am > What meds did you give the patients before giving > them the BMBs? Local anaesthesia only >Have you ever actually had one done to yourself? No. I haven't had a laparotomy or an MRI scan either..... > Did all the > patients you gave them to respond identically to all the other patients you [quoted text clipped - 7 lines] > > 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 . > 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 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 > . > [quoted text clipped - 13 lines] > 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! > > 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 [quoted text clipped - 10 lines] > 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 |
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