Neuromuscular Unit
Request for Muscle or Nerve Biopsy
Patient details
(use sticker if possible)
Date of request
Requesting physician
(+ contact phone / bleep)
Responsible consultant
(+ contact e-mail address)
Destination for report
(department and hospital)
Muscle Biopsy /
Nerve Biopsy
(please check as appropriate)
Site and side
(target muscle or nerve – discuss nonquadriceps muscle or non-sural nerve
biopsies with surgeon)
Clinical Information
Distribution of weakness / Time course of
progression etc.
Clinical Question
CK level (if muscle biopsy)
EMG / NCS summary
Please attach formal report if possible
Special issues:
e.g. on warfarin, aspirin, other bleeding
diathesis
Special tests?


mtDNA or other genetics?
Respiratory chain enzyme
analysis?
All fields must be completed. This request form should be sent to neuropathology with the sample. See additional information
overleaf.
Atkinson Morley Regional Neurosciences Centre
St George’s Healthcare NHS Trust
Additional Information
Request Forms

This referral form must be submitted with all samples.

There are nationally commissioned services for certain rare neuromuscular disorders. In
general neuropathology can advise following initial analysis if further referral is warranted.
However, if it is known beforehand that the following are required additional request forms
need to be completed. These can be obtained from neuropathology or the day unit coordinator
(contact details below).
o
o
o

Genetic studies on muscle tissue for rare mitochondrial disorders (Newcastle – not
required for standard mitochondrial studies)
Immunohistochemical or genetic studies for rare limb-girdle muscular dystrophies
(Newcastle – not required for standard dystrophy panel)
Studies for congenital myopathies or congenital muscular dystrophies (Great Ormond
Street Hospital)
.
Requests for respiratory chain enzyme analysis require discussion beforehand.
Organising muscle and nerve biopsies:

Elective muscle or nerve biopsies can be organised via the Neurosciences Day Unit Coordinator, ext. 5188.

Emergency muscle biopsies for inpatients may be arranged via the neurosurgical or plastic
surgery teams. Pathology will need at least 24 hours notice.

Emergency nerve biopsies for inpatients can be organised via the neurosurgical on-call team,
but patients will require a neurology consultant review before this will be undertaken.
Pathology will need at least 24 hours notice.

Guidelines for Muscle and Nerve Biopsies are available from Cellular Pathology
(extensions 5256 or 5257) or the Neurosciences Day Unit co-ordinator (extension 5188). It is
essential that teams requesting urgent inpatient biopsies, as well as surgeons performing the
procedure, are familiar with these guidelines to ensure an adequate sample and appropriate
and timely processing.

Muscle and nerve biopsy patient information leaflets are available from the Neurosciences Day
Unit Co-ordinator, extension 5188.
Useful Contacts:


Cellular Pathology: 020 8725 5256 or 5257
Neurosciences Day Unit Co-ordinator:
 020 8725 5188, Email: neurodayunit@stgeorges.nhs.uk
Atkinson Morley Regional Neurosciences Centre
St George’s Healthcare NHS Trust