Recommended Site for Bone Marrow Examination
The posterior iliac crest is the preferred site for bone marrow examination due to its safety profile, specimen quality, and patient comfort. 1, 2, 3
Primary Recommended Site: Posterior Iliac Crest
- The posterior iliac crest provides high-quality specimens with greater length and area compared to other sites 2
- It is considered safer with fewer complications compared to sternal aspirations, which carry a rare risk of cardiac tamponade 4
- Patients report significantly less pain with posterior iliac crest biopsies compared to anterior iliac crest procedures 2
- The American College of Medical Genetics and Genomics (ACMG) specifically identifies bone marrow aspirate as the preferred specimen for most hematologic neoplasms, with the posterior iliac crest being the optimal site 1
Alternative Sites
- Anterior iliac crest: Can be used but produces smaller specimens and causes more patient discomfort 2, 3
- Sternum: Historically used but carries higher risk including rare fatal complications from cardiac tamponade 4
- Bone marrow core biopsy: Required in cases with dry tap, requiring special processing techniques 1
- Metaphysis of distal femur and proximal tibia: Alternative sites with similar cell phenotype and differentiation potential, but with lower mononuclear cell concentration compared to iliac crest 5
Procedural Considerations
- Specimens should be collected under sterile conditions in sodium heparin tubes (not lithium heparin) 1
- Optimal concentration of sodium heparin should be 20 IU/mL of specimen 1
- For adults, approximately 1-3 mL of bone marrow should be collected 1
- The first or second draw should be used for cytogenetic analysis as it typically contains more neoplastic bone marrow cells 1
- Specimens should be transported at ambient temperature and received by the laboratory within 24 hours 1
Special Circumstances
- For neuroblastoma detection, the International Neuroblastoma Risk Group Task Force recommends collecting the first bone marrow aspirate (2-5 ml) from each iliac crest 1
- In lymphoma staging, PET-CT may replace the need for bone marrow biopsy in Hodgkin lymphoma if the PET scan is negative or shows homogeneous bone marrow uptake 1, 6
- For patients with suspected plasma cell neoplasms, specific processing techniques may be required 1
Clinical Pearls and Pitfalls
- When large sample volumes are required for multiple diagnostic tests, changing the bone marrow aspiration site is necessary to avoid hemodilution 1
- If staying at the same puncture site, the needle should be reinserted at different angles 1
- For biobanking purposes, all cells not used for diagnostics should be preserved, with viable cells stored in liquid nitrogen 1
- In cases of dry tap, bone marrow core biopsy or smear/touch imprint preparations can be used for analysis 1
- Specimens should be processed as soon as possible after receipt by the laboratory 1
The posterior iliac crest remains the gold standard site for bone marrow examination due to its optimal balance of safety, specimen quality, and patient comfort.