Tips, quips, and pearls
Technique of the Sural Nerve Biopsy

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A sural nerve biopsy may be useful to enable the clinician to diagnose the etiology and underlying pathology of patients presenting with symptoms of a peripheral neuropathy, when no clear underlying cause has been determined with conventional assessment such as electrophysiology or quantitative sensory testing. Given the prevalence of lower extremity neurological pathology, it is surprising that few descriptions in the peer-reviewed medical literature exist on the rationale and technique for biopsy of the sural nerve. We review the usefulness of this procedure, describe the technique, and discuss the potential complications.

Section snippets

Technique

The surgical technique for attaining an adequate specimen has been described in detail by Dyck et al (7). The procedure is performed as an outpatient while the patient is under local anesthetic with or without conscious sedation. The patient is positioned supine on the operating room table, with a bolster under the ipsilateral hip and the foot slightly everted to relax the sural nerve (7). No tourniquet is used, and bipolar cautery is used for hemostasis to avoid damaging the specimen or

Potential Complications

Theriault et al (11) carried out a detailed review of the neurological deficits and complications after whole sural nerve biopsy. Postoperative symptoms were described as irritating (78%) but not painful; allodynia was present in 19% at 12 months; and on a scale of discomfort 0 to 10, the rating at 12 months was 3.0. After fascicular biopsy, Solders (12) reported that after 6 months, 11% of patients had significant discomfort, which was described as pinprick or a “tight” sensation during

Conclusion

Although a sural nerve biopsy can be a valuable tool and greatly contribute to establishing a diagnosis for peripheral neuropathy, it should be reserved for cases that cannot be diagnosed by other means. Performing the biopsy is not a technically difficult procedure given the relatively superficial anatomic location of the sural nerve. However, patients should be carefully informed of the risks of long-lasting discomfort, sensory deficit, infection, and wound dehiscence. It is the

Acknowledgment

We thank Dr. David Z. Shechter for his help with this manuscript.

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    This chapter will consider the significant contribution that sural nerve biopsy studies have made to our understanding of the pathology and pathogenesis of human diabetic neuropathy and will then also evaluate the increasing contribution of recent studies utilizing skin biopsies (Lauria and Lombardi, 2012) and the novel technique of corneal confocal microscopy in evaluating human diabetic neuropathy (Quattrini et al., 2007; Umapathi et al., 2007; Loseth et al., 2008). The majority of nerve biopsy studies have been undertaken in the sural nerve due to the fact that it is distal, sensory, and relatively easy to biopsy (Bevilacqua et al., 2007). In the upper limb the posterior interosseous nerve, a sensory branch of the radial nerve, has also been biopsied and studied (Thomsen et al., 2009a).

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    These characteristics make the sural nerve the most commonly biopsied peripheral nerve. In conventional sural nerve biopsies, the lesser saphenous vein is used as the most reliable landmark [2]. However, in cases where there is variation of sural nerve location, it is possible that a surgeon can become disoriented during surgical exploration without seeing the sural nerve beforehand.

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1

Fellow, Center for Lower Extremity Ambulatory Research (CLEAR), Clinical Instructor; Department of Surgery, Dr. William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine and Science, North Chicago, IL.

2

Fellow, Center for Lower Extremity Ambulatory Research (CLEAR), Clinical Instructor; Department of Surgery, Dr. William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine and Science, North Chicago, IL.

3

Senior Lecturer and Consultant Physician, Cardiovascular Research Group, Division of Cardiovascular and Endocrine Sciences, Manchester Royal Infirmary and University of Manchester, Manchester, United Kingdom.

4

Director, Center for Lower Extremity Ambulatory Research (CLEAR), Professor of Surgery and Associate Dean, Dr. William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine and Science, North Chicago, IL.

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