Pelvic Neuralgias by Neuro-Vascular Entrapment: Anatomical Findings in a Series of 97 Consecutive Patients Treated by Laparoscopic Nerve Decompression

Abstract

Background: Some patients have pelvic, pudendal, or low lumbar pain radiating into the legs that is worse while sitting but differs from pudendal neuralgia. The purpose of this study was to present a new clinical entity of neuropathic pelvic pain by pelvic neuro-vascular entrapment. Objectives: To report about the locations of predilection for pelvic neurovascular entrapment. Study Design: Prospective cohort pre- and post-intervention. Setting: University referral unit specializing in advanced gynecological surgery and neuropelveology. Methods: Patients, Intervention: In a prospective study, 97 patients presenting with intractable pelvic neuropathic pain (pudendal pain, gluteal pain, vulvodynia, coccygodynia, and sciatic pain) underwent laparoscopic exploration with decompression of compressed pelvic somatic nerves. The population included 76 (78.3%) women and 21 men. Indication for laparoscopic exploration of pelvic nerves suspected to be involved in pain has been indicated after neuropelveological work up, pelvic neuromagnetic resonance imaging (MRI) and Doppler-sonography. Pain evolution was recorded over 2 years after the procedure. Measurements and Main Results: Three entities were isolated: pudendal neuralgie by compression at the less sciatic notch, sacral radiculopathy at S2-4 by compression at the infracardinal level of the sacral plexus, and sciatica L5-S1/2 by compression at the greater sciatic notch. Pain was worse sitting (98%), during menstrual bleeding in women, and during Valsalva maneuver, but the pain did not wake the patients up at night and was not accompanied by neurologic dysfunctions. A decrease in VAS scores (> 50%) at 2 years follow-up was observed in 86 patients (88.6%). Conclusions: Neuro-vascular entrapment is a pathophysiologic phenomenon implicated in several pelvic neuropathies. The most common are L5-S1 sciatica, pudendal neuralgia, and sacral radiculopathy. After intraoperative confirmation, laparoscopic exploration of the entire sacral plexus is essential to diagnose conflict. Laparoscopic decompression is a treatment of choice, based on the separation of the offending vessel from the nerves. Those procedures are safe, with a high success rate; the neuropelveological approach is essential in order to obtain good treatment results. The laparoscopic approach gives the possibility of reducing morbidity and improving results by providing wider insight into the operating field with smaller intraoperative injury. Key words: Vulvodynia, coccygodynia, chronic pelvic pain, pudendal pain, neuro-vascular conflict