To use meta-analysis to determine the complication rate and diagnostic accuracy of image-guided percutaneous needle biopsy of the spleen. Several electronic databases were searched through July 2010 without language restrictions. Two reviewers independently selected studies that met the inclusion criteria for the diagnostic accuracy and complication rate arms of the study. Study data were independently extracted by the two reviewers. The primary 2 × 2 data were investigated with a random-effects meta-analysis of sensitivity and specificity. The complication rate data were investigated with a random-effects meta-analysis; sensitivity analysis of complication rate, excluding needles larger than 18 gauge, was performed. Four studies met the inclusion criteria for the diagnostic accuracy arm (639 patients), and nine met the inclusion criteria for the complication rate arm (741 patients). The meta-analysis showed a pooled sensitivity of 87.0% (95% confidence interval [CI]: 80.7%, 91.4%) and specificity of 96.4% (95% CI: 81.4%, 99.4%). The pooled major complication rate was 2.2% (95% CI: 0.8%, 5.6%). Sensitivity analysis with the removal of biopsies performed with needles larger than 18 gauge showed a major complication rate of 1.3% (95% CI: 0.6%, 2.5%). The most commonly encountered complications were hemorrhage followed by pain. Image-guided percutaneous biopsy of the spleen demonstrates high diagnostic accuracy and a major complication rate, for needles 18 gauge or smaller, that is similar to that reported for the liver and kidney. This technique should be considered a favorable alternative to splenectomy.