Bone Marrow Aspiration

The procedure known as trepanning, or trephination, of bone is the oldest surgical practice that continues to have clinical relevance in modern times.

Bone marrow consists of stem cells, which are large, "primitive," undifferentiated cells supported by fibrous tissue called stroma. There are two main types of stem cells, and thus, bone marrow consists of two types of cellular tissue. One type of stem cell is involved in producing blood cells, and the other is involved in producing stromal cells, which are responsible for the supporting stroma.

Sampling of the marrow consists of aspiration of the cellular component, acquisition of tissue fragments, or both. Aspiration of the marrow has been primarily utilized for cytologic assessment, with analysis directed toward assessing the morphology and obtaining a differential cell count. Further sampling allows material to be directed toward other ancillary tests, such as cytogenetics, molecular studies, microbiologic cultures, immunohistochemistry, and flow cytometry.

Biopsies, on the other hand, allow evaluation of the marrow’s overall cellularity, detection of focal lesions, and determination of the extent of infiltration by various pathologic entities.

For patient education information, see the Osteoporosis Center and the Cancer Center, as well as Bone Marrow Biopsy.

  • Patient Education and Consent
  • Obtain informed patient consent that provides procedural information and potential complications (eg, hemorrhage, infections, and pain . This will minimize any apprehension that the patient may have.

Bone marrow biopsies can be done regardless of the platelet count and while the patient is on anticoagulation, provided that the INR is not severely abnormal (eg, INR ≥5). Care should be taken to maintain hemostatic pressure longer in patients with bleeding diatheses.

  • Anesthesia: Local anesthesia is employed. General anesthesia is required for pediatric cases, some sternal bone marrow sampling cases, and in those patients who are highly anxious
  • Positioning: The patient is placed in the lateral decubitus position, with the top leg flexed and the lower leg straight. Alternatively, the patient may be placed in the prone position.


Any of several needle models can be utilized; however, the Jamshidi needle has been the most popular. This disposable needle is tapered at the distal end to help retain the specimen for improved extraction. Powered drill devices have also been employed for this purpose and currently appear to yield comparable results.

Patient preparation is carried out in the manner previously described for bone marrow aspiration. Some kits allow aspiration and biopsy to be done with the same needle, which is convenient for the patient. However, if the latter is used, it is important to change the needle position slightly to a different area of bone after aspiration is obtained. Otherwise, an aspiration artifact is created where the marrow has been aspirated out of the core.

The needle, with stylet locked in place, is held within the palm and index finger and repositioned so that a new insertion site is created for biopsy sampling. Once the needle touches the bone surface, the stylet is removed.

With firm pressure applied, the needle is slowly rotated in an alternating clockwise-counterclockwise motion and advanced into the bone marrow cavity to obtain an adequate bone marrow specimen measuring approximately 1.6-3 cm in length.

The needle is rotated along its axis to help loosen the sample, pulled back approximately 2-3 mm, and then advanced again slightly, at a different angle, to help secure the specimen. After this procedure, the needle is slowly pulled out while being rotated in an alternating clockwise and counterclockwise motion.

The specimen is removed from the needle, and a probe is introduced through the distal cutting end. If the aspirate was unsuccessful (ie, a dry tap), the core biopsy may be used to make touch preparations .This must be performed before the specimen is placed in formalin. Finally, the specimen is placed in formalin solution for histologic processing.

Sternal bone marrow aspiration has a higher risk of complications than other sites because of the delicate bone structure in this area (~1 cm thick in adults). Penetration of the underlying mediastinal organs can result in mediastinitis, pulmonary embolism, pneumothorax, cardiac tamponade, and cardiac tissue injury, and for these reasons, biopsies are not to be performed from the sternum.

Awareness of anatomic variations and pathologies that may affect bone density (eg, osteoporosis and multiple myeloma) can prevent further complications and injuries.

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