Smarter Decisions,
Better Care

UpToDate synthesizes the most recent medical information into evidence-based practical recommendations clinicians trust to make the right point-of-care decisions.

  • Rigorous editorial process: Evidence-based treatment recommendations
  • World-Renowned physician authors: over 5,100 physician authors and editors around the globe
  • Innovative technology: integrates into the workflow; access from EMRs

Choose from the list below to learn more about subscriptions for a:


Subscribers log in here


Related Searches

Bone marrow aspiration and biopsy: Indications and technique

INTRODUCTION

Bone marrow examination is useful in the diagnosis and staging of hematologic disease, as well as in the assessment of overall bone marrow cellularity. Because of easy accessibility, aspiration, biopsy, and culture of the bone marrow may also play a role in the assessment of patients with fever of undetermined origin as well as in the diagnosis of various storage and infiltrative disorders.

The indications, contraindications, technique, and complications of bone marrow aspiration and biopsy will be reviewed here [1]. Evaluation of bone marrow aspirates and biopsies is presented separately. (See "Evaluation of bone marrow aspirate smears".)

BACKGROUND INFORMATION

The bone marrow is one of the most widely distributed organs in the human body. It is the principal site of blood formation beginning at the time of birth, at which time all bone cavities are filled with hematopoietic tissue. (See "Overview of hematopoiesis and stem cell function", section on 'Bone marrow anatomy and microenvironment'.)

By adolescence, active marrow is usually only found in the cavities of axial bones (sternum, ribs, vertebrae, clavicles, scapulae, skull, pelvis, and the proximal ends of the femurs and humeri) (image 1) [2,3]. Overall bone marrow cellularity approximates 100 percent at birth and declines with time, paralleling an age-associated reduction in hematopoietic activity. Accordingly, bone marrow cellularity in the normal adult is approximately 50 percent, with the remainder of the marrow being composed of adipose tissue (picture 1). (See "Evaluation of bone marrow aspirate smears", section on 'Estimation of cellularity and myeloid to erythroid ratio'.)

Under physiologic conditions, all sites of hematopoiesis tend to exhibit uniform cellularity and cell lineage proportions. Thus, generalizations can be made regarding overall hematopoiesis from the evaluation of bone marrow at a single site. In most hematologic disorders, study of bone marrow at multiple sites has not been shown to improve diagnostic accuracy [2]. Exceptions include malignancies which may have patchy marrow involvement (eg, multiple myeloma, lymphoma, metastatic disease), requiring either larger specimens or specimens from multiple sites (see 'Adequacy of the biopsy specimen' below).

                                          

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Oct 2014. | This topic last updated: Sep 17, 2014.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2014 UpToDate, Inc.
References
Top
  1. Malempati S, Joshi S, Lai S, et al. Videos in clinical medicine. Bone marrow aspiration and biopsy. N Engl J Med 2009; 361:e28.
  2. Foucar K. Bone Marrow Pathology, 2nd ed, ASCP Press, Chicago 2001.
  3. Ryan DH, Cohen HJ. Bone marrow aspiration and morphology. In: Hematology: Basic Principles and Practice, 3rd ed, Hoffman R, Benz EJ, Shattil SJ, et al. (Eds), Churchill Livingstone, Philadelphia 2000. p.2460.
  4. Bain BJ. Bone marrow aspiration. J Clin Pathol 2001; 54:657.
  5. Subramanian R, Basu D, Badhe B, Dutta TK. Role of bone marrow trephine biopsy in the diagnosis of marrow involvement in Hodgkin's disease. Indian J Pathol Microbiol 2007; 50:640.
  6. Ozkalemkas F, Ali R, Ozkocaman V, et al. The bone marrow aspirate and biopsy in the diagnosis of unsuspected nonhematologic malignancy: a clinical study of 19 cases. BMC Cancer 2005; 5:144.
  7. Moid F, DePalma L. Comparison of relative value of bone marrow aspirates and bone marrow trephine biopsies in the diagnosis of solid tumor metastasis and Hodgkin lymphoma: institutional experience and literature review. Arch Pathol Lab Med 2005; 129:497.
  8. Subramanian R, Basu D, Dutta TK. Significance of bone marrow fibrosis in multiple myeloma. Pathology 2007; 39:512.
  9. Ahmad Z, Durrani NU, Hazir T. Bone marrow examination in ITP in children: is it mandatory ? J Coll Physicians Surg Pak 2007; 17:347.
  10. Herndon G, Rogers HJ. Multiple "doughnut" granulomas in Coxiella burnetii infection (Q fever). Blood 2013; 122:3099.
  11. Dittus C, Semmel D. Leishmania amastigotes visualized on bone marrow aspirate in a leishmaniasis and HIV coinfected patient presenting with pancytopenia. Blood 2013; 122:4162.
  12. Xu Z, Roth VR. BCGitis induced inflammatory granuloma of the bone marrow. Blood 2014; 123:613.
  13. Emani M, Malhotra S, Rana F. Bone marrow aspirate showing Histoplasma capsulatum. Blood 2014; 123:957.
  14. Suner L, Mathis S. Disseminated cryptococcosis in bone marrow. Blood 2014; 123:3070.
  15. Hyun BH, Gulati GL, Ashton JK. Bone marrow examination: techniques and interpretation. Hematol Oncol Clin North Am 1988; 2:513.
  16. ELLIS LD, JENSEN WN, WESTERMAN MP. NEEDLE BIOPSY OF BONE AND MARROW; AN EXPERIENCE WITH 1,445 BIOPSIES. Arch Intern Med 1964; 114:213.
  17. Rebulla P. Platelet transfusion trigger in difficult patients. Transfus Clin Biol 2001; 8:249.
  18. Eikelboom JW. Bone marrow biopsy in thrombocytopenic or anticoagulated patients. Br J Haematol 2005; 129:562.
  19. Johns Hopkins: The Harriet Lane Handbook: A Manual for Pediatric House Officers, 16th ed, Mosby, 2002.
  20. Devaliaf V, Tudor G. Bone marrow examination in obese patients. Br J Haematol 2004; 125:538.
  21. Talamo G, Liao J, Joudeh J, et al. Perceived levels of pain associated with bone marrow aspirates and biopsies. J Support Oncol 2012; 10:166.
  22. von Gunten CF, Soskins M. Bone marrow biopsy symptom control and palliative care consultation. J Pain Symptom Manage 2007; 33:236.
  23. Talamo G, Liao J, Bayerl MG, et al. Oral administration of analgesia and anxiolysis for pain associated with bone marrow biopsy. Support Care Cancer 2010; 18:301.
  24. Henry DW, Burwinkle JW, Klutman NE. Determination of sedative and amnestic doses of lorazepam in children. Clin Pharm 1991; 10:625.
  25. Burkle CM, Harrison BA, Koenig LF, et al. Morbidity and mortality of deep sedation in outpatient bone marrow biopsy. Am J Hematol 2004; 77:250.
  26. Dunlop TJ, Deen C, Lind S, et al. Use of combined oral narcotic and benzodiazepine for control of pain associated with bone marrow examination. South Med J 1999; 92:477.
  27. Milligan DW, Howard MR, Judd A. Premedication with lorazepam before bone marrow biopsy. J Clin Pathol 1987; 40:696.
  28. Vanhelleputte P, Nijs K, Delforge M, et al. Pain during bone marrow aspiration: prevalence and prevention. J Pain Symptom Manage 2003; 26:860.
  29. Gudgin EJ, Besser MW, Craig JI. Entonox as a sedative for bone marrow aspiration and biopsy. Int J Lab Hematol 2008; 30:65.
  30. Steedman B, Watson J, Ali S, et al. Inhaled nitrous oxide (Entonox) as a short acting sedative during bone marrow examination. Clin Lab Haematol 2006; 28:321.
  31. Parapia LA. Trepanning or trephines: a history of bone marrow biopsy. Br J Haematol 2007; 139:14.
  32. Douglas DD, Risdall RJ. Bone marrow biopsy technic. Artifact induced by aspiration. Am J Clin Pathol 1984; 82:92.
  33. Brynes RK, McKenna RW, Sundberg RD. Bone marrow aspiration and trephine biopsy. An approach to a thorough study. Am J Clin Pathol 1978; 70:753.
  34. Brunning RD, Bloomfield CD, McKenna RW, Peterson LA. Bilateral trephine bone marrow biopsies in lymphoma and other neoplastic diseases. Ann Intern Med 1975; 82:365.
  35. Menon NC, Buchanan JG. Bilateral trephine bone marrow biopsies in Hodgkin's and non-Hodgkin's lymphoma. Pathology 1979; 11:53.
  36. Juneja SK, Wolf MM, Cooper IA. Value of bilateral bone marrow biopsy specimens in non-Hodgkin's lymphoma. J Clin Pathol 1990; 43:630.
  37. George TB, Natkunam FL, Geaghan Y, et al. Bone marrow biopsy for focal disease detection: evaluation of optimal biopsy length and comparison of bilateral to equivalent-length unilateral biopsies. Mod Pathol 2004; 17:248a.
  38. Campbell JK, Matthews JP, Seymour JF, et al. Optimum trephine length in the assessment of bone marrow involvement in patients with diffuse large cell lymphoma. Ann Oncol 2003; 14:273.
  39. Hazarika B. Touch imprint matters…. Blood 2013; 121:2585.
  40. Ferrant A, Rodhain J, Cordier A, et al. Selective hypoplasia of pelvic bone marrow. Scand J Haematol 1980; 25:12.
  41. Ghosh K. Bone marrow examination in obese patients: CAT or not to CAT! Br J Haematol 2004; 127:230.
  42. 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.
  43. Knowles S, Hoffbrand AV. Bone-marrow aspiration and trephine biopsy (1). Br Med J 1980; 281:204.
  44. Knowles S, Hoffbrand AV. Bone-marrow aspiration and trephine biopsy (2). Br Med J 1980; 281:280.
  45. Riley RS, Hogan TF, Pavot DR, et al. A pathologist's perspective on bone marrow aspiration and biopsy: I. Performing a bone marrow examination. J Clin Lab Anal 2004; 18:70.
  46. Bain BJ. Bone marrow biopsy morbidity and mortality. Br J Haematol 2003; 121:949.
  47. Bain BJ. Morbidity associated with bone marrow aspiration and trephine biopsy - a review of UK data for 2004. Haematologica 2006; 91:1293.
  48. Salem P, Wolverson MK, Reimers HJ, Kudva GC. Complications of bone marrow biopsy. Br J Haematol 2003; 121:821.
  49. Le Dieu R, Luckit J, Sundarasun M. Complications of trephine biopsy. Br J Haematol 2003; 121:822.
  50. Pedersen LM, Jarner D, Winge J. Bone-marrow biopsy of the iliac bone followed by severe retroperitoneal hemorrhage. Eur J Haematol 1993; 51:52.
  51. Bailey MA, Farquharson NR, Coughlin PA, et al. Internal iliac artery pseudoaneurysm in an infant following bone marrow trephine biopsy. Br J Haematol 2011; 153:1.
  52. Sullivan CM, Regi JM. Pseudoaneurysm of the superior gluteal artery following bone marrow biopsy. Br J Haematol 2013; 161:289.
  53. Citron ML, Krasnow SH, Grant C, Cohen MH. Tumor seeding associated with bone marrow aspiration and biopsy. Arch Intern Med 1984; 144:177.
  54. Kansara G, Hussain M, Dimauro J. A case of plasmacytoma in muscle as a complication of needle tract seeding after percutaneous bone marrow biopsy. Am J Clin Pathol 1989; 91:604.
  55. Ginaldi S, Williams CD. Seeding of malignant lymphoma along the tract after bone marrow biopsy. South Med J 1985; 78:1007.
  56. van Marum RJ, te Velde L. Cardiac tamponade following sternal puncture in two patients. Neth J Med 2001; 59:39.
  57. Roth JS, Newman EC. Gluteal compartment syndrome and sciatica after bone marrow biopsy: a case report and review of the literature. Am Surg 2002; 68:791.
  58. Gilsanz V, Grunebaum M. Radiographic appearance of lliac marrow biopsy sites. AJR Am J Roentgenol 1977; 128:597.
  59. Murphy WA. Exostosis after iliac bone marrow biopsy. AJR Am J Roentgenol 1977; 129:1114.
  60. Singer J, Cole J, Vas W. Bone marrow biopsy changes in the iliac bone mimicking multiple colonic polypi. Australas Radiol 1990; 34:262.
  61. Roman MR, Angelides S. Extrarenal uptake of 99mTc-DTPA at the site of bone marrow biopsy. Ann Nucl Med 2002; 16:143.
  62. Minnema MC, de Keizer B. False-positive PET scan after bone marrow biopsy. Br J Haematol 2013; 161:753.