Surgical Anatomy of the Saphenous Nerve

Victor Dayan, Leandro Cura, Santiago Cubas and Guillermo Carriquiry

Ann Thorac Surg 2008;85:896-900
DOI: 10.1016/j.athoracsur.2007.11.032

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
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The Annals of Thoracic Surgery is the official journal of The Society of Thoracic Surgeons and the
Southern Thoracic Surgical Association. Copyright © 2008 by The Society of Thoracic Surgeons.
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CARDIOVASCULAR
Surgical Anatomy of the Saphenous Nerve
Victor Dayan, MD, Leandro Cura, MD, Santiago Cubas, MD,
and Guillermo Carriquiry, MD
Cardiovascular Surgery Department of the National Institute of Cardiac Surgery, and Anatomy Department of the Medicine
School of Uruguay, Montevideo, Uruguay
Background. During harvest of the saphenous vein
(SV), the most important relationship to take into account
is the saphenous nerve (SN) to avoid pain and paresthe-
sias after surgery.
Methods. We harvested the SV and SN in 20 cadaveric
lower limbs. Relationships between both structures were
recorded using a millimetric ruler, and distances were
measured from the medial malleolus at the ankle.
Results. The SV was superficial to the leg fascia 32 cm
above the malleolus in 95% of the legs. During its course
in the leg, 40% of SNs are posterior to the SV; 40% are
anterior and then posterior to the SV; and 10% are posterior
and then hidden by the SV. The SN crosses the SV in 55%
T he surface anatomy of the anterior leg compartment
has focused its attention on the saphenous vein
(SV), neglecting the saphenous nerve (SN). The SV is
frequently used as a graft during vascular bypass proce-
dures. During harvest of the SV, the most important
relationship that the surgeon must pay attention to is
with the SN. A careless dissection or lack of knowledge of
the anatomy of this nerve, or its branches, will lead to
sensory alterations (pain, paresthesias, and anesthesia) in
the medial aspect of the leg.
Saphenous neuralgia [1] describes the symptom com-
plex that includes anesthesia, hyperesthesia, and pain
within the distribution of the SN. Besides its description
after SV harvesting for coronary artery bypass graft
procedures [2], it has also been described after varicose
vein [3], arterial [4], and orthopedic [5] procedures.
We centered our attention on the SN in the leg, as it is
in this region in which relationships with the SV matter
and where the SN is at its greatest risk of being injured.
Material and Methods
The study protocol was reviewed and approved by the
National Institute of Cardiac Surgery and Medical School
institutional review board, and did not require individual
patient consent.
Twenty cadaveric lower limbs were studied, 8 of them
from male cadavers and 12 from female cadavers. We
harvested the SN in the superficial medial aspect of the
Accepted for publication Nov 12, 2007.
Address correspondence to Dr Dayan, Instituto Nacional de Cirugía
Cardiaca, 26 de Marzo 3459, Apt 602, Montevideo, Uruguay; e-mail:
vdayan@adinet.com.uy.
© 2008 by The Society of Thoracic Surgeons
Published by Elsevier Inc
Downloaded from ats.ctsnetjournals.org by Leandro Cura Hochbaum on March 1, 2008
of the legs. Three constant branches of the SN were iden-
tified: middle-posterior, middle-anterior, and inferior-ante-
rior. The SN ends by splitting 5.9 cm above the malleolus.
A vulnerable region occurs in the lowest 13.2 cm, where
the SN adheres to the SV. At this level the SN gives off
the inferior-anterior branch that crosses the SV in 66%
of the legs. Between 21.6 cm and 28.8 cm the SN crosses
deep to the SV.
Conclusions. During harvest of the SV, the most vul-
nerable area is the inferior third of the leg because of
venonervous adhesion.
(Ann Thorac Surg 2008;85:896 –900)
© 2008 by The Society of Thoracic Surgeons
leg up to the superficial fasciae. A continuous incision
was made from the medial malleolus at the ankle to the
medial condyle at the knee. Two flaps were made to
expose the SN and SV.
We considered the medial malleolus at the ankle as the
initial site from which distances were recorded. Measure-
ments were made using a millimetric ruler and expressed
in centimeters. Distances were always recorded by the
same observer and correlated to the lower limb longi-
tude to minimize the errors of using absolute measures.
Distances recorded were divided by the distance be-
tween the medial malleolus at the ankle and the knee
fold. Therefore, 0% corresponded to the medial malleolus
and 100% to the knee fold.
The data recorded were the level of surface of the SN,
relationships the SN has with the SV down its passage in
the leg, the number of branches the SN gives off, rela-
tionships of these branches with the SV and their skin
innervation territory, ending site, and delimitation of safe
and vulnerable regions where the SN could be damaged.
We defined a safe region as one in which the separation
between the nerve or its branches with the vein were
greatest, therefore the risk of nerve injury during SV
harvest would be minimal. The vulnerable regions were
those in which the SV and SN were in close contact or
adhered and where branches given off by the SN crossed
the SV. At these regions, the SN or its branches would be
at greatest risk of injury during harvest of the SV.
Results
Origin
The surface point of the SN was in 95% of the legs (n ⫽
19) below the knee fold, whereas in a single case (5%), the
0003-4975/08/$34.00
doi:10.1016/j.athoracsur.2007.11.032
Ann Thorac Surg
2008;85:896 –900
Fig 1. The surface point of the saphenous nerve (SN) at the knee
fold is deeper than the saphenous vein (SV). Both are separated by
an important adipose layer. The middle-posterior branch does not
cross the saphenous vein. The middle-anterior branch crosses super-
ficially the saphenous vein.
supraaponeurotic origin was above. The distance from
the medial malleolus at the ankle was 32 ⫾ 4 cm (89% ⫾
7%) in 50% of the cases, with maximum values of 40 cm
and a minimum of 27 cm.
The relationship with the SV at this level showed that
in 45% (n ⫽ 9) of cases the SN was posterior to the vein,
in 45% (n ⫽ 9) anterior, and hidden by the vein in 10%
(Fig 1).
Course
During its course down the leg, the position of the SN
with regard to the SV changes. The SN was posterior to
the SV in 40% (n ⫽ 8) of cases. In another 40% (n ⫽ 8), the
SN was anterior to the SV initially and posterior to it
Fig 2. The saphenous nerve (SN) ends splitting in a supramalleolar
and dorsomedial branch. In this area of the leg, the saphenous nerve
and saphenous vein are adhered. The inferior-anterior branch given
off by the saphenous nerve crosses the saphenous vein superficially.
This branch is at great risk of injury during the saphenous vein
harvest.
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DAYAN ET AL 897
CARDIOVASCULAR
SURGICAL ANATOMY OF THE SAPHENOUS NERVE
Fig 3. As the nerve descends along the leg, it approaches the saphe-
nous vein and determines a safe and vulnerable region.
later. In 5% (n ⫽ 1) the SN was hidden by the SV all along
its course, and in 5% (n ⫽ 1) it was hidden initially and
later was posterior to the SV. In 10% (n ⫽ 2), the SN was
posterior and then became hidden by the SV.
The SN crossed the SV in 55% (n ⫽ 11) of the legs, with
the SV superficial to the SN at the crossing point in 90%
(n ⫽ 18) of them. The crossing area in 50% (n ⫽ 10) of the
legs was at 22.7 ⫾ 5 cm (63% ⫾ 13%) from the medial
malleolus with a maximum of 30 cm and minimum of
13 cm.
Branches of the Saphenous Nerve
The most frequent presentation was the presence of
three branches: middle-posterior, middle-anterior, and
inferior-anterior branch. The middle-anterior branch
ended at the anterior middle third of the leg; the inferior-
anterior branch ended at the anterior distal third of the
leg, and the middle-posterior branch ended at the pos-
terior middle third of the leg. The middle-anterior branch
originated in 50% of the legs at 20.6 ⫾ 5.1 cm (56% ⫾ 15%)
with a maximum of 32 cm and minimum of 13 cm. The
middle-posterior branch originated in 50% of the legs at
24.4 ⫾ 6.5 cm (67% ⫾ 18%) with a maximum of 34 cm and
minimum of 11 cm. The inferior-anterior branch origi-
nated in 50% at 11.8 ⫾ 5 cm (33% ⫾ 15%) with a
maximum of 30 cm and minimum of 6 cm.
These three branches were present in 100% of the legs.
Other less frequent branches had the following designa-
tions: anterior proximal third of the leg (present in 35% of
the legs), posterior distal third (in 30% of the legs), and
posterior proximal third (in 10% of the legs).
Ending of the Saphenous Nerve
The SN ended in 50% of the legs at 5.9 ⫾ 2.7 cm (15% ⫾
7%) with a maximum of 11 cm and minimum of 1 cm. In
95% of the legs, the nerve divided into a supramalleolar
and dorsomedial branch that follows the SV to the
dorsum of the foot. In 1 case (5%), the nerve did not
divide and continued as a dorsal branch (Fig 2).
 898 DAYAN ET AL
CARDIOVASCULAR
SURGICAL ANATOMY OF THE SAPHENOUS NERVE
Safe Region
The safe region extended from the point the SN surfaces
to 24.11 ⫾ 3.5 cm (68% ⫾ 9%) of the medial malleolus in
50% of the legs. The maximum extension was up to 20 cm,
whereas the minimum was 30 cm. In these cases, the
nerve was located 1 or 2 cm deeper and anterior or
posterior to the vein, separated by an adipose layer.
These values varied according to the adipose layer of the
leg. In legs of female cadavers, the safe zone extended up
to 23.2 ⫾ 3.2 cm of the medial malleolus in 50% of the
legs. In men it was up to 25.8 ⫾ 3.6 cm of the medial
malleolus (Fig 1).
In 35% of legs another safe region could be delimited in
which the nerve was located more than 0.5 cm posterior
to the vein but at the same depth level. This zone was
between 15.8 cm (45%) and 24.4 cm (68%).
Vulnerable Region
At the distal end of the leg, the SN was adhered to the
vein, covered by a common fascia. This intimate relation-
ship between both structures extended in 50% of the
cases, from the medial malleolus at the ankle to 13.2 ⫾ 5.2
cm (37% ⫾ 17%), with a maximum extension of 25 cm
(78%) and a minimum of 3 cm (9%). At this region, the SN
was hidden by the SV in 15% (n ⫽ 3) and was posterior to
it in 85% (n ⫽ 17) of legs.
As we previously stated, a vulnerable region corre-
sponded to the crossing point of the SV and SN, which
was between 21.6 and 28.8 cm (61% to 80%). The last
vulnerable segment extended from 7.2 to 10.8 cm. (21% to
30%) of the medial malleolus; in this section, the inferior-
anterior branch of the SN crossed the SV in 90% (n ⫽ 18)
of the legs (Fig 3).
There were no differences between the right and left
lower limbs. Between those of male and female cadavers,
their differences were based on the thickness of the fatty
layer and therefore in the extension of the safe region.
Comment
The saphenous nerve is the terminal sensory branch of the
femoral nerve (L2, L3, and L4) supplying the skin of the
anteromedial aspect of the leg through its two major
divisions: the sartorial and infrapatellar nerves. After its
origin at the inguinal region, the SN travels with the
femoral artery through the femoral canal. It perforates
the anterior wall of the canal and becomes superficial. At
this point the SN comes in close proximity with the SV,
and the risk of a lesion increases as it descends down the
leg.
The presence of saphenous neuralgia as a complication
of SV harvesting has been previously described [6]. Its
incidence was reported by Mountney and Wilkinson [2]
in 35 (90%) of the lower limbs examined 3 days after
surgery, with 23 (72%) still symptomatic in a mean
follow-up of 20 months. The main symptom was anes-
thesia, whereas hyperesthesia and pain were less fre-
quently encountered. Budillon and associates [7] report
saphenous neuralgia after harvesting of the SV as a rare
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Ann Thorac Surg
2008;85:896 –900
consequence. The main symptom reported was anesthe-
sia, which lasted no longer than 2 months. After an
extensive review of the current bibliography, we could
not find any descriptive anatomy of the SN at this area
that could explain the sensory deficits after SV harvest.
To analyze the collected data, we will discuss the
anatomy of the supraaponeurotic segment of the SN with
regard to its origin, course, relationships, branches, and
ending, comparing it in each case with those published.
Origin
The origin was found in most of the legs below the knee
fold. At this level the SN perforates the superficial fascia
between the gracilis and sartorius muscles. There is no
published description as to the superficial origin of the
nerve.
Course
The SN descended through the medial aspect of the tibia
from the medial condyle at the knee fold to the medial
malleolus at the ankle, following an anterior concave
course. A compartment occupied by the SV and the SN
throughout their course in the leg was described by
Caggiati [8]. This compartment is limited deeply by the
muscular fascia and superficially by the superficial fascia;
laterally both fascia are fused, following two lines that go
from the medial condyle at the knee to the medial
malleolus at the ankle.
Relationships
The SN relationships were basically with the SV and
varied throughout the leg. At its origin, the nerve lay
deeper than the vein. This depth varied from 1 to 2 cm
and depended on the adipose layer of the leg. The nerve
was located anterior or posterior to the SV, and the
frequency was similar in both cases. The separation in
depth between the SN and SV diminished as it de-
scended, with both existing at the same depth level in the
distal half of the leg.
To take its final location in the distal half of the leg, the
course of the SN at the proximal half was different
according to the superficial origin. In those cases in
which the SN originated anterior to the vein, the nerve
crossed the vein along its course. This crossing was deep
with respect to the vein in 90% of legs and occurred at the
proximal half of the leg.
The crossing point is separated by adipose tissue and
protects the nerve from being damaged by the surgeon.
This segment represents a safe region, which will depend
on the adipose content of the leg.
The SN reaches its definitive position at the distal half of
its course. This position was in 85% posterior to the vein
and hidden in 15%. Our findings differ from a previously
published report that states an anterior position of the
nerve with respect to the SV in 70% of the legs [12].
We deduce that the SN variability in position with
respect to the vein is the consequence of the venous
variability, because as a general rule, vein anatomy is
much more variable than nerve anatomy.
Ann Thorac Surg
2008;85:896 –900
Fig 4. In this sketch, the leg is divided into thirds. The three constant
branches of the saphenous nerve (SN) arise at the superior third (mid-
dle-posterior branch), between the superior and middle third (middle-
anterior branch), and between the middle and distal third of the leg
(inferior-anterior branch). (SV ⫽ saphenous vein.)
In the last segment, the nerve remained adhered to the
vein, surrounded by a common fascia, being difficult to
dissect between both structures.
Branches
There were only three constant branches. We named
them according to their skin distribution at the medial
aspect of the leg (Fig 4).
The first one was the middle-posterior branch. It orig-
inated at the superior third of the leg and traveled obliquely
downward and posterior. There was no crossing with the
vein unless the SN was located anterior to the vein; in this
case, the crossing was deep owing to the deeper position of
the nerve with respect to the SV at this region.
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DAYAN ET AL 899
CARDIOVASCULAR
SURGICAL ANATOMY OF THE SAPHENOUS NERVE
The second branch we called the middle-anterior
branch. It originated between the superior and middle
third of the leg, went downward and anterior, crossing
the vein deeply in those cases in which the SN was
posterior to the SV.
The last branch was called the inferior-anterior branch.
It originated between the middle and inferior third of the
leg and went downward and anterior, crossing the vein in
100% of the legs, as at this segment the SN was hidden or
posterior to the vein. The crossing was generally super-
ficial to the SV.
Mountney and Wilkinson [2] described three areas as
the most frequent sites of anesthesia in their patients,
which correlate with the innervation territory of the three
branches of the SN described. This means that the
sensory deficit could be explained by careless injury to
the SN branches.
There is no descriptive systematization of the SN
branches in the bibliography reviewed. They are de-
scribed simply as anterior and posterior branches [9 –11].
Branches found with lesser frequency were called supe-
rior-anterior, superior-posterior, and inferior-posterior.
Ending of the Saphenous Nerve
The ending of the nerve was practically constant and in
accordance with the bibliography reviewed [12, 13]. At
the distal fifth of the leg, it splits into a dorsomedial
branch that follows the course of the SN and a supramal-
leolar branch to the medial malleolus.
Vulnerable Region
We concluded that the region of greatest precaution
during the harvest of the SV is the inferior third of the
leg. At this sector, the nerve is adhered to the vein by a
common fascia. The nerve is located posterior to the SV
or hidden by the vein. This last disposition increases the
complexity of the dissection.
Between 7.2 and 10.8 cm (20% to 30%) from the medial
malleolus at the ankle, the SN gives off the inferior-
anterior branch, which crosses superficially the SV in two
thirds and deeply in one third of the legs. We consider
this last disposition of great importance; not taking it into
account probably would lead to damaging the inferior-
anterior branch of the SN and the presence of sensory
deficits after surgery (Fig 3).
The importance of this region was demonstrated by
Mountney and Wilkinson [2] in which the most common
affected area (of the three they describe) after SV harvest
was the anterior and distal third of the medial leg. The
high incidence of sensory effect in this area could be
explained by injury to the inferior-anterior branch of the
SN during harvest of the SV.
In patients with little adipose tissue, the crossing of the
SN with the vein, which is seen approximately in the
inferior third of superior half of the leg, represents
another vulnerable region.
Safe Region
The safe region is located at the superior half of the leg.
Here, an adipose layer separates the SN and SV. During
 900 DAYAN ET AL
CARDIOVASCULAR
SURGICAL ANATOMY OF THE SAPHENOUS NERVE
the dissection of female lower limbs, this region was
greater, owing to a thicker layer of adipose tissue.
Conclusions
Little has been described regarding the surgical anatomy
of the SN at the leg. We consider the correct anatomic
knowledge of this sector of the nerve of great importance
because of the relationships with the SV, and therefore it
is of importance in cardiac surgery or any vascular
procedure that seeks this conduit.
The most significant vulnerable region found in our
work was at the distal third of the leg. This is where
sensory alterations appear most frequently after SV har-
vesting as demonstrated by Mountney and Wilkinson [2].
Future studies should be aimed at establishing the
presence of sensory deficits after harvest of the SV, in
which the SN branches described here are correctly
identified and preserved. Although the number of sam-
ples is small to reach definitive conclusions, this study
constitutes a line of investigation to be continued.
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 Surgical Anatomy of the Saphenous Nerve
Victor Dayan, Leandro Cura, Santiago Cubas and Guillermo Carriquiry
Ann Thorac Surg 2008;85:896-900
DOI: 10.1016/j.athoracsur.2007.11.032

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