PL-US GUIDED: Postero-Lateral Ultrasound Guided Technique for Bone Marrow Aspiration Volume 60- Issue 4

Palmerindo Antônio Tavares de Mendonça Néto¹*, Mayara Magda Dantas Tavares de Mendonça¹, Dirceu de Moraes Junior², Carlos Stefano Hoffmann Brito³, Daniel Ramos Gonçalves Lopes⁴ and Ronaldo Magalhães Lins⁵

• ¹Regenera Dor Institute, Brazil
• ²Lumius Clinic, Brazil
• ³Carlos Stéfano Institute, Brazil
• ⁴Gaio & Lopes Specialized Medicine, Brazil
• ⁵CETRUS, Brazil

Received: February 10, 2025; Published: February 17, 2025

*Corresponding author: Palmerindo Antônio Tavares de Mendonça Néto, Regenera Dor Institute, Brazil

DOI: 10.26717/BJSTR.2025.60.009471

Abstract PDF

The article addresses the ultrasound-guided bone marrow aspirate (BMA) collection technique, highlighting its importance in regenerative medicine. The traditional BMA collection technique involves blind approaches or fluoroscopy, which present challenges such as difficulty of access in obese patients and risks of radiation exposure. The ultrasound-guided technique allows real-time visualization of anatomical structures, facilitating the optimal location for puncture and minimizing complications. The study describes the collection of BMA by posteromedial approach, with the patient in the prone position, using local anesthesia and the Jamshidi needle. The sonoguided approach offers greater safety and comfort to the patient, reducing local trauma and recovery time. BMA collection is essential to obtain progenitor cells used in regenerative therapies, such as the treatment of osteoarthritis and tendon injuries. The technique described in the article represents a safe and effective alternative to traditional approaches, in line with trends towards minimally invasive and image-guided procedures. The use of ultrasound improves the accuracy of the puncture, resulting in less pain and greater efficiency in collection.

Keywords: Bone Marrow Aspirate (BMA); Ultrasonography; Posteromedial Approach; Minimally Invasive Technique; Guided Collection

Abbreviations: BMA: Bone Marrow Aspirate; CAGR: Compound Annual Growth Rate; PRP: Platelet-Rich Plasma; PRF: Platelet-Rich Fibrin; iPRF: Injectable PRF; SVF: Stromal Vascular Fraction; BMAC: Bone Marrow Aspirate Concentrate; PSIS: Posterosuperior Iliac Spine; MSCs: Mesenchymal Stem Cells; PPM: Plasma Power Mix

Regenerative medicine has shown exponential growth in recent years. Estimates indicate that the global market for this area was valued at approximately USD 31.90 billion in 2023, with projections pointing to an increase to USD 349.93 billion by 2033, representing a compound annual growth rate (CAGR) of 27.06% in the period from 2023 to 2033 [1]. This advance is driven by technological development, increased prevalence of chronic diseases, and population aging [2-4]. Within this promising field, orthobiologicals emerge as essential tools in regenerative therapies. These biological products, derived from autologous or allogeneic sources, are used to promote the repair and regeneration of musculoskeletal tissues [5,6]. Blood products include platelet-rich plasma (PRP), an autologously obtained orthobiological, rich in growth factors that aid in the treatment of lesions by inducing tissue regeneration [2,6,7]. Platelet-rich fibrin (PRF), a three-dimensional matrix containing platelets and leukocytes, which releases growth factors in a sustained manner to favor tissue regeneration [7,8]. Injectable PRF (iPRF), a liquid variant of PRF, which can be injected, expanding its use in different clinical settings [5-8].

Platelet-rich and monocyte-rich PRP (PRP-PM) concentrates, in addition to platelets, monocytes, cells involved in inflammatory modulation and tissue repair [9,10]. Adipose tissue derivatives include stromal vascular fraction (SVF), a cell fraction rich in mesenchymal stem cells isolated from adipose tissue, which has significant regenerative potential [5,11-13]. NanoFAT is a processed adipose tissue emulsion used to improve skin quality and stimulate regeneration in specific areas [11,14]. In addition, expanded medical signaling stem cells are grown in the laboratory to increase their quantity before therapeutic application, aiming to enhance the regenerative effects [13-16]. Among the bone marrow derivatives, bone marrow aspirate (BMA) stands out, which consists of the collection of progenitor cells and growth factors directly from the bone marrow, used to enhance tissue regeneration. Bone marrow aspirate concentrate (BMAC) is an enriched version of BMA, with higher density of mesenchymal stem cells and other bioactive components [2,17-21]. These products have been widely applied in the treatment of osteoarthritis, tendon injuries, and cartilaginous defects, demonstrating efficacy in reducing pain and improving joint function [2,3,17-23].

Bone marrow aspirate (BMA) collection is an essential procedure for obtaining progenitor cells used in regenerative therapies [2,18,19,22]. Traditionally, the technique involves approaches to the anterior or posterior iliac crest, performed “blindly” or with the aid of fluoroscopy [24,25]. However, these approaches present challenges such as difficulty of access in patients who are obese or have complex anatomy, significant discomfort from needle manipulation, and risks associated with exposure to ionizing radiation. [24-26]. The use of ultrasound- guided techniques has taken interventional pain medicine to another level [2,27-29]. Ultrasound allows real-time visualization of anatomical structures, facilitating the ideal location for puncture and minimizing the risk of complications [24,25,27-29]. In this context, the present study aims to describe and evaluate a technique for collecting BMA by ultrasound-guided posteromedial approach, seeking to offer a safe and effective alternative to traditional approaches. This innovation is in line with current trends in minimally invasive and image-guided procedures, aiming to optimize therapeutic outcomes.

With the patient in the prone position, antisepsis of the lumbar region and hip is performed, followed by the placement of sterile drapes. The posterosuperior iliac spine (PSIS) is identified by ultrasonography, using a convex transducer to define the anatomical target. A local anesthetic is used to numb the skin and periosteum at the site of marrow collection. Lidocaine or another local anesthetic may be used if the patient has no history of adverse reactions to the drug. Complete local anesthesia, which avoids discomfort during the procedure, is ensured by waiting for adequate time after administration (Figure 1). The anesthetic used is usually prepared using 5 mL of sterile 2% lidocaine hydrochloride with 4 mL of normal saline and 1 mL of sterile 8.4% sodium bicarbonate solution (1 mEq/mL) in a 10 mL plastic syringe fitted with a 1-1/2-inch 22-gauge needle. Packing lidocaine with sodium bicarbonate improves pain perception from local anesthesia, which is usually caused by the acidity of lidocaine. This solution is applied intradermally, forming a small 5mm papule, through which the larger needles will be inserted to anesthetize the subsequent anatomical planes until it reaches the surface of the periosteum (Figure 2). After ultrasound identification of the PSIS, the needle is guided to the periosteum, where anesthetic infiltration with 1% lidocaine is performed for periosteal hydro dissection.

Figure 1

Figure 2

The anesthetic onset time (usually 10 minutes) is respected before puncture.After the waiting time for latency of the anesthetic a small incision can be made with a scalpel blade at 11 or the Jamshidi needle can be introduced directly Under Direct Sonovisualization of the PSIS, to confirm the parallelism between the needle and the iliac, the Jamshidi needle is then advanced with constant pressure and a slight twisting motion through the anesthetized skin and subcutaneous tissue to the posteromedial aspect of the posterior iliac crest. At this point, the patient should be asked about pain to assess whether there is a need for anesthetic supplementation. If there are no complaints from the patient, the needle should be gently advanced through the cortical bone by rotation and constant pressure. A feeling of decreased resistance usually indicates penetration of the cortex and needle entry into the cancellous bone. This causes an uncomfortable or even painful sensation in some patients. The needle should be advanced about 1 cm into the cancellous bone of the spinal cord. BMA collection is performed using a sonoguided posterolateral approach and with a Jamshidi needle parallel to the iliac cortical, using 10 mL syringes to aspirate 5 mL at a time. After each aspiration, the needle is progressively advanced along the iliac crest, until it reaches the desired volume (Figure 3).

Figure 3

Direct Sonovisualization and the identification of vascular and nerve structures allow greater safety in the procedure, reducing the risk of complications. The positioning of the needle parallel to the iliac cortical allows the progression of the puncture with minimal local trauma, which contributes to less intra- and post-procedure pain.

In the field of regenerative medicine, orthobiologicals play a vital role. These biological products, obtained from autologous or allogeneic sources, are used to promote the repair and regeneration of musculoskeletal tissues. Peripheral blood products such as platelet- rich plasma (PRP), platelet-rich fibrin (PRF), and plasma power mix (PPM) have shown significant efficacy in tissue healing and regeneration, with a number of studies and meta-analyses validating the technique for a range of pathologies [2,5,7,15,17,19,20,23,30]. However, the need for a biological safety center for the processing of PRP without risks of contamination and the lack of standardization in the processing of this biological is an inexhaustible source of criticism and prevents the technique from being easily replicated in many clinics around the world [31-34] (Figure 4). Among bone marrow derivatives, bone marrow aspirate (BMA) and bone marrow aspirate concentrate (BMAC) are particularly important. BMA consists of collecting progenitor cells and growth factors directly from the bone marrow, whereas BMAC is an enriched version of BMA, with a higher density of mesenchymal stem cells and other bioactive components. [17-21] Bone marrow aspirate (BMA) collection has been consolidated as an essential technique in regenerative medicine, particularly in the application of orthobiologicals for the treatment of musculoskeletal diseases [22].

Figure 4

Obtaining an autologous, anticoagulant-free, minimally processed orthobiological makes this product a highly viable and safe option for tissue regeneration. The absence of anticoagulants reduces the risk of complications related to coagulation, while minimal processing preserves the biological and functional properties of the cells and growth factors present in the aspirate. In this way, the use of BMA processed in an autologous and natural way not only improves therapeutic efficacy but also ensures greater compatibility and lower risk of adverse reactions in patients. This advance in regenerative medicine opens new possibilities for the treatment of various musculoskeletal conditions, with an autologous product without the need for biological processing centers for its preparation [17-21,35].

BMA collection has traditionally involved “blind” techniques or the use of fluoroscopy to guide the puncture [36]. However, these approaches present significant challenges, including difficult access in obese patients or patients with complex anatomy, discomfort from needle manipulation, and risks associated with exposure to ionizing radiation, in addition to the high cost generated by the use of fluoroscopy in a hospital setting [22,23,25,26]. Recent studies highlight the advantages of using ultrasound-guided techniques in BMA collection [4,24] (Figure 5). Ultrasound allows for real-time visualization of anatomical structures, facilitating precise location for puncture and minimizing the risk of complications. According to Peng. (2009), the use of ultrasound significantly reduces the risk of complications and improves the accuracy of collection. In addition, the technique eliminates exposure to ionizing radiation, benefiting both patients and medical staff [27-29,37].

Figure 5

Performing a single-punch approach, rather than multiple punches, has several advantages. Studies have shown that a single puncture minimizes trauma to the patient and reduces the pain associated with the procedure. In addition, a simple puncture decreases the risk of infections and other complications, making the procedure safer and more comfortable. This approach is particularly beneficial in patients who may have higher pain sensitivity or a higher risk of complications [38]. The study by Oliver, et al. [38] compares two bone marrow aspiration (BMA) techniques – one performed at a single site with needle redirection and the other at multiple sites – to determine which method provides a high-quality bone marrow aspirate with less pain to the patient. The results showed that both techniques provided similar final cell concentrations and culture results, with no significant differences in the amount of mesenchymal stem cells (MSCs) obtained. However, the single-site aspiration technique stood out for being significantly less painful, both during the procedure and 24 hours afterward, compared to the multi-site technique. The findings of this study have important implications for clinical practice, especially in the context of orthobiological therapies and regenerative medicine. The single insertion technique not only ensures that a high-quality bone marrow aspirate is obtained but also improves the patient experience by reducing the pain associated with the procedure. These results suggest that the single-insertion approach may be preferred in clinical settings to maximize patient comfort and minimize risks and complications associated with multiple punctures [38].

The choice of the posteromedial approach over the lateral approach is based on the safety and efficacy of the procedure. The posteromedial approach allows better access to the bone marrow, especially in patients with complex anatomy. Direct Sonovisualization of critical anatomical structures, provided by the ultrasound-guided posteromedial approach, minimizes the risk of vascular and nerve injuries. In addition, this approach facilitates the collection of an adequate volume of aspirate with less need for needle manipulation, reducing local trauma [2,4,24,39,40].

The posterosuperior iliac spine (PSIS) is a bony prominence located at the posterior end of the iliac crest, serving as an important anatomical landmark in medical procedures. Easily palpable, the PSIS is located following the posterior contour of the iliac crest, with the patient in the lateral decubitus position or standing [36,41]. The blood supply of the PSIS is primarily supplied by the superior and inferior gluteal arteries, which are branches of the internal iliac artery. The corresponding veins accompany these arteries, draining blood into the internal iliac vein. In addition, branches of the lateral sacral artery also contribute to the vascularization of adjacent areas. The anatomical relationship of the PSIS to adjacent structures, such as the iliac crest, the sacroiliac joint, and the thoracolumbar fascia, is critical for the safe and effective performance of interventional procedures. Detailed knowledge of these anatomical relationships helps prevent vascular and nerve injuries during puncture [41]. The innervation of the PSIS is conducted by branches of the superior and inferior gluteal nerves, responsible for the sensory and motor innervation of adjacent structures. Branches of the superior clonic nerve, originating from the posterior division of L1-L3, innervate the skin overlying the PSIS. The posterior sacral nerves also contribute to the sensory innervation of the medial and inferior area of the PSIS [41].

Ultrasound is used to identify PSIS accurately. During the scan, the probe is positioned over the patient’s skin, and the image generated clearly shows the bony bulge. The visual identification of the PSIS through ultrasonography ensures accurate and safe puncture, minimizing risks and increasing the effectiveness of bone marrow aspirate collection. After the PSIS is identified, the area is marked and prepared. The puncture is performed with a suitable needle, which is inserted through the skin and subcutaneous tissue until it reaches the bone marrow. The continuous use of ultrasound during needle insertion ensures that the needle stays on the correct path and penetrates the bone marrow accurately. The use of ultrasound significantly improves the accuracy in locating the PSIS. This visualization allows for an exact puncture and minimizes the margin of error. In addition, clear identification of anatomy by ultrasound reduces the risk of injury to surrounding tissues and nerves, making the procedure safer [42] (Figure 6). probe to locate the needle and perform the BMA collection by sound-guided approach.

Figure 6

The sonoguided procedure tends to be less painful due to the precision of the puncture, resulting in less tissue trauma. Because it is a less invasive method, the post-procedure recovery time is usually shorter. Ultrasound visualization allows healthcare professionals to perform the procedure with more confidence and fewer attempts, increasing the overall efficiency of the collection [28,29,42-44] (Figure 7). Sonoguided collection of spinal cord aspirate in the posterosuperior iliac spine not only increases the success rate of the procedure but also provides greater comfort and safety to the patient. Ultrasound technology, with its ability to provide real-time images, revolutionizes the approach to these procedures, offering a modern and effective alternative that is confluent with the minimally invasive approaches used in the practice of regenerative medicine.

Figure 7

The use of ultrasound significantly improves the accuracy in locating the PSIS. This visualization allows for an exact puncture and minimizes the margin of error. In addition, clear identification of anatomy by ultrasound reduces the risk of injury to surrounding tissues and nerves, making the procedure safer. The sonoguided procedure tends to be less painful due to the precision of the puncture, resulting in less tissue trauma. Because it is a less invasive method, the post-procedure recovery time is usually shorter. Ultrasound visualization allows healthcare professionals to perform the procedure with more confidence and fewer attempts, increasing the overall efficiency of the collection. Sonoguided collection of spinal cord aspirate in the posterosuperior iliac spine not only increases the success rate of the procedure but also provides greater comfort and safety to the patient. Ultrasound technology, with its ability to provide real-time images, revolutionizes the approach to these procedures, offering a modern, safe, and effective alternative.

As perspectives for future studies we can suggest on comparative analyses with traditional techniques in terms of patient outcomes, procedural success rates, and long-term efficacy and a more detailed quantitative analysis of pain levels, procedural duration, and recovery timelines compared to conventional methods would strengthen the clinical applicability of the study. An exploration of how operator experience influences the success rate of the ultrasound-guided technique could be useful for standardizing training and ensuring reproducibility.

1. (2025) Spherical Insights. Regenerative Medicine Market: Trends, Growth, Forecast 2033. Recovered from Regenerative Medicine Market: Trends, Growth, Forecast 2033.
2. Schneider N, Sinnott M, Patel N, Joseph R (2024) The use of platelet-rich plasma and stem cell injections in musculoskeletal injuries. Cureus 16(5): e59970.
3. Ochi M, Nakasa T, Kamei G, Usman MA, Mahmoud E (2014) Regenerative medicine in orthopedics using cells, scaffolds, and microRNA. J Orthop Sci 19(4): 521-528.
4. Centeno C J, Jerome M A, Pastoriza S M, Shapiro S, Mautner K, et al. (2021) Use of Bone Marrow Concentrate to Treat Pain and Musculoskeletal Disorders: An Academic Delphi Investigation. Pain Physician 24(3): 263-273.
5. Mavrogenis AF, Karampikas V, Zikopoulos A, Spyridon Sioutis, Dimitrios Mastrokalos, et al. (2023) Orthobiologicals: a review. International Orthopedics 47(7): 1645-1662.
6. Mendrone Junior A (2009) Peripheral blood as a cell source for cell therapy. Brazilian Journal of Hematology and Hemotherapy 31(suppl 1): 19-24.
7. Lana J F, Purita J, Everts P A, De Mendonça Neto P A T, Tomas Mosaner, et al. (2023) Platelet-Rich Plasma Power-Mix Gel (PMP)—An Orthobiologic Optimization Protocol Rich In Growth Factors And Fibrin. Gels 9(7): 553.
8. Pereira VBS, Lago CAP, Almeida RAC, Barbirato DDS, Vasconcelos BCDE (2023) Biological and cellular properties of advanced platelet-rich fibrin (A-PRF) compared to other platelet concentrates: systematic review and meta-analysis. Int J Mol Sci 25(1): 482.
9. Schär MO, Diaz-Romero J, Kohl S, Zumstein MA, Nesic D (2015) Platelet-rich concentrates differentially release growth factors and induce cell migration in vitro. Clin Orthop Relat Res 473(5): 1635-1643.
10. Maia L, Souza M V de (2009) Platelet-rich components in the repair of ligamentous and osteoarticular tendon disorders in animals. Rural Science 39(4): 1267-1274.
11. Frese L, Dijkman PE, Hoerstrup SP (2016) Adipose-derived stem cells in regenerative medicine. Transfusion drugs and hemotherapy: offizielles Organ der Deutschen Gesellschaft für Transfusionsmedizin und Immunhamatologie 43(4): 268–274.
12. Yarak S, Okamoto O K (2010) Stem cells derived from human adipose tissue: current challenges and clinical perspectives. Anais Brasileiros De Dermatologia 85(5): 647-656.
13. Schweich-Adami L de C, Kassuya C A L, da Silva R A, Baranoski A, Brochado Antoniolli Silva, et al. (2021) Effects of mesenchymal stem cells in the treatment of knee osteoarthritis: a case report in the Brazilian Unified Health System. Brazilian Journal of Orthopedics 56(3): 300-310.
14. Jeyaraman M, Muthu S, Sharma S, Ganta C, Ranjan R, et al. (2021) Nanofat: A therapeutic paradigm in regenerative medicine. World Journal of Stem Cells 13(11).
15. Si Z, Wang X, Sun C, Kang Y, Xu J, et al. (2019) Nanofat: A therapeutic paradigm in regenerative medicine. World Journal of Stem Cells 114: 108765.
16. Mazini L, Rochette L, Amine M, Malka G (2019) Regenerative Capacity of Adipose-Derived Stem Cells (ADSCs), Comparison with Mesenchymal Stem Cells (MSCs). International journal of molecular sciences 20(10): 2523.
17. Lana J F, da Fonseca L F, Azzini G, Santos G, Braga M, et al. (2021) Bone marrow aspirate matrix: a convenient ally in regenerative medicine. International journal of molecular sciences 22(5): 2762.
18. Santos Duarte Lana J F, Furtado da Fonseca L, Mosaner T, Tieppo C E, Marques Azzini G O, et al. (2020) Bone marrow aspirate clot: A feasible orthobiologic. Journal of Clinical Orthopedics and Trauma 11(Suppl 5): S789–S794.
19. Moyal A J, Li A W, Adelstein J M, Moon T J, Napora J K (2024) Bone marrow aspirate and bone marrow aspirate concentrate: Does the literature support its use in long-bone pseudoarthrosis and provide new insights into the mechanism of action?. European Journal of Orthopaedic Surgery and Traumatology: Traumatological Orthopaedics 34(6): 2871-2880.
20. Kim G B, Seo M S, Park W T, Lee G W (2020) Bone marrow aspirate concentrate: its uses in osteoarthritis. International journal of molecular sciences 21(9): 3224.
21. Balderrama Í de F, Stuani V de T, Cardoso M V, Cunha G V, Manfredi G G do P, et al. (2022) The optimization of the use of biomaterials in maxillary sinus lift surgeries associated with concentrated bone marrow aspirate. Matter (rio De Janeiro) 27(1): e13162.
22. Chahla J, Mannava S, Cinque M E, Geeslin A G, Codina D, et al. (2016) Bone Marrow Aspirate Concentrate Harvesting and Processing Technique. Arthroscopy Techniques 6(2): e441-e445.
23. Colberg R E, Vélez J A J, Walsh K P, Fleisig G (2020) Short-term outcomes after injection of pure bone marrow aspirate for severe knee osteoarthritis: a case series. Regenerative Medicine 15(7): 1851-1859.
24. Mayo F Friedlis, Christopher J Centeno (2016) Performing a Better Bone Marrow Aspiration. Physical Medicine and Rehabilitation Clinics of North America 27(4): 919-939.
25. Shane A Shapiro, Jennifer R Arthurs (2022) Ultrasound-guided needle placement for bone marrow aspiration of the anterior iliac crest. Journal of Cartilage & Joint Preservation 2(3): 100057.
26. Bain B J (2003) Bone marrow biopsy morbidity and mortality. British Journal of Haematology 121(6): 949-951.
27. Soneji N, Peng P W H (2009) Ultrasound-Guided Interventional Procedures in Pain Medicine: A Review of Anatomy, Sonoanatomy, and Procedures. Regional Anesthesia and Pain Medicine 34(5): 458-474.
28. Peng P W, Narouze S (2009) Ultrasound-guided interventional procedures in pain medicine: a review of anatomy, sonoanatomy, and procedures: part I: non-axial structures. Regional anesthesia and pain medicine 34(5): 458-474.
29. Narouze S, Peng P W (2010) Ultrasound-guided interventional procedures in pain medicine: a review of anatomy, sonoanatomy, and procedures. Part II: Axial structures. Regional Anesthesia and Pain Medicine 35(4): 386-396.
30. Singjie L C, Kusuma S A, Saleh I, Kholinne E (2023) Potency of Platelet-Rich Plasma for Chronic Low Back Pain: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Asian Spine Journal 17(4): 782-789.
31. Penna P M M, Aquino C F, Castanheira D D, Brandi I V, Cangussu A S R, et al. (2010) BIOSAFETY: A REVIEW. Archives of the Biological Institute 77(3): 555-565.
32. Chahla J, Cinque M E, Piuzzi N S, Mannava S, Geeslin A G, et al. (2017) A Call for Standardization in Platelet-Rich Plasma Preparation Protocols and Composition Reporting: A Systematic Review of the Clinical Orthopaedic Literature. The Journal of Bone and Joint Surgery 99(20): 1769-1779.
33. Andia I, Rubio-Azpeitia E, Martin J I, Abate M (2015) Current concepts and translational uses of platelet-rich plasma biotechnology. InTech.
34. Pavlovic V, Ciric M, Jovanovic V, Trandafilovic M, Stojanovic P (2021) Platelet-rich fibrin: Basics of biological actions and protocol modifications. Open Medicine 16(1): 446-454.
35. Santos A P, Oliveira R A (2021) Knee osteoarthritis and bone marrow aspirate as a treatment choice - A narrative review. Research Society and Development 10(12):
36. Riley R S, Hogan T F, Pavot D R, Forysthe R, Massey D, et al. (2004) A pathologist's perspective on bone marrow aspiration and biopsy: I. performing a bone marrow examination. J Clin Laboratory Anal 18: 70-90.
37. (2023) NYSORA. Physics of Ultrasound.
38. Oliver K, Awan T, Bayes M (2017) Single- or multi-site harvesting techniques for bone marrow concentrate: assessment of aspirate quality and pain. Orthopedic Journal of Sports Medicine 5(8):
39. Khadavi M, Pourcho A, Podesta L (2023) Protocols and Techniques for Orthobiological Procedures. Physical Medicine and Rehabilitation Clinics 34(1): 105-115.
40. (2023) Regenerative Medicine. BoD – Books on Demand. In: Choudhery MS (Edt.).,.
41. Smith D R, Robinson R R (2018) Nerve Supply to the Pelvic Region: Clinical Implications for Health Professionals. Anatomical Science International 14(2): 341-348.
42. Shapiro S A, Arthurs J R (2017) Bone Marrow Aspiration for Regenerative Orthopedic Intervention: Technique with Ultrasound Guidance for Needle Placement. Regenerative Medicine 12(8): 917-928.
43. Kim H J, Choi H S, Lee J H (2017) Biomechanical properties of the sacroiliac joint in the elderly. Journal of Biomechanics 50:  124-129.
44. Mette Grønkjær, Connie F Hasselgren, Anne Sofie L Østergaard, Preben Johansen, June Korup, et al. (2016) Bone marrow aspiration: a randomized controlled trial evaluating the quality of bone marrow samples using slow and fast aspiration techniques and assessing pain intensity. Acta Haematol 135(2): 81-87.