Radial nerve biopsy with Avance processed nerve allograft and Axoguard nerve protector reconstruction
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Nerve biopsy may be required to assist in the diagnosis of atypical neurological presentations or to direct treatment. The sural nerve is relatively expendable and is most commonly used for this purpose. Often a neurologist requests a specimen from a nerve involved in the disease process. When an upper limb nerve is required, the superficial radial nerve may be used as a biopsy site. The larger diameter nerve enables immunohistological evaluation of the fascicles and the associated blood vessels. It is helpful in the diagnosis of rare vasculitic disorders.
The biopsy may be performed under local anaesthetic or regional anaesthesia, avoiding a general anaesthetic in a patient with neurological symptoms and diagnostic uncertainty. The superficial radial nerve lies deep to the brachioradialis muscle in the proximal third of the forearm and biopsy can be followed with immediate reconstruction to minimise the risk of a symptomatic neuroma. The typical length of nerve harvest is 10-15mm and therefore the gap length is too large for meaningful recovery to be expected through a conduit. Autologous nerve grafting would create a defect in another sensory nerve and recovery may be uncertain due to the underlying neurological condition.
The Avance processed nerve allograft may be used to reconstruct the defect after biopsy and there is no anatomical cost to the patient. Should regeneration follow the biopsy, there is a scaffold to support regeneration and prevent local neuroma formation. The area of nerve reconstruction may further be wrapped in a collagen nerve wrap to protect the neurorraphies and to prevent scar tether at the repair site.
The Axoguard nerve protector is a porcine extracellular matrix collagen wrap that can be used for this purpose. The operative technique described demonstrates superficial radial nerve biopsy, immediate reconstruction using Avance processed nerve allograft and the use of the Axoguard nerve protector to protect the reconstruction site.
Author: Dominic Power MA MB BChir FRCS Tr & Orth, Consultant Hand and Peripheral Nerve Surgeon
Institution: The Queen Elizabeth Hospital, Birmingham, UK.