HUSAIN ALKHALDY · REVIEWS  —  REVIEW

Bone marrow aspiration and biopsy: an evidence-based review

Husain Alkhaldy

HaematologyInterventional radiologyLiterature searched to 2 October 2026
Search strategy and selection criteria

We searched PubMed to 2 October 2026 for “bone marrow biopsy”, “bone marrow aspiration”, “bone marrow examination” and “trephine”, combined with terms for history, indications, specimen adequacy and length, needle type, pain, analgesia, sedation, powered devices, complications, haemorrhage, anticoagulation, thrombocytopenia, obesity, and CT, fluoroscopic, ultrasound, PET/CT and SPECT/CT guidance. Randomised trials, meta-analyses, national surveys and large cohorts were prioritised; single-centre series were used where nothing stronger exists, as is the case for most image-guided techniques. Dates for the early history were checked against historical reviews; the primary papers from 1903 to 1952 were not re-read. Every reference was checked against its PubMed record. Quantitative results were taken from the published abstracts.

Introduction

Bone marrow examination underpins the diagnosis of leukaemia, myelodysplasia, myeloma, the myeloproliferative neoplasms and marrow failure, and much of the staging of lymphoma and childhood solid tumours. The aspirate and the trephine biopsy answer different questions and are complementary: the aspirate carries morphology, flow cytometry, cytogenetics and molecular testing, while the trephine shows cellularity, fibrosis, architecture and patchy infiltrates, and is the only specimen when the aspirate is a dry tap.1 In 2026 the International Council for Standardization in Haematology (ICSH) revised its 2008 guidance for the first time, putting the integrated report — morphology, immunophenotype and genetics read together against current classifications — at its centre.2

Three developments justify a review of how the specimen is obtained. Powered drivers have been tested in randomised trials. Image guidance with CT, fluoroscopy, ultrasound and PET/CT is now widely available, and its cost has been modelled. And PET/CT has removed the indication for staging biopsy in several lymphomas. This review covers the history of the procedure, its indications, technique, analgesia and safety, and gives particular attention to the patient in whom a blind biopsy is difficult or likely to miss disease.

History of the procedure

Trephination of the skull is the oldest surgical act known, and the trephine was adapted to the marrow only in the twentieth century.3 Table 1 gives the milestones.

Table 1 · Milestones in bone marrow sampling

YearMilestoneSignificance
1903Pianese samples marrow by trephining the femurFirst marrow sampling for diagnosis
1908Giovanni Ghedini (1877–1959) conceives clinical marrow sampling4Marrow study enters clinical haematology
Early 1920sSeyfarth aspirates the sternum with a needleThe needle replaces the open trephine
1926–29Arinkin refines sternal puncture, published in Folia Haematologica in 1929Sternal aspiration becomes the standard for three decades
c 1950–52The pelvis, then specifically the posterior iliac crest (Bierman, 1952), proposed as the site5A safer site with a larger marrow volume, and room for a core
1971Jamshidi and Swaim describe a tapered core needle giving “unaltered architecture”6,7Aspirate and core from one site under local anaesthesia; still the reference manual needle
1995–2003British Society for Haematology surveys of adverse events8The first quantified estimate of risk
2011–12Randomised trials of a battery-powered driver9,10Powered access enters routine practice
2010s–20sCT, fluoroscopic, ultrasound and PET/CT guidance; PET/CT replaces staging biopsy in some lymphomasTargeted options for the difficult patient and the focal lesion

Dates for Pianese, Seyfarth, Arinkin and Bierman follow historical reviews;3 the primary papers were not re-read for this review.

Sternal aspiration survives as a fallback, but it is aspiration only, never trephine. In 129 patients who had CT after sternal aspiration, 69 showed irregularity and thinning of the inner cortex, three a sternal foramen and one an incomplete fracture, which argues against routine use where the iliac crest is accessible.11

Indications, contraindications and site

When to sample the marrow

The ICSH lists the core indications: unexplained cytopenias; suspected leukaemia, myelodysplasia, myeloma, myeloproliferative neoplasm or marrow failure; staging and response assessment of lymphoma and of some solid tumours of childhood; fever of unknown origin and suspected granulomatous or opportunistic infection, with culture; storage disorders; and measurable residual disease testing.1,2 Since 2014, the Lugano classification no longer requires a staging biopsy in Hodgkin lymphoma or most diffuse large B-cell lymphomas when PET/CT is done.12

Typical immune thrombocytopenia is not an indication. Among 353 patients with isolated thrombocytopenia, marrow examination gave no new diagnosis,13 and among 324 adults with relapsed or refractory immune thrombocytopenia, the marrow was abnormal in 4% of those examined.14

Contraindications

Contraindications are relative: infection of the skin or bone at the site; previous radiotherapy to the field, which leaves a hypocellular, unrepresentative marrow; and severe uncorrected coagulopathy such as haemophilia without factor cover. Thrombocytopenia alone is not a contraindication (see Bleeding risk).

Choice of site

The posterior iliac crest, approached at the posterior superior iliac spine with the patient in the lateral decubitus position, is the standard site in adults and children. In a cadaver and CT study, angling the needle laterally toward the ipsilateral anterior superior iliac spine caused less neurovascular injury and avoided the sacroiliac joint compared with a straight anterior path.15 Table 2 gives the alternatives.

Table 2 · Sampling sites

SiteUseCaveats
Posterior iliac crestAspirate and trephine; first choice in adults and childrenAim laterally, toward the ipsilateral anterior superior iliac spine15
Anterior iliac crestAspirate with or without trephine when the patient cannot lie prone or lateral, or the posterior crest has been irradiatedThinner cortex, smaller marrow cavity, shorter cores
SternumAspirate only, adultsNever trephine; inner-cortex abnormalities common on CT11
Proximal anteromedial tibiaInfants, generally under 1–2 yearsStandard paediatric practice; little comparative evidence
Vertebral body or other boneFocal lesionsImage guidance only (see The difficult patient)

Technique and specimen quality

Core length and the number of sites

In 172 patients with diffuse large cell lymphoma, marrow involvement was found in 20% of trephines shorter than 20 mm and in 35% of those 20 mm or longer (p=0·023). Yield rose with the number of levels examined but did not depend on the number of sites sampled, so one long core examined at four or more levels can replace bilateral biopsy.16 A core of at least 15 mm of evaluable marrow is the general standard, and 20 mm the target for lymphoma staging.

The operator

Who performs the biopsy matters more than any other measured factor. In 1191 specimens, cores taken by a dedicated in-house team had a mean of 16·0 mm of interpretable marrow, against 10·0 mm and 7·0 mm for two groups of referred specimens; the 15 mm standard was reached in 61·4%, 26·6% and 19·1%, and spicules were present in 93% of in-house aspirates against 71–74%.17 Referred specimens also needed more immunohistochemistry, flow cytometry and genetic testing. Across 1938 trephines from five institutions, the proportion of adequate cores ranged from 15·9% to 87·8% between operators, and was best among those performing more than 100 biopsies in 30 months.18 Feedback works: in one quality-improvement project, education and sharing each operator's data raised mean core length from 12·8 mm to 15·2 mm, and switching from an 11-gauge to an 8-gauge needle gave 18·3 mm against 13·3 mm.19

Needle and aspiration technique

In 280 specimens reviewed blind, triple-bevel manual needles gave 1·33 mm less evaluable marrow than single-bevel needles, and were 4·2 times more likely to cause crush artefact and 2·4 times more likely to give a haemodilute aspirate.20 In a randomised trial of 482 patients, slow aspiration was more likely than rapid aspiration to give a poor-quality aspirate, both for cellularity (odds ratio 3·05, 95% CI 1·79–5·31) and for particles (2·52, 1·51–4·28), while lowering median pain by only one point on a visual analogue scale.21 Rapid aspiration of a small first volume for morphology is therefore preferred. Taking the trephine through a separate puncture did not reduce artefact with a powered driver.22

Pain, analgesia and sedation

Under local anaesthesia alone, 70% of patients report pain and 35% describe it as severe.23 Anxiety before the procedure predicts pain in several trials, and is the most useful thing to ask about beforehand.24,25 Table 3 summarises the randomised evidence.

Table 3 · Randomised evidence on analgesia and distraction

InterventionDesignEffect on painVerdict
Warmed, buffered lidocaineRCT, n=100Infiltration pain median NRS 2·0 vs 4·0; no effect on aspiration or biopsy24Use; helps the first step only
Inhaled methoxyfluraneDouble-blind RCT, n=100Worst pain 4·90 vs 6·0; during aspiration 3·3 vs 5·0; grade 1 adverse events 20·4% vs 4·2%23Effective where licensed
50% nitrous oxide in oxygenPatient-blinded RCT, n=70No difference from 50% oxygen25Not supported alone
Sublingual fentanyl 100–200 μgRCT, n=160No difference; more dizziness26Do not use
Intravenous lorazepam 1 mgRCT, n=138VAS 6·0 vs 6·2; patients more willing to repeat27Anxiolysis, not analgesia
Virtual reality vs nitrous oxidePhase 3 RCT, n=126VAS 3·0 vs 3·5, no difference28Alternative when nitrous oxide is contraindicated
Distraction; powered device; acupoint stimulationMeta-analysis, 18 studies, 1017 patientsSMD −0·85, −0·27 and −1·02; hypnosis not significant29Distraction is cheap and reasonable
MusicMeta-analysis, 4 studies, 257 patientsSMD −1·0530GRADE certainty very low
Short film before the procedure, childrenRCT, n=60Lower pain (p=0·001), higher satisfaction31Exploratory

RCT=randomised controlled trial. NRS=numerical rating scale (0–10). VAS=visual analogue scale (0–10). SMD=standardised mean difference.

Children usually have the procedure under deep sedation or general anaesthesia. In adults, propofol sedation is feasible at scale: among 12 134 consecutive procedures in one outpatient centre, problems were confined to febrile patients who also had a productive cough and oxygen saturation below 92%.32

Powered and manual needles

Four small randomised trials, with 256 patients in total, compared a battery-powered driver with manual needles (Table 4). The powered device roughly halved procedure time and gave longer or larger cores; pain was modestly lower, mainly at needle insertion and in patients without sedation. The gain was largest for operators in training.33 Retrospective series give a less favourable picture of quality: cores were longer but carried more crush artefact, so a longer core did not always mean more evaluable marrow.22,34 None of the trials blinded patients or operators.

Table 4 · Powered compared with manual biopsy

StudyDesignTime, powered vs manualCorePain
Berenson et al9RCT, 10 sites, n=102102 vs 203 sVolume 36·8 vs 20·4 mm³; quality similarOverall VAS 3·8 vs 3·5 (NS); pain-free next day 67% vs 33%
Swords et al10RCT, 2 centres, n=50100 vs 224 sArea 25·4 vs 11·9 mm²Insertion VAS 2·6 vs 4·1; end of procedure NS
Reed et al33RCT, trainees, n=54175 vs 292 sLength 15·3 vs 9·8 mmSubjective end points favoured powered
Bucher et al35RCT, expert operators, n=50SimilarDiagnostic 25/30 vs 24/30; length similarSimilar overall; without sedation median 3 vs 7
Lynch et al34Paired retrospective, 68 patients—Longer (16·9 vs 14·4 mm) but less evaluable marrow (7 vs 9·7 mm)—
Forwood et al22Retrospective, 164 trephines—Similar assessable length; more crush artefact—
Mihailescu et al36Retrospective, 439 patients—Length 14·3 vs 11·2 mm; interpretability equal—

NS=not significant.

Powered drivers are most useful for trainees, for unsedated patients, and for patients with deep or dense bone, including obese patients.36 They are also the usual instrument for fluoroscopic biopsy by radiologists. Device cost is the main barrier.

Complications and safety

How often things go wrong

The British Society for Haematology surveys remain the largest source. Between 1995 and 2001, 26 adverse events, including one death, were reported among an estimated 54 890 biopsies; haemorrhage was the commonest and most serious, and the associated factors were a myeloproliferative neoplasm, aspirin, warfarin, disseminated intravascular coagulation and obesity.8 In 2002 there were 17 events in 13 506 procedures, including nine haemorrhages, four infections and two broken needles.37 In 2003 there were 16 in 19 259 (0·08%), 11 of them haemorrhage; the risk factors, in order, were a myeloproliferative neoplasm, aspirin, other platelet dysfunction and thrombocytopenia.38

Later data shift attention from the laboratory to the needle. In 443 palpation-guided iliac biopsies followed by pelvic imaging within 30 days, 22% of tracts were improper, and all 11 complications (nine bleeds, one fracture, one facet-joint injury) occurred in those. Operators with 12 months' experience or less were more likely to misdirect the needle; platelet count, INR, antiplatelet and anticoagulant use were not associated with complications.39 Retroperitoneal haematoma after penetration of the inner cortex is the classic catastrophic event.40 Infection is rare but can be serious, including iliopsoas abscess and sacroiliac osteomyelitis.41

Bleeding risk

In 981 CT-guided biopsies there was no bleeding of Society of Interventional Radiology class C or above, including in 187 patients with platelets of 20–50×10⁹ per L and 33 below 20×10⁹ per L.42 Fluoroscopic drill biopsy in patients with platelets below 20×10⁹ per L produced no excess of haematoma on CT.43 In 524 biopsies managed by a standard protocol there was no major bleeding; clinically relevant non-major bleeding (0·19%) was linked to a low platelet count and not to coagulation tests or antithrombotic therapy, with or without bridging.44 Routine prophylactic platelet transfusion is not needed above about 20×10⁹ per L.

Marrow biopsy is a procedure of low to moderate bleeding risk, and routine interruption of anticoagulation is not consistently recommended.45 The Society of Interventional Radiology consensus sets out periprocedural management for image-guided procedures;46 its thresholds were not re-read for this review. Patients with a myeloproliferative neoplasm need extra care because of acquired von Willebrand syndrome.45 After the procedure, a compression dressing without a sandbag gave no more bleeding and less pain at two hours.47

The difficult patient: image-guided biopsy

Image guidance earns its cost in two situations: when the crest cannot be found or reached, and when disease is focal and an iliac biopsy may miss it. For diffuse disease in a patient whose landmarks can be felt, a blind biopsy gives specimens of equal quality at about a twelfth of the cost of CT.48

Why blind biopsy fails

Body habitus is the commonest reason. In a series of 301 CT-guided and 317 matched blind biopsies, patients referred for CT had a mean body-mass index of 34·4 against 26·8 kg/m², and a skin-to-bone distance of 4·8 against 2·5 cm. The commonest reasons for referral were large body habitus (47·7%), a failed attempt (18·8%) and no stated reason (17·4%).48 Misdirection is the second: in the imaging series above, 22% of palpation-guided tracts were improper, and inexperience, not body-mass index, predicted it.39 Focal disease is the third. In aggressive lymphoma, seven of nine patients with marrow lesions on MRI and PET/CT had them away from the iliac crest, where the blind biopsy had been taken.49

The options compared

Table 5 · Approaches to the difficult biopsy

ApproachBest forEvidenceYield and safetyTrade-offs
Landmark, manual or poweredDefault; diffuse disease; palpable posterior superior iliac spineDecision model50Most cost-effective strategy in 100% of simulationsDepends on the operator; misdirected tracts
CT-guidedObesity; failed attempt; abnormal anatomy; focal or non-iliac targets301 CT vs 317 blind;48 981 patients, including thrombocytopenia42Quality equal to blind biopsy, longer cores; no bleeding of class C or aboveUS$3945 vs $310; ICER $334 043 per QALY against landmark;50 radiation
CT without a planning scanAs for CT109 patients51Same yield and procedure timeDose–length product 51 vs 269 mGy·cm (−81%)
Fluoroscopy with a powered drillBusy interventional practice with little CT time775 procedures;52 technical notes53,54Diagnostic in 95·0%; complications 0·3%; safe below 20×10⁹ platelets per L43Excluded by extended dominance in the cost model50
Ultrasound localisationObesity at the bedside; no radiation254 patients, BMI up to 54;55 20 patients56Technical success 100%, no adverse events, no dry tapsSingle-centre, retrospective, no comparator; finds the spine, cannot see into bone
PET/CT-targetedFDG-avid focal lesions in lymphoma299 lymphomas;57 44 with robotic-arm guidance58Sensitivity 92·5% vs 52·5% for iliac trephine; iliac biopsy false-negative in 25 of 30 focal casesNeeds a PET/CT suite; selective use
SPECT/CT-targetedSuspected bone metastases49 patients with breast cancer59Higher negative predictive value than SPECT/CT alone; receptor status often changed in the metastasisSingle centre
Photon-counting CT with marrow-oedema mapsComplex bone lesions10 patients60Yield 70%, accuracy 87·5%Exploratory; dose–length product about 645 mGy·cm

ICER=incremental cost-effectiveness ratio. QALY=quality-adjusted life-year. BMI=body-mass index (kg/m²). FDG=fluorodeoxyglucose. Costs in US dollars, from one US institution and one US model.

A practical approach

Marrow sampling needed Focal avid lesion on PET/CT? Targeted biopsy under PET/CT or CT guidance add iliac trephine if uptake diffuse PSIS palpable and reachable? Landmark biopsy, manual or powered Ultrasound to find PSIS, longer needle or driver CT or fluoroscopic guidance, low-dose, no planning CT yes yes no no fails, or non-iliac target
Figure · Choosing guidance for marrow biopsy. Landmark biopsy remains the default; imaging is added for focal disease or when the crest cannot be reached. PSIS=posterior superior iliac spine.
  1. Use the patient's previous CT or MRI to measure the depth from skin to the posterior superior iliac spine, and choose the needle length before the procedure.
  2. A longer needle, a powered driver, or ultrasound localisation of the spine will rescue many obese patients without referral for CT.
  3. Refer for CT or fluoroscopic guidance after one failed attempt, for a target outside the iliac crest, or when the posterior crest has been irradiated or fused.
  4. Ask for a low-dose protocol without a full planning scan.51
  5. When PET/CT shows focal FDG-avid lesions, biopsy the lesion under PET/CT or CT guidance. An iliac trephine is still needed when uptake is diffuse or absent.57

The evidence for image guidance is retrospective and mostly single-centre. No trial has randomised obese patients between CT-guided and landmark biopsy, and the cost argument rests on one decision model and one institution's billing data.48,50

PET/CT and the indication for biopsy

The biggest change in practice is fewer biopsies rather than a better needle. Across 13 studies of 2396 patients with non-Hodgkin lymphoma, PET/CT was more sensitive than marrow biopsy, with a summary area under the curve of 0·977 against 0·692.61 This does not apply to every subtype. In mature T-cell and NK-cell lymphomas, PET/CT had a pooled sensitivity of 0·62; its negative predictive value was excellent in early-stage disease but its specificity fell to 0·77 in advanced stages.62 Biopsy remains necessary in low-grade lymphoma, myeloma and the leukaemias, and when PET/CT uptake is diffuse or negative.57

Uncertainties and future research

  • No trial has randomised obese patients between CT-guided and landmark biopsy, and no study has compared ultrasound with CT directly.
  • The powered-device trials total 256 patients; none blinded patients or operators, and later series disagree about artefact.
  • There are no modern prospective complication data. The published national survey data stop in 2003, before direct oral anticoagulants were in use.
  • Few trials have enrolled obese or highly anxious patients, the groups with the most pain and the most failed attempts.
  • All cost data come from the USA; settings with different prices and access to CT are unstudied.

Conclusion

A century after Pianese and Ghedini, the marrow is still sampled from the iliac crest with a hand-held needle, and the procedure is safe. What determines a useful specimen is mostly the operator and the length of the core, both of which a service can improve by concentrating the work and feeding back the results. Pain is undertreated, and the adjuncts that work are cheap. Image guidance should be reserved for the patients who need it: those in whom the crest cannot be reached, and those whose disease is focal. For many patients with lymphoma, PET/CT now makes the biopsy unnecessary.

Contributors and a note on method

Husain Alkhaldy is the sole author. The literature search and the text were prepared with the help of AI; every reference was checked against its PubMed record, and the author approved the review for publication. This review is written for clinicians and is not a substitute for a guideline or for the judgement of the physician treating the patient.

References

  1. Lee SH, Erber WN, Porwit A, Tomonaga M, Peterson LC. ICSH guidelines for the standardization of bone marrow specimens and reports. Int J Lab Hematol 2008; 30: 349–64. doi:10.1111/j.1751-553X.2008.01100.x PMID 18822060
  2. Erber WN, Tzankov A, Pozdnyakova O, Matsushita H, Zini G, Saft L. ICSH Guidance on Bone Marrow Examination and Reporting. Int J Lab Hematol 2026; published online. doi:10.1111/ijlh.70214 PMID 42695770
  3. Parapia LA. Trepanning or trephines: a history of bone marrow biopsy. Br J Haematol 2007; 139: 14–9. doi:10.1111/j.1365-2141.2007.06749.x PMID 17854303
  4. Pizzi M, Binotto G, Rigoni Savioli G, Dei Tos AP, Orazi A. Of drills and bones: Giovanni Ghedini and the origin of bone marrow biopsy. Br J Haematol 2022; 198: 943–952. doi:10.1111/bjh.18206 PMID 35510703
  5. Hernigou P. The history of bone marrow in orthopaedic surgery (part I trauma): trepanning, bone marrow injection in damage control resuscitation, and bone marrow aspiration to heal fractures. Int Orthop 2020; 44: 795–808. doi:10.1007/s00264-020-04506-z PMID 32060614
  6. Jamshidi K, Swaim WR. Bone marrow biopsy with unaltered architecture: a new biopsy device. J Lab Clin Med 1971; 77: 335–42. PubMed PMID 5540776
  7. Jamshidi K, Windschitl HE, Swaim WR. A new biopsy needle for bone marrow. Scand J Haematol 1971; 8: 69–71. doi:10.1111/j.1600-0609.1971.tb02673.x PMID 5566975
  8. Bain BJ. Bone marrow biopsy morbidity and mortality. Br J Haematol 2003; 121: 949–51. doi:10.1046/j.1365-2141.2003.04329.x PMID 12786808
  9. Berenson JR, Yellin O, Blumenstein B, et al. Using a powered bone marrow biopsy system results in shorter procedures, causes less residual pain to adult patients, and yields larger specimens. Diagn Pathol 2011; 6: 23. doi:10.1186/1746-1596-6-23 PMID 21429220
  10. Swords RT, Anguita J, Higgins RA, et al. A prospective randomised study of a rotary powered device (OnControl) for bone marrow aspiration and biopsy. J Clin Pathol 2011; 64: 809–13. doi:10.1136/jclinpath-2011-200047 PMID 21606230
  11. Fujita H, Nishimura S, Oyama K. [Retrospective study on CT findings on the sternal bone after bone marrow aspiration procedure in hematological patients]. Rinsho Ketsueki 2009; 50: 1687–91. PubMed PMID 20068275
  12. Cheson BD, Fisher RI, Barrington SF, et al. Recommendations for initial evaluation, staging, and response assessment of Hodgkin and non-Hodgkin lymphoma: the Lugano classification. J Clin Oncol 2014; 32: 3059–68. doi:10.1200/JCO.2013.54.8800 PMID 25113753
  13. Purohit A, Aggarwal M, Singh PK, et al. Re-evaluation of need for bone marrow examination in patients with isolated thrombocytopenia. Indian J Hematol Blood Transfus 2015; 32: 193–6. doi:10.1007/s12288-015-0533-2 PMID 27065582
  14. Taparia K, Wall E, Arnold DM, Sun HL. Frequency and utility of bone marrow examination in relapsed/refractory immune thrombocytopenia. J Thromb Haemost 2022; 20: 2119–2126. doi:10.1111/jth.15802 PMID 35751575
  15. Konda B, Pathak S, Edwin I, et al. Safe and successful bone marrow biopsy: an anatomical and CT-based cadaver study. Am J Hematol 2014; 89: 943–6. doi:10.1002/ajh.23790 PMID 24942104
  16. Campbell JK, Matthews JP, Seymour JF, Wolf MM, Juneja SK. Optimum trephine length in the assessment of bone marrow involvement in patients with diffuse large cell lymphoma. Ann Oncol 2003; 14: 273–6. doi:10.1093/annonc/mdg055 PMID 12562655
  17. Marinelli LM, Fang H, Howard MT, et al. Bone Marrow Biopsy Operator Experience and Impact on Aspirate, Biopsy, and Ancillary Testing Quality. Mayo Clin Proc Innov Qual Outcomes 2018; 2: 241–247. doi:10.1016/j.mayocpiqo.2018.06.007 PMID 30225457
  18. Rudzki Z, Partyła T, Okoń K, Stachura J. Adequacy of trephine bone marrow biopsies: the doctor and the patient make a difference. Pol J Pathol 2005; 56: 187–95. PubMed PMID 16477878
  19. Yang RK, Nazeef M, Patel SS, et al. Improving bone marrow biopsy quality through peer discussion and data comparisons: A single institution experience. Int J Lab Hematol 2018; 40: 419–426. doi:10.1111/ijlh.12804 PMID 29575638
  20. Brestoff JR, Toland A, Afaneh K, et al. Bone Marrow Biopsy Needle Type Affects Core Biopsy Specimen Length and Quality and Aspirate Hemodilution. Am J Clin Pathol 2019; 151: 185–193. doi:10.1093/ajcp/aqy126 PMID 30307478
  21. Grønkjær M, Hasselgren CF, Østergaard AS, et al. Bone Marrow Aspiration: A Randomized Controlled Trial Assessing the Quality of Bone Marrow Specimens Using Slow and Rapid Aspiration Techniques and Evaluating Pain Intensity. Acta Haematol 2015; 135: 81–7. doi:10.1159/000438480 PMID 26505268
  22. Forwood KM, Lee E, Crispin PJ. Comparison of the bone marrow trephine sample quality between OnControl drill system and the Jamshidi needle. Int J Lab Hematol 2019; 41: 373–379. doi:10.1111/ijlh.12984 PMID 30779423
  23. Spruyt O, Westerman D, Milner A, Bressel M, Wein S. A randomised, double-blind, placebo-controlled study to assess the safety and efficacy of methoxyflurane for procedural pain of a bone marrow biopsy. BMJ Support Palliat Care 2013; 4: 342–8. doi:10.1136/bmjspcare-2013-000447 PMID 24644183
  24. Kuivalainen AM, Ebeling F, Rosenberg P. Warmed and buffered lidocaine for pain relief during bone marrow aspiration and biopsy. A randomized and controlled trial. Scand J Pain 2014; 5: 43–47. doi:10.1016/j.sjpain.2013.10.003 PMID 29913658
  25. Kuivalainen AM, Ebeling F, Poikonen E, Rosenberg PH. Nitrous oxide analgesia for bone marrow aspiration and biopsy - A randomized, controlled and patient blinded study. Scand J Pain 2015; 7: 28–34. doi:10.1016/j.sjpain.2015.01.001 PMID 29911602
  26. Kuivalainen AM, Ebeling F, Rosenberg PH. Pre-medication with sublingual fentanyl did not relieve pain associated with bone marrow aspiration and biopsy: a randomized feasibility trial. Eur J Pain 2013; 17: 1357–64. doi:10.1002/j.1532-2149.2013.00303.x PMID 23509019
  27. Park SH, Bang SM, Nam E, et al. A randomized double-blind placebo-controlled study of low-dose intravenous Lorazepam to reduce procedural pain during bone marrow aspiration and biopsy. Pain Med 2008; 9: 249–52. doi:10.1111/j.1526-4637.2006.00284.x PMID 18298709
  28. Le Du K, Septans AL, Maloisel F, et al. A New Option for Pain Prevention Using a Therapeutic Virtual Reality Solution for Bone Marrow Biopsy (REVEH Trial): Open-Label, Randomized, Multicenter, Phase 3 Study. J Med Internet Res 2023; 25: e38619. doi:10.2196/38619 PMID 36790852
  29. Li C, Zhang X, Zhuang X, et al. The effectiveness of non-pharmacological interventions on reducing pain in patients undergoing bone marrow aspiration and biopsy: A systematic review and meta-analysis of randomized controlled trials. J Clin Nurs 2024; 33: 2829–2848. doi:10.1111/jocn.17121 PMID 38549254
  30. Sheikhnezhad L, Magbouli K, Zahedi H, Hassankhani H. Music Therapy for Pain and Anxiety control in Patients Undergoing Bone Marrow Biopsy and Aspiration: A Systematic review and Meta-analysis. J Caring Sci 2026; 15: 9–19. doi:10.34172/jcs.026.33805 PMID 42388684
  31. Karakul A, Şaşmaz A, Doğan P, Düzkaya DS, Karahan F, Ünal S. The effect of short film on anxiety, fear, pain, and satisfaction in children undergoing bone marrow aspiration and biopsy: A randomized controlled trial. J Pediatr Nurs 2026; 89: 482–491. doi:10.1016/j.pedn.2026.05.017 PMID 42172856
  32. Warner ME, Martin DP, Muchtar E, Sprung J, Weingarten TN, Warner MA. Safety of Sedation for Patients Undergoing Bone Marrow Biopsy and Aspiration While Febrile. Mayo Clin Proc Innov Qual Outcomes 2017; 2: 26–29. doi:10.1016/j.mayocpiqo.2017.11.003 PMID 30225429
  33. Reed LJ, Raghupathy R, Strakhan M, et al. The OnControl bone marrow biopsy technique is superior to the standard manual technique for hematologists-in-training: a prospective, randomized comparison. Hematol Rep 2011; 3: e21. doi:10.4081/hr.2011.e21 PMID 22593813
  34. Lynch DW, Stauffer SL, Rosenthal NS. Adequacy of powered vs manual bone marrow biopsy specimens: a retrospective review of sequential marrow aspirates and biopsies in 68 patients. Am J Clin Pathol 2015; 143: 535–9. doi:10.1309/AJCP67WITVPVVTNF PMID 25780005
  35. Bucher CM, Lehmann T, Tichelli A, et al. Comparison of a powered bone marrow biopsy device with a manual system: results of a prospective randomised controlled trial. J Clin Pathol 2012; 66: 24–8. doi:10.1136/jclinpath-2012-201167 PMID 23105124
  36. Mihailescu SD, Jaselme P, Fontoura ML, et al. Comparison of bone marrow trephine sample quality between a drill-powered system and a manual needle system. Ann Diagn Pathol 2022; 59: 151952. doi:10.1016/j.anndiagpath.2022.151952 PMID 35468352
  37. Bain BJ. Bone marrow biopsy morbidity and mortality: 2002 data. Clin Lab Haematol 2004; 26: 315–8. doi:10.1111/j.1365-2257.2004.00630.x PMID 15485459
  38. Bain BJ. Bone marrow biopsy morbidity: review of 2003. J Clin Pathol 2005; 58: 406–8. doi:10.1136/jcp.2004.022178 PMID 15790706
  39. Khdhir M, Jabbour Y, Azzi C, El-Alam R, Muallem N, Moukaddam H. Complications associated with improper palpation-guided iliac bone marrow biopsy tracts identified on follow-up imaging. Skeletal Radiol 2022; 51: 2155–2166. doi:10.1007/s00256-022-04078-6 PMID 35612650
  40. Gundabolu K, Silva Aguiar R. Retroperitoneal hemorrhage following a bone marrow biopsy. Blood 2021; 138: 1283. doi:10.1182/blood.2021011319 PMID 34617998
  41. Tural-Kara T, Özdemir H, Fitöz S, Çiftçi E, Yalçınkaya F. Bone marrow aspiration complications: Iliopsoas abscess and sacroiliac osteomyelitis. Turk J Pediatr 2016; 58: 562–565. doi:10.24953/turkjped.2016.05.019 PMID 28621103
  42. Liu B, Limback J, Kendall M, et al. Safety of CT-Guided Bone Marrow Biopsy in Thrombocytopenic Patients: A Retrospective Review. J Vasc Interv Radiol 2017; 28: 1727–1731. doi:10.1016/j.jvir.2017.08.009 PMID 29042170
  43. Stensby JD, Long JR, Hillen TJ, Jennings JW. Safety of bone marrow aspiration and biopsy in severely thrombocytopenic patients. Skeletal Radiol 2020; 50: 915–920. doi:10.1007/s00256-020-03623-5 PMID 33011873
  44. Grange L, Killian M, Tavernier E, Fouillet L, Guyotat D, Chalayer E. Management of bone marrow biopsy related bleeding risks: a retrospective observational study. J Thromb Thrombolysis 2021; 54: 109–114. doi:10.1007/s11239-021-02616-y PMID 34817787
  45. Moore C, Kotchetkov R. Anticoagulation and bone marrow biopsy: is it safe to proceed? Hematology 2021; 26: 206–209. doi:10.1080/16078454.2021.1880762 PMID 33594950
  46. Patel IJ, Rahim S, Davidson JC, et al. Society of Interventional Radiology Consensus Guidelines for the Periprocedural Management of Thrombotic and Bleeding Risk in Patients Undergoing Percutaneous Image-Guided Interventions-Part II: Recommendations: Endorsed by the Canadian Association for Interventional Radiology and the Cardiovascular and Interventional Radiological Society of Europe. J Vasc Interv Radiol 2019; 30: 1168–1184.e1. doi:10.1016/j.jvir.2019.04.017 PMID 31229333
  47. Lee SH, Kim CG, Kwon J, et al. Comparison of Bleeding, Hematoma, Pain, and Discomfort After Bone Marrow Examination With or Without Sandbag Compression. Asian Nurs Res (Korean Soc Nurs Sci) 2021; 15: 150–156. doi:10.1016/j.anr.2021.02.004 PMID 33609762
  48. Alshumrani Y, Droukas D, Carney BJ, Willim R, Brook A, Wu JS. CT guided versus non-image guided bone marrow aspiration and biopsy: Comparison of indications, specimen quality and cost. Clin Imaging 2024; 113: 110236. doi:10.1016/j.clinimag.2024.110236 PMID 39106655
  49. Ribrag V, Vanel D, Leboulleux S, et al. Prospective study of bone marrow infiltration in aggressive lymphoma by three independent methods: whole-body MRI, PET/CT and bone marrow biopsy. Eur J Radiol 2007; 66: 325–31. doi:10.1016/j.ejrad.2007.06.014 PMID 17651934
  50. Gyftopoulos S, Cardoso MDS, Wu JS, Subhas N, Chang CY. Bone Marrow Biopsies: Is CT, Fluoroscopy, or no Imaging Guidance the Most Cost-Effective Strategy? Acad Radiol 2024; 31: 2880–2886. doi:10.1016/j.acra.2024.01.019 PMID 38290886
  51. Devita R, Chagarlamudi K, Durieux J, et al. Omission of Planning CT Reduces Patient Radiation Exposure during CT-Guided Bone Marrow Biopsy and Aspiration. Tomography 2021; 7: 747–751. doi:10.3390/tomography7040062 PMID 34842812
  52. Long JR, Stensby JD, Wiesner EL, Bryson WN, Hillen TJ, Jennings JW. Efficacy and safety of bone marrow aspiration and biopsy using fluoroscopic guidance and a drill-powered needle: clinical experience from 775 cases. Eur Radiol 2020; 30: 5964–5970. doi:10.1007/s00330-020-06987-3 PMID 32518988
  53. Tomasian A, Long J, Jennings JW. Fluoroscopy-guided bone marrow aspiration and biopsy: technical note. Diagn Interv Radiol 2021; 27: 283–284. doi:10.5152/dir.2021.20243 PMID 33599207
  54. Kaufman CS, Kuo KT, Anand K. Image Guided Bone Marrow Biopsy. Tech Vasc Interv Radiol 2021; 24: 100771. doi:10.1016/j.tvir.2021.100771 PMID 34861972
  55. Cushman C, Smith A, Morris K, et al. Enhancing conventional biopsies: ultrasound-guided percutaneous bone marrow biopsy and aspiration. J Ultrasound 2026; 29: 309–315. doi:10.1007/s40477-026-01125-z PMID 41845083
  56. Islam A. Ultrasound: a new tool for precisely locating posterior iliac crests to obtain adequate bone marrow trephine biopsy specimen. J Clin Pathol 2013; 66: 718–20. doi:10.1136/jclinpath-2013-201463 PMID 23493477
  57. Hao B, Zhao L, Luo NN, et al. Is it sufficient to evaluate bone marrow involvement in newly diagnosed lymphomas using 18F-FDG PET/CT and/or routine iliac crest biopsy? A new approach of PET/CT-guided targeted bone marrow biopsy. BMC Cancer 2018; 18: 1192. doi:10.1186/s12885-018-5104-0 PMID 30497426
  58. Mahdi RA, Dasagrathi V, Kumar R, et al. Comparison of automated robotic arm-assisted PET/computed tomography-guided metabolic bone marrow biopsy with conventional bone marrow trephine biopsy for evaluating bone marrow infiltration in newly diagnosed lymphoma. Nucl Med Commun 2026; 47: 1102–1110. doi:10.1097/MNM.0000000000002170 PMID 42087722
  59. Li X, An C, Zhang W. Is it sufficient to evaluate metastatic bone involvement in breast cancer using SPECT/CT? A new approach of SPECT/CT-guided targeted bone marrow biopsy. BMC Cancer 2022; 22: 614. doi:10.1186/s12885-022-09702-1 PMID 35659208
  60. Alvarez de Sierra Garcia B, Urtasun-Iriarte C, Nieto P, Alonso Burgos A. Photon-counting CT-guided bone biopsy with real-time bone marrow edema mapping. Eur Radiol Exp 2026; 10. doi:10.1186/s41747-026-00690-6 PMID 41838307
  61. Wang J, Zeng Q. Direct comparison of bone marrow biopsy and PET/CT for the detection of bone marrow infiltration in patients with non-Hodgkin lymphoma: a meta-analysis. Q J Nucl Med Mol Imaging 2024; 68: 161–168. doi:10.23736/S1824-4785.24.03529-5 PMID 38990192
  62. Guo L, Wang R, Hou N, Kuang A, Shen G. FDG PET/CT may replace bone marrow biopsy for the evaluation of bone marrow involvement in selected mature T- and natural killer-cell lymphomas: A meta-analysis. Eur J Radiol 2024; 172: 111353. doi:10.1016/j.ejrad.2024.111353 PMID 38320330