Objective <p>This study aimed to determine the diagnostic yield of CT-guided bone biopsies in pediatric patients, the outcome of non-diagnostic CT biopsy results, and to establish factors associated with non-diagnostic biopsy results.</p> Materials and methods <p>This is a retrospective study of consecutive pediatric patients ≤ 21 years who underwent CT-guided bone biopsies in three tertiary referral hospitals from December 2011 to March 2022. Clinical information, pre-biopsy CT and MRI images, procedural details, pathological results, and follow-up were assessed. Fisher’s exact test was used to compare categorical variables. Mann–Whitney <i>U</i>-test and unpaired <i>t</i>-test were used to compare non-parametric and parametric variables, respectively. Statistical significance was set a <i>p</i> &lt; 0.05.</p> Results <p>A total of 138 patients (mean age 13.9 ± 4.5 years; 95 (60%) male patients) with 157 CT-guided bone biopsies were studied, which yielded 38.2% (60/157) non-diagnostic, 23.6% (37/157) benign, and 38.2% (60/157) malignant results. Most non-diagnostic lesions (88.3% [53/60]) were subsequently determined to be benign. Factors associated with non-diagnostic biopsy results were cystic lesions (<i>p</i> = 0.003) incidental lesions (<i>p</i> = 0.03), fewer (<i>p</i> = 0.02) and shorter (<i>p</i> = 0.01) tissue cores, non-aggressive radiological features, including narrow zone of transition (<i>p</i> &lt; 0.001), sclerotic margin (<i>p</i> &lt; 0.001), no cortical destruction (<i>p</i> &lt; 0.001), no periosteal reaction (<i>p</i> &lt; 0.001), or no extra-osseous soft tissue mass (<i>p</i> &lt; 0.001).</p> Conclusion <p>About one-third of CT-guided bone biopsies in pediatric patients yielded non-diagnostic results, though most were ultimately confirmed to be benign. In children and adolescents with suspected primary bone tumors, CT-guided bone biopsy with non-diagnostic histopathological results strongly favors benignity in lesions with non-aggressive imaging features and should align management towards a more conservative approach.</p> Key Points <p><Emphasis Type="BoldItalic">Question</Emphasis> <i>Limited data exist on the prevalence and outcome of non-diagnostic CT-guided bone biopsy in pediatric patients to guide clinical management</i>.</p> <p><Emphasis Type="BoldItalic">Findings</Emphasis> <i>About one-third of CT-guided bone biopsies in pediatric patients were non-diagnostic, though most were ultimately benign. Lesions with non-aggressive features were associated with non-diagnostic results</i>.</p> <p><Emphasis Type="BoldItalic">Clinical relevance</Emphasis> <i>In the setting of multidisciplinary care for patients with suspected primary bone tumors, non-diagnostic CT-guided bone biopsy—particularly in lesions with non-aggressive imaging features—strongly favors benignity, which should steer management towards a more conservative approach</i>.</p> Graphical Abstract <p></p>