Imaging Recommendation for Post-Bone Marrow Biopsy Pain
Order X-rays of both the lumbar spine AND pelvis/hip, not the lumbar spine alone. This patient's severe radiating leg pain after a right posterior iliac crest bone marrow biopsy requires evaluation of both the spine (for radiculopathy) and the pelvis/hip (for procedure-related complications at the biopsy site).
Rationale for Combined Imaging
Pelvis and Hip Imaging is Essential
The American College of Radiology recommends that radiographs of the pelvis and hip should be the first test ordered for evaluation of patients with hip pain, rating both X-ray pelvis and X-ray hip as 9/9 (usually appropriate) and noting they are complementary studies 1.
Bone marrow biopsy from the posterior iliac crest creates a known iatrogenic lesion that appears as a circular lytic defect with sclerotic border at the biopsy site, which can be a source of pain 2.
Sacroiliac joint (SIJ) pain is a recognized complication following iliac bone marrow aspiration and biopsy, with studies showing 34% of patients without prior back pain developing SIJ pain after the procedure, demonstrating a statistically significant linear correlation (p < 0.01) 3.
For chronic hip pain evaluation, a view of the pelvis plus additional imaging of the proximal femur is superior to radiographs limited to the ipsilateral hip alone, as it allows comparison to the contralateral side and evaluation of associated pelvic structures 1.
Lumbar Spine Imaging is Also Necessary
The patient's 8/10 pain radiating down the right leg is a classic radicular pattern that requires evaluation of the lumbar spine for nerve root compression, disc herniation, or other spinal pathology 1.
Radiating leg pain is considered a clinical red flag in back pain evaluation that warrants diagnostic imaging to exclude serious pathology 1.
Anteroposterior and lateral radiographs of the spine remain the standard of care for initial imaging evaluation of back pain, with studies showing 9-22% diagnostic yield when combined with clinical examination 1.
Practical Implementation
Order the Following Studies
AP and lateral views of the lumbar spine to evaluate for degenerative changes, disc space narrowing, spondylolisthesis, or other causes of radiculopathy 1.
AP pelvis radiograph to evaluate the sacroiliac joints bilaterally, the iliac crests (including the biopsy site), and hip joints 1.
Additional views of the right hip (such as cross-table lateral or frog-leg lateral) to fully evaluate the hip joint and proximal femur 1.
Common Pitfalls to Avoid
Do not assume the pain is purely spinal in origin simply because it radiates down the leg—referred pain from the SIJ or hip can mimic radiculopathy, and the recent biopsy makes local pathology highly relevant 3.
Do not order only lumbar spine films based on the radicular pattern alone, as this will miss potential complications at the biopsy site including fracture, hematoma, or SIJ dysfunction 3, 2.
Do not dismiss the temporal relationship between the bone marrow biopsy and symptom onset—the procedure is a known cause of SIJ pain and can cause local complications 3.
If Initial Radiographs Are Negative
Consider MRI of the lumbar spine without IV contrast if radicular symptoms persist and radiographs are negative, as MRI can detect disc herniations, nerve root compression, and soft tissue pathology not visible on plain films 1.
Consider MRI of the pelvis/hip without IV contrast if localized hip or pelvic pain persists with negative radiographs, as MRI is highly sensitive for detecting bone marrow edema, occult fractures, soft tissue injury, and SIJ inflammation 1, 4.