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Bone Marrow Aspiration and Biopsy from Iliac Crest

Medical editor Ellen Aurlien MD
Internist, Oncologist
Oslo University Hospital

Håvar Knutsen MD
Oslo University Hospital


The cells in the blood and lymph system originate from stem cells in the bone marrow. A bone marrow examination is performed to diagnose lymphoma, leukemia, and metastasis to bone marrow. The examination usually includes an aspiration and/or biopsy from the iliac crest. When diagnosing Hodgkin's lymphoma, an aspirate and biopsy are taken from both sides. Sometimes, aspiration from the sternum is appropriate. In special cases, the aspiration is performed with the help of image guidance in cooperation with the nuclear medicine department. 

A bone marrow examination involves:

  • Smear for primary examination, otherwise for special indications
  • Imprint of biopsy - the biopsy is placed on the slide glass and rolled out. This can be done if there are problems with the aspirate.  
  • Peripheral blood smear is taken if there is suspicion of leukemization (malignant cells in the blood circulation)

An expanded examination may include

  • Flow cytometry immunphenotyping (marker testing)
  • Cytogenetics (chromosome testing)
  • Other molecular testing (For example PCR: polymerase chain reaction, FISH: fluorescence in situ hybridization) 
  • Special examinations associated with studies

The examination is usually performed under local anesthesia. General anesthesia is reserved for children and/or very anxious patients.


  • To diagnose lymphoma patients
  • Diagnosis of lymphoma infiltration of bone marrow
  • Diagnosis of hematological diseases
  • To check the effect of radiation/chemotherapy on bone marrow if there are problems with long-term cytopenia
  • To diagnose metastatic tumors in bone marrow


  • To diagnose or exclude disease involvement in the bone marrow

The only contraindication for carrying out a bone marrow biopsy is serious hemophilia. This must be performed in cooperation with a hemophilia clinic.

In case of warfarin treatment, the INR should be ≤ 3.

NSAIDs/ASA need not be discontinued. One should be aware of possible thrombocytopenia.


  • Surgical drape
  • Steri strips  
  • Scalpel head
  • Cannulas: blue, pink, and long green
  • Syringes 1 x 10 ml and 2 x 5 ml
  • Local anesthesia
  • Aspiration cannula: short or long as needed. Short is used on the sternum. 
  • Biopsy needle
  • Gloves
  • Sterile care kit
  • Sterile swabs
  • Broad-spectrum antiseptic
  • Pen for marking
  • Straw to mark the puncture point
  • Methanol-stable pen for marking slide
  • 8 slides marked with the patient's initials date of birth if smear is required. Three of them should be marked with the patient's full surname and birth year.
  • Equipment for drawing blood 
  • Fast-acting anticoagulant


  • The patient should be sufficiently informed about why the test is being taken and how it will be carried out
  • The examination is carried out by a doctor and usually takes 20-30 minutes.
  • The patient should lie comfortably on the opposite side of the point of puncture.
  • Place a drape under the point of puncture to catch anything which might spill.
  • Patients to be given general anesthesia shall have premedication.


This is an aseptic procedure.

Finding the level for puncture

  • Locate the upper iliac crest with access to the posterior iliac spine. 
  • Find the midline by the spinous process.
  • Feel the iliac crest between fingers with the left hand. On an average body frame, the location for sample taking will be about 8 cm caudal to the iliac crest and about 5 cm lateral to the midline of the spinous process.
  • Mark with pen.
  • The point of puncture is marked (for example with a straw).
  • Wash with colored chlorhexidine 5 mg/ml.

Local anesthesia

Correct injection of local anesthesia is crucial for the patient's experience of the procedure.

  • Inject 5–10 ml Xylocain® 10 mg/ml with adrenaline to reduce bleeding in the area.
  • Inject a minimal amount intracutaneously.
  • The patient will feel when the needle apex meets the periosteum. 
  • Rotate the syringe 180° to distribute the local anesthesia in the area.
  • Allow the anesthesia to work before expanding the area by angling the cannula in four directions.
  • To keep the cannula from simply turning in the same area, the cannula should be pulled back slightly each time before changing directions.

Bone marrow aspiration

  • Make a small incision with the scalpel before the biopsy to avoid unnecessary trauma of the skin. The incision will heal better.
  • Insert the cannula toward the posterior iliac spine. Find the middle of the crest and rotate the cannula with careful pressure as it perforates the cortex.
  • When the cannula reaches the spongy bone, the resistance will be significantly less.
  • Some patients experience pain when the cortex is perforated.
  • Remove the mandrin.
  • Attach a 5 ml syringe to the aspiration cannula.
  • Quickly aspirate 0.2–2 ml of marrow for a normal bone marrow smear.
  • Plug the aspiration cannula.

Making the smear

  • Hold the syringe with the cannula pointing down. The bone marrow plugs contain lipids and will then rise.
  • Place 3 small and 7 larger smears on the slides.
  • Redraw up a small amount of the blood on the smears by tilting the slide and aspirate the blood which collects below the smear. This must be done before the smear coagulates.
  • Prepare some regular smears and some with pressure applied.
  • The smears should be dried in air using a fan before fixation and staining.

Aspiration for flow cytometry

  • Aspirate in 0.5 ml Monoparin 1000 IE/ml in a 5 ml syringe to prevent coagulation of the aspirate.
  • Some connect a new aspiration cannula and others use the same cannula.
  • Aspirate 4–5 ml of bone marrow in the syringe containing Monoparin.
  • Carefully pull out the aspiration cannula.
  • Carefully inject the aspirate into a 10 ml specimen container.
  • Compress with swabs.

Punch biopsy

The punch biopsy is carried out as a continuation of the procedure. A cylinder of the bone is removed by drilling a core sample. 

  • Use a biopsy cannula.
  • Enter via the aspiration incision.
  • Insert the biopsy cannula toward the posterior crest. Find the middle of the crest to avoid starting the biopsy-taking on the edge of the iliac crest.
  • Rotate the cannula with steady pressure until it fastens in the hip bone. Avoid sliding into an unanesthesized area.
  • When the cannula is fastened in the to the hip bone, retrieve the mandrin. Turn the cannula so that it points toward the anterior superior iliac spine and has a slope of about 15°.
  • Ask the patient if they experience any pain during the procedure. Pain may indicate that the cannula is pointing in an unfavorable direction. 
  • If it starts to hurt, the insertion must stop. If the cannula is inserted far enough in (2–3 cm), the procedure can be concluded. If the cannula is not inserted far enough, attempt to alter its direction. If the patient still experiences pain, the cannula should be retrieved. A new biopsy attempt can be made with a new puncture next to the initial one. 
  • Insert the "withdrawal spoon" in the cannula.
  • Rotate the biopsy cannula 2–3 rotations in both directions to "loosen" the biopsy.
  • Retrieve the biopsy cannula with the "withdrawal spoon." 
  • Compress the wound well.
  • Carefully take out the spoon with the biopsy.
  • Put the biopsy in saline. 
  • Wash away any blood from the patient. Do not use alcohol since this will fixate the blood. Use sterile swabs and NaCl or cold water.
  • Close the incision with strips. Do not use using sutures to avoid a separate consultation for removal. Sutures increase the risk of infection.
  • Apply an adhesive bandage. 
  • The patient may return to the ward or home after the procedure. 


  • The risk of complications is minimal.
  • For anticoagulation/thrombocytopenia, observe for local bleeding, compression.
  • The bandage should be kept clean and dry for 4–5 days - use a shower bandage.
  • The strips can be removed after 7 days.
  • No other restrictions or observations.

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