Pelvic and perineal truncular and radicular neuropathic pain. R ROBERT Anatomist- Neurosurgeon Nantes FRANCE
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1 Pelvic and perineal truncular and radicular neuropathic pain R ROBERT Anatomist- Neurosurgeon Nantes FRANCE
2 Anatomical facts 1 perineal muscles 2 fibrous central perineal nucleus 3 external anal sphincter 4 median raphe 5 pubo prerectal fibers 6 Pubo retrorectal fibers 7 ilioretrorectal fibers 8 ischiococcygian fibers 9 sacrospinal ligament V RR L
3 Cr V Morphogenesis 1 cloacum 2 urin. Tube 3 rectal Tube 4 pelv-per spur 5 peritoneum 6 levator ani M 7 ext sphinct 8 caudal scler. RR
4 Cr V 1 UG 2 REC 3 LA 4 sphin 5 perit. 6 S roots 7 Pud N 8 CFNP RR
5 Two kinds of innervation Somatic: Pudendal nerve and al Vegetative: sympathetic for pain
6 Pudendal nerve entrapment A classical syndrom R ROBERT, JJ LABAT, T RIANT, B RIOULT, S PLOTEAU, A LEVEQUE Nantes France
7 A pain reaching different peripheral structures may be from neuropathic origin
8
9 An unknown entity 30 years ago Idiopathic proctalgias, vulvodynias Ano-rectal neuropathy pelvic neuralgias, coccygodynias, prostatodynias (prostatitis ou chronic pelvic pain syndrom), levator ani syndrom, idiopathic chronical rectal pain, etc.. pudendal neuralgia... G.AMARENCO 1987: Perineal neuropathic syndrom: clinical datas R.ROBERT 1989: Anatomical findings. Entrapment syndrom
10 La névralgie pudendale : pathologie neurologique Topographie tronculaire Position assise Brûlures Examen clinique normal Complication neuro du Richter = expérimental! Données EMG: la LD Thérapeutique Résistance aux antalgiques habituels Efficacité des médic de la douleur neuropathique Efficacité des infiltrations Latence distale
11 SOMATIC INNERVATION
12 PUDENDAL NERVE: Somatic innervation Pudendal nerve S2, S3 S4 Dorsal nerve of the penis Sacro spinal ligament Sacro tuberal ligament Pudendal canal Perineal branch Rectal inferior nerve
13 ( Kamina) A:Ilio-inguinal, Ilio hypogastric, Genitofemoral nerves B: Pudendal nerve C: Inferior Cluneal nerve
14 Sensitive supply Seated position may entrap two nerves: CLUN. PUD.
15 Pudendal nerve
16 Pudendal neuralgia Anatomy Dorsal nerve of the penis Pudendal nerve Mainly S3 Sacrospinous ligament Sacrotuberal ligament Alcock s tunnel Perineal nerve Rectal nerve
17 Pudendal neuralgia Anatomy cranial ventral Sacrotuberal ligament Sacrospinous ligament Falciform process
18 Pudendal neuralgia Anatomy Internal obturator muscle? Sacral plexus Levator ani muscle
19 Pudendal neuralgia Anatomy Sacral roots Falciform process Sacro Spinous ligament
20 Pudendal neuralgia Anatomy Section of the sacrospinous ligament Cadaver in a seated position: possible entrapments of the nerve
21 Infiltration au LSE Utilité diagnostique Principale zone de conflit En première intention En amont du canal d Alcock Variation anatomique
22 Inferior cluneal nerve
23 Cranial Right Inferior gluteal nerve Dorsal Cutaneous nerve of the thigh
24
25 Ischiatic tuberosity GLUTEU S MAXIMU S Hamstring muscles
26 ANUS LABIA VULV E
27 HERE IS THE PROBLEM Ischiatic trunk Dorsal cutaneous nerve of the thigh Ischiatic tuberosity Fibrous arcade
28
29
30 Nantes criteria Pain in the PN territory Does not awake patient when sleeping In sitting position Normal neurological examination One positive block
31 Anatomy guides the surgery: transgluteal approach Piriformis muscle Sacrotuberal ligament Ischiatic nerve Ischial tuberosity
32 Goal of the surgery: liberation of the nerve entrapments Sacro tuberal ligament Has been resected Pudendal nerve Sacrospinous ligament
33 Liberation - transposition of the pudendal nerve Section of the SS ligament Section of the fascia of the internal obturator muscle
34 Surgery of the pudendal nerve: a randomized prospective controlled trial Surgery versus control group Principal goal: Surgery improves 60% patients at 3 months No surgery ( control ) improves 30%patients at 3 months Ris k α=5% et ß= 10% Secondary goals Improvment at 12 months Side effects of each procedure
35 Prospective randomized study Inclusion criterias: Pain VAS 7 verbal scale 6 levels 3 Efficacity when: VAS decreases < 3 cms VS decreases < 2
36 Randomized prospective study: the 2 cohortes 32 patients recruited no consent:1 16 Control group 15 consultations 181 patients Inclusions ended at 15 months 16 Surgery group no consent:2
37 Randomized controlled trial Efficacy Groups 3 months 12 months Surgical 8/14 10/14 Control 1/15 1/15
38 Surgical procedure with Robert s technic is therefore validated. It allows a complete decompression of the nerve, without more complication than any other surgery. No sphincterian nor sexual problems No sacro-iliac joint instability
39 Results and long time effect of the surgery 70% improve or are painless 29 have no benefit 1% is worse 70% of improvment
40 Robert s surgery: transgluteal approach The nerve under view Entrapment zones: -Ligamentous claw -Falciform process -Alcock s tunnel
41
42 Per op views No specific complication
43 Our Inferior cluneal nerve: aim of the surgery
44 Surgery (R ROBERT, S PLOTEAU) - Same approach than for PN surgery - More caudal - Latero-STL dissection - Nerve under view - The arcade must be cut
45 FREQUENCY: ONE YEAR 245 CASES Isolated pudendal nerves: 176 cases (72%) Isolated ICN: 30 cases (12%) Pudendal+ ICN: 39 (16%) Total ICN : 28% So do not forget it Gluteal approach required
46 Nerves from above
47 Organization of the sympathtic system
48 Vegetative innervation Left endopelvic view Cr V Hypogastric nerve Sacral sympathetic ganglias Erector nerves (ECKARDT)
49 Ortho sympathetic Mixt Vegetative system Para sympathetic
50 Master I Les bases anatomiques de l infiltration du ganglion impar le Clerc Quentin Côme Laboratoire d anatomie de Nantes
51 Le ganglion impar
52
53 craniâle Latéral droite Latéral gauche caudal
54
55
56 Higher level
57 PIRIFORMIS SYNDROM
58 Ischiatic nerve: a possible muscular claw Contingent tibial= dorsal. Contingent Fibulaire= ventral
59
60 Piriformis syndrom 5 cms internal obturator syndrom
61 TROLARD S NERVE
62 PRE SACRAL CONFLICTS? Pudendal neuralgias Negative pudendal block Positive S3 block Entrapment of roots?
63 Crânial Ventral
64 Conflicts with the muscles: Scalene like syndrom Ventral Caudal
65 Crânial Gauche
66 Crânial Latéral
67 Crânial Latéral
68
69 CORTICAL STIMULATION
70 CONUS STIMULATION 10 patients Prospective study 6 improvment 3 better seated position but pain is still there 1= nul Let s go
71 CONCLUSIONS Two main roads for pain Two kinds of pain Two targets for blocks The future: 1. Definition of pain (pluri or monometameric) 2. Appropriated blocks or peripheral nerves surgery 3. Stimulation of the inhibitor systems
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