Figure 3-1 Targeted fascicular biopsy.

Figure 3-2 Representative targeted fascicular biopsies. A, Single fascicle obtained from tibial division of sciatic nerve in buttock region shows nodularity. Histology showed onion bulbs characteristic of chronic inflammatory demyelinating polyneuropathy. B, Single fascicle obtained from the tibial nerve in distal thigh showed sheets of amyloidosis. C, Single fascicle obtained from sciatic nerve in buttock showed “blue” infiltrate and proved to be prostate adenocarcinoma.

Hemostasis is achieved with a bipolar cautery. The wound is irrigated copiously and closed in anatomic layers. Subcuticular sutures are placed with adhesive skin closures (Steri-Strips, St. Paul, Minnesota). The procedures take between 45 and 90 minutes, depending on the site of the biopsy and need for intraoperative pathology interpretation.

Patients are discharged from the hospital the same day or observed after a 23-hour observation period and re-evaluated together with the neurologist at several weeks postoperatively, when the pathology is finalized. At that time, recommendations for target-specific therapy are discussed with the patient.

SURGICAL LESSONS LEARNED

• If at all possible, avoid biopsying a functioning nerve

• Select the least important nerve (for example, tibial division rather than peroneal division of the sciatic nerve)

• Select the most accessible nerve in the most accessible region (sciatic nerve in buttock rather than lumbosacral plexus in pelvis or cauda equina)

• Obtain as lengthy a specimen as possible (plexal involvement and interdigitation of fascicles may limit length of specimens or make the same fascicular biopsy more technically demanding).

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