Sural nerve biopsy

1. Identification and description of procedure Nerve biopsy involves extracting a small peripheral nerve specimen for optical and electron microscope analysis. The biopsy is performed under local anaesthetic, with no need for prior preparation. It is performed on the sural nerve (at ankle level). The physician performing the biopsy will inject local anaesthetic at the site where the biopsy is to be performed. Then an approximately three to five centimetre incision will be made to take the specimen. Once extracted, some suture stitches will be applied, to be removed after around 8 days. 2. Purpose of the procedure and expected benefits If you are showing symptoms suggesting neuropathy, it will be necessary to perform a sural nerve biopsy to ascertain its cause. Neuropathies are a group of diseases affecting limb nerves. Performance of the nerve biopsy may enable diagnosis of your disease and allow for treatment in the event of a treatable disease. 3. Reasonable alternatives to this procedure The alternative not to authorise performance of sural nerve biopsy. In which case it will be impossible to diagnose your disease. Nevertheless, it might be the case that the biopsy does not allow for an accurate diagnosis of your disease. 4. Foreseeable consequences of its performance The foreseeable consequence of performance is the option to determine the cause of your neuropathy, and provide you with treatment if available. 5. Foreseeable consequences of non performance If the procedure is not carried out, it is possible that the cause of your neuropathy will not be ascertained. 6. Frequent risks The physical risk and most frequent discomfort of a sural nerve biopsy is minor pain. Later on, approximately 10% of patients can feel numbness or painful dysesthesia (afterburn) in the skin area innerved at sural nerve extraction site (outer face of ankle and foot), which can be secondary to the onset of neuroma or scarring of the biopsied nerve. 7. Infrequent risks Wound infection (cellulitis) is very infrequent as the procedure is performed under sterile conditions. Other very rare complications are local bruising at the puncture site, appearing more frequently in patients with blood diseases or treated with anticoagulants, or fainting. 8. Risks depending on patient's clinical situation Other risks or complications that might appear, given your clinical situation and your personal circumstances, are ____________________________________________________________________________ _________________________________________________________________________________. In your current clinical state, the benefits arising from the performance of this procedure outweigh the possible risks. Hence you have been told that it is appropriate for it to be performed on you. If complications were to arise, the medical and nursing staff who are treating you are qualified and have the means available for trying to resolve them.

BIOPSY

Sural nerve biopsy

Declaration of consent Mr./Mrs./Miss. aged , with home address at , National Identity No. and SIP number

Mr./Mrs./Miss. friend) Hereby declare: That the Doctor situation to perform a

aged , with home address at acting in the capacity of (the patient's legal representative, relative or close , with National Identity No.

has explained to me that it is advisable/necessary in my

and that I have adequately understood the information he/she has given me. In Signed: Mr./Mrs./Miss. on ,2 With National Identity Card No

Signed: Dr. Associate number

With National Identity Card No

Revocation of the consent I hereby revoke the consent granted on the date of to carry on with the treatment that I hereby terminate on this date. In on ,2 ,2 and I do not wish

Signed: The Doctor Associate number:

Signed: The patient

BIOPSY