Optimizing diagnostic yield in computed tomography-guided musculoskeletal bone biopsy: a narrative review

Abstract

Computed tomography (CT) -guided percutaneous bone biopsy is a cornerstone technique in the diagnostic evaluation of musculoskeletal lesions, offering high diagnostic accuracy with lower morbidity and cost compared with open surgical biopsy. Despite its widespread use, diagnostic yield varies considerably across studies, influenced by lesion biology, anatomical location and modifiable technical factors. Non-diagnostic sampling remains a clinically relevant problem, particularly in sclerotic, occult and necrotic or cystic intraosseous lesions, often leading to repeat procedures and delayed definitive management. This narrative review synthesizes current evidence on the diagnostic performance of CT-guided musculoskeletal bone biopsy and organizes predictors of biopsy success into lesion-related, site-related and technique-related domains. Particular emphasis is placed on technical strategies aimed at optimizing diagnostic yield and specimen adequacy, including meticulous pre-procedural planning, appropriate needle selection, multi-core sampling, use of on-site cytologic or histologic assessment and advanced imaging guidance for challenging lesions. Emerging low-cost innovations such as the “sandwich technique” are discussed as potential solutions for traditionally low-yield scenarios, especially in resource-constrained settings. The review also highlights important gaps in the existing literature, which is dominated by retrospective single-centre studies from high-income environments and underscores the need for prospective, protocol-driven, multicentre research using standardized outcome definitions and inclusive of low- and middle-income settings. Continued refinement and validation of pragmatic biopsy strategies are essential to reduce non-diagnostic rates, minimize repeat procedures and improve the efficiency and equity of musculoskeletal biopsy care worldwide.