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Purpose and principlesIndications, selection and cautionsMethod and interpretationClinical next stepsProcedure and medicine safetyRisks, monitoring and follow-upSpecial situationsCommon pitfallsQuestionsSources
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Educational draft · awaiting clinical reviewThe full textbook explains uncertainty but does not replace live national or local guidance, specialist advice, or current prescribing information.

Bone-marrow aspiration and biopsy

Haematology and transfusion · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

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Time-critical presentation

Bone-marrow sampling is rarely the first resuscitative action. Suspected acute promyelocytic leukaemia, neutropenic sepsis, major bleeding, tumour lysis, cord compression or symptomatic severe cytopenia needs immediate treatment and haematology escalation while diagnostic samples are coordinated. After biopsy, uncontrolled bleeding, hypotension, expanding pain or swelling, fever, neurological symptoms or suspected deep infection requires urgent reassessment.

Purpose and principles

Select bone-marrow aspiration, trephine biopsy and ancillary studies for a defined clinical question, prepare the patient safely and translate morphology, flow and genetics into a coherent diagnosis.

Bone-marrow examination is an invasive diagnostic package rather than a single test. The decision starts with whether peripheral blood, imaging, biochemical or molecular testing can answer the question more safely. Persistent unexplained pancytopenia, blasts, a leucoerythroblastic film, suspected plasma-cell or marrow-infiltrative disease and selected staging questions commonly justify sampling. Isolated stable iron deficiency, a readily explained transient cytopenia or a clonal lymphocyte population already classifiable from blood may not. The expected effect on diagnosis or management should be recorded before consent.

Aspiration and trephine are complementary. Aspirated particles show cytological detail and permit differential counting, iron assessment, flow and many genetic techniques. A core biopsy shows overall cellularity, distribution of lineages, megakaryocytes, fibrosis, granulomas, necrosis and focal metastatic or lymphomatous infiltration. Good practice anticipates every required specimen: EDTA for morphology or molecular work, heparinised material for cytogenetics, dedicated flow medium and sterile samples for microbiology according to local laboratory instructions. Retrospective sampling is often impossible once the patient has received corticosteroids, chemotherapy or transfusion.

Indications, selection and cautions

Unexplained marrow failure

Persistent cytopenia across lineages, low reticulocytes and no reversible peripheral cause supports aspiration and trephine to assess cellularity, dysplasia, aplasia and infiltration.

Acute leukaemia suspicionRed flag

Blasts, abnormal promyelocytes, rapidly worsening cytopenias, infection, bleeding or leukostasis symptoms require urgent blood and marrow classification within an emergency haematology pathway.

Fibrotic or infiltrative pattern

Dry tap, teardrops, leucoerythroblastosis, splenomegaly, bone pain or a known solid tumour raises fibrosis, myelophthisis or focal infiltration and increases trephine value.

Plasma-cell phenotype

Paraprotein, lytic bone disease, renal impairment, hypercalcaemia or unexplained anaemia may require marrow plasma-cell quantification plus flow, cytogenetics and imaging correlation.

Post-procedure complicationRed flag

Persistent bleeding, syncope, severe escalating buttock or back pain, neurological change, fever or wound discharge after sampling requires immediate examination and cause-directed imaging or treatment.

Method and interpretation

  1. 01
    Pre-procedure FBC, film and haemostasis reviewFirst step
    Why
    Confirm the indication and plan bleeding-risk mitigation before an invasive sample.
    Interpretation and limitations
    Review platelet count, trend, clinical bleeding, anticoagulants, antiplatelets, liver or renal dysfunction and inherited bleeding history. Use local procedural policy and haematology advice rather than a single universal threshold.
  2. 02
    Bone-marrow aspirate morphology
    Why
    Assess lineage proportions, maturation, dysplasia, blasts, plasma cells, iron and infective organisms.
    Interpretation and limitations
    Quality depends on particles and limited blood dilution. The differential is interpreted with peripheral counts; morphology suggests but does not alone establish modern integrated disease classification.
  3. 03
    Trephine histology and immunohistochemistry
    Why
    Assess architecture, cellularity, fibrosis and focal or spatially distributed disease.
    Interpretation and limitations
    Core length and intact marrow spaces affect sensitivity. Histology can reveal aplasia, granulomas, lymphoma, metastatic cancer or fibrosis missed by aspirate, especially after a dry tap.
  4. 04
    Flow cytometry
    Why
    Define abnormal lineage and immunophenotype in acute leukaemia, lymphoid disease or plasma-cell disorders.
    Interpretation and limitations
    Fresh viable cells and an appropriate panel are required. Flow findings support clonality and lineage but must be reconciled with morphology and genetics, particularly after treatment.

Clinical next steps

01DecisionConfirm that marrow will change careFirst stepPersistent blood, clinical or imaging abnormalities raise a marrow diagnosis but immediate instability has been addressed.+
  1. 1Review peripheral film, reticulocytes, haematinics, haemolysis, renal, liver, infection, imaging and medicine causes first, documenting the unresolved question that marrow should answer.
  2. 2PreferredAlternativeThe preferred plan is combined aspirate and trephine when cellularity, architecture or infiltration matters; aspiration alone is an alternative only when the specific question is cytological and the core would not add value.
  3. 3EscalationEscalate urgent suspected acute leukaemia, aplasia or aggressive infiltration to the specialist team so sampling, supportive care and treatment timing are coordinated rather than scheduled routinely.
02Procedure

Procedure and medicine safety

Reduces superficial and periosteal procedural pain while allowing the patient to remain safely positioned.

Lidocaine 1% local anaesthetic

Infiltrate skin, subcutaneous tissue and periosteum incrementally, aspirating before injection, using the smallest effective volume and staying below 3 mg/kg and 200 mg total without adrenaline.

Ask about allergy, aspirate before incremental injection, include lidocaine already administered and observe for neurological or cardiovascular toxicity; use a lower limit in frailty, severe hepatic or low-output cardiac disease or when the SmPC requires it, and remember that aspiration can still cause brief deep pain.

Risks, monitoring and follow-up

  • Observe the puncture site, pain, pulse, blood pressure and symptoms until immediate bleeding or vasovagal effects have settled.
  • Give written advice on dressing care, analgesia and urgent return for persistent bleeding, fever, discharge, severe increasing pain, weakness or numbness.
  • Track aspirate, trephine, flow, cytogenetic, molecular and microbiology results through one named clinician because they mature on different timescales.
  • For acute leukaemia or severe marrow failure, continue serial counts, infection, bleeding and metabolic monitoring while classification is pending.
  • Review whether a non-diagnostic or discordant sample needs expert rereview, additional stains, a different site or alternative tissue rather than automatically repeating the same procedure.

Special situations

The first pull is precious

Early aspirate is least diluted by peripheral blood and should be allocated deliberately to morphology and the highest-priority ancillary test.

Dry tap is a clue

Fibrosis, packed marrow and infiltration can prevent aspiration. A good trephine and touch imprints may become more diagnostically valuable than repeated suction.

Architecture changes the answer

Aspirated cells can look individually normal while the core reveals patchy lymphoma, metastatic deposits, abnormal topography or severe hypocellularity.

Variants need phenotype

Age-related clonal variants can occur without overt malignancy. Diagnosis integrates allele burden, morphology, counts, clinical context and longitudinal change.

Pain deserves preparation

Explaining the distinct pressure and brief aspirate pain, agreeing a pause signal and infiltrating periosteum properly improves trust and procedural success.

Common pitfalls

  1. 01

    Requesting marrow without stating the diagnostic question or required ancillary studies.

  2. 02

    Using aspirate alone when architecture, fibrosis or focal infiltration is central.

  3. 03

    Drawing repeated aspirates and sending diluted material for morphology after the best sample was discarded.

  4. 04

    Applying a universal platelet threshold without individual bleeding, urgency and local procedural guidance.

  5. 05

    Calling a dry tap technical failure and failing to preserve the trephine and touch imprints.

  6. 06

    Starting corticosteroids for possible lymphoma before diagnostic tissue when no emergency indication exists.

  7. 07

    Failing to reconcile a preliminary flow result with the final integrated haematopathology report.

Practice

Two practice questions

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Question 1 of 2
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Haematology and transfusionOriginal SBA

Dry marrow aspirate

An adult with splenomegaly, teardrop cells and a leucoerythroblastic film undergoes marrow sampling. No aspirate particles can be obtained despite correct positioning. What is the best interpretation and action?

Choose one answer, then submit
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Sources and review status5 sources · checked 27 Aug 2026 · clinical review pending+
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

  • BSH myelofibrosis guidelineTrephine, fibrosis and integrated molecular diagnosis in a dry-tap phenotype.
  • NICE NG12 suspected cancer recommendationsUrgent referral context for unexplained cytopenia and suspected haematological malignancy.
  • Royal College of Pathologists bone marrow reporting datasetUK marrow-core adequacy, architecture and reporting framework.
  • NHS bone marrow biopsy patient guidanceNational patient-facing biopsy preparation, consent and aftercare principles.
  • BNF lidocaine hydrochloride monographUK local-infiltration dosing limits, contraindications and systemic-toxicity precautions.

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

Authoring stateComplete draftClinical stateAwaiting review

The posterior iliac crest procedure is usually performed under local anaesthesia with sterile technique and pressure afterwards. Pain has a sharp aspirate component and a deeper biopsy component; honest preparation, paced technique and additional analgesia or sedation in selected patients improve tolerability. Bleeding is uncommon but risk rises with severe thrombocytopenia, anticoagulation, platelet dysfunction and myeloproliferative disease. Local thresholds differ because the procedure is compressible and urgency varies; haematology and transfusion should make an individual plan rather than using an invented universal cut-off.

Key points

  • Define the question before the procedure: unexplained cytopenia, suspected acute leukaemia, myelodysplasia, marrow infiltration, plasma-cell disorder, lymphoma staging, fibrosis, storage disease or fever of unknown cause each needs different samples.
  • Aspiration provides individual-cell morphology, differential counts, flow cytometry, cytogenetics, molecular tests and microbiology; the trephine preserves architecture, cellularity, fibrosis, focal infiltrates and spatial relationships.
  • Most adult samples come from the posterior iliac crest. Sternal aspiration is an expert-only alternative in selected circumstances and cannot provide a trephine; the sternum is not used for routine biopsy.
  • Check identity, indication, consent, allergies, pregnancy status where relevant, infection, platelet and coagulation context, antithrombotic medicines, positioning and the exact laboratory containers before starting.
  • A dry tap is information, not merely failure. Fibrosis, packed leukaemia, metastatic infiltration and technical factors can prevent aspiration, making trephine touch imprints and core quality especially important.
  • Collect aspirate promptly because dilution increases with repeated pulls. Direct the first material to morphology and the highest-priority ancillary test agreed with the laboratory.
  • A normal aspirate does not exclude patchy disease or architectural abnormality. Conversely, a hypocellular aspirate may reflect dilution and must be reconciled with trephine cellularity.
  • 05
    Cytogenetic and molecular studies
    Why
    Identify diagnostic, prognostic and treatment-directing chromosomal or sequence changes.
    Interpretation and limitations
    Send the correct specimen before therapy where feasible. Germline versus somatic interpretation, variant significance and measurable residual disease require disease-specific laboratory and genetics expertise.
  • 06
    Microbiology and special stains
    Why
    Investigate selected infection, granuloma, storage or metabolic questions.
    Interpretation and limitations
    Request prospectively and use sterile material when culture is needed. A positive molecular organism signal may reflect contamination or disseminated disease and requires clinical correlation.
    • Prepare, sample and preserve quality
    An indicated posterior iliac crest marrow procedure has been agreed.
    +
    1. 1Complete consent and identity checks, review haemostasis and antithrombotics, position safely, mark the posterior iliac site and confirm containers, labels, transport and priority tests with the laboratory.
    2. 2Use sterile technique and adequate local anaesthesia; obtain the first aspirate for morphology and key ancillary work before dilution, then take an intact trephine through the trained technique.
    3. 3AlternativeEscalationApply firm pressure and a secure dressing, reassess pain and bleeding, document sample adequacy and complications, and escalate a dry tap by preserving trephine, touch imprints and alternative material.
    03IntegrationTurn several reports into one diagnosisMorphology, flow, histology, cytogenetic or molecular results are returning at different times.+
    1. 1Reconcile peripheral blood, aspirate and trephine, asking whether dilution, patchy disease or treatment timing explains discordance and whether any critical preliminary result needs immediate action.
    2. 2PreferredUse integrated disease criteria through the preferred haematopathology multidisciplinary process; an isolated molecular variant is not automatically the disease when morphology and clinical phenotype disagree.
    3. 3EscalationEscalate missing, failed or inadequate studies promptly while viable material remains, communicate the working diagnosis and uncertainty, and assign ownership for final addenda and treatment review.
    JurisdictionUnited Kingdom
  • Results require integration at a multidisciplinary level: morphology, immunophenotype, karyotype, fluorescence studies and molecular variants can conflict or describe different parts of one clonal process.