Lumbosacral Lumbosacral PlexusPlexus SurgerySurgery

Hector Giocoli, MDHector Giocoli, MDBuenos Aires - ArgentinaBuenos Aires - ArgentinaHector Giocoli, MDHector Giocoli, MDBuenos Aires - ArgentinaBuenos Aires - Argentina

CharacteristicsCharacteristics Low incidence:Low incidence: Rarely reported lesions, witch, Rarely reported lesions, witch,

if posttraumatic, may remain undiagnosed if posttraumatic, may remain undiagnosed because of the variable destination of the patients because of the variable destination of the patients in emergency in emergency

Difficult level diagnosis:Difficult level diagnosis: Patients witch Patients witch different parenchimal or visceral lesions, with different parenchimal or visceral lesions, with different problems witch hinder motility (And different problems witch hinder motility (And frequently affected by severe pain)frequently affected by severe pain)

Difficult surgical treatment:Difficult surgical treatment: Analogous lesions in the brachial plexus are Analogous lesions in the brachial plexus are

normally treated, and results are quite well normally treated, and results are quite well known.known.

In this anatomical district surgical approach is In this anatomical district surgical approach is not so comfortable and familiar not so comfortable and familiar

Low incidence:Low incidence: Rarely reported lesions, witch, Rarely reported lesions, witch, if posttraumatic, may remain undiagnosed if posttraumatic, may remain undiagnosed because of the variable destination of the patients because of the variable destination of the patients in emergency in emergency

Difficult level diagnosis:Difficult level diagnosis: Patients witch Patients witch different parenchimal or visceral lesions, with different parenchimal or visceral lesions, with different problems witch hinder motility (And different problems witch hinder motility (And frequently affected by severe pain)frequently affected by severe pain)

Difficult surgical treatment:Difficult surgical treatment: Analogous lesions in the brachial plexus are Analogous lesions in the brachial plexus are

normally treated, and results are quite well normally treated, and results are quite well known.known.

In this anatomical district surgical approach is In this anatomical district surgical approach is not so comfortable and familiar not so comfortable and familiar www.hgiocoli.com

EtiologyEtiology

Traumatic EventsTraumatic Events

Obstetrical traumaObstetrical trauma

Surgery Surgery Abdominal surgeryAbdominal surgery Gynecological proceduresGynecological procedures

TumorsTumors IntrapelvicIntrapelvic Terminal branchesTerminal branches

Traumatic EventsTraumatic Events

Obstetrical traumaObstetrical trauma

Surgery Surgery Abdominal surgeryAbdominal surgery Gynecological proceduresGynecological procedures

TumorsTumors IntrapelvicIntrapelvic Terminal branchesTerminal branches

• HerniorrhaphyHerniorrhaphy• AppendectomyAppendectomy• HysterectomyHysterectomy• Lumbar sympatectomyLumbar sympatectomy• Lateral approach to the Lateral approach to the

spinespine

• HerniorrhaphyHerniorrhaphy• AppendectomyAppendectomy• HysterectomyHysterectomy• Lumbar sympatectomyLumbar sympatectomy• Lateral approach to the Lateral approach to the

spinespine

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AnatomyAnatomy

Lumbar PlexusLumbar Plexus Spinal roots L2, L3, and L4 Spinal roots L2, L3, and L4

(L1 and L5)(L1 and L5) Located in the corner Located in the corner

between vertebral bodies between vertebral bodies and lateral apophisisand lateral apophisis

Covered byCovered by Ascending iliac and cava Ascending iliac and cava

veins, and by psoas veins, and by psoas musclemuscle

By aorta and common iliac By aorta and common iliac arteries on the right side arteries on the right side

By iliac arterial and By iliac arterial and venous plexuses on the venous plexuses on the leftleft

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AnatomyAnatomy

Lumbar PlexusLumbar Plexus Subserved Muscle are:Subserved Muscle are: AbdominalAbdominal PsoasPsoas IliacIliac PectineusPectineus SartoriusSartorius Quadriceps femorisQuadriceps femoris Adductors of the thigh Adductors of the thigh

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AnatomyAnatomySacral PlexusSacral Plexus Spinal roots L5, S1, Spinal roots L5, S1,

and L2 (L4) and L2 (L4) Lies on the sacro iliac Lies on the sacro iliac

junction junction Medial to psoas muscle Medial to psoas muscle

between it and the column between it and the column Hypogastric artery Hypogastric artery

intermigles the nerve intermigles the nerve trunks and asending veins trunks and asending veins cover the plexuscover the plexus

The lumbosacral trunk is The lumbosacral trunk is given by components from given by components from L4 and from L5L4 and from L5

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AnatomyAnatomy

Sacral PlexusSacral Plexus Subserved Muscle are:Subserved Muscle are: GluteiGlutei ObturatorObturator PiriformPiriform GemelliGemelli QuadratusQuadratus Muscle or posterior thighMuscle or posterior thigh Anterior tibialAnterior tibial Peroneal foot abductors Peroneal foot abductors

and extensorsand extensors Triceps surae and plantar Triceps surae and plantar

flexorsflexorswww.hgiocoli.com

Surgical TechniquesSurgical Techniques

Anterior:Anterior: extraperitoneal extraperitoneal Lateral:Lateral: extraperitoneal extraperitoneal Anterior:Anterior: transperitoneal transperitoneal Posterior:Posterior: sacrectomy sacrectomy

In some cases is impossible to access to the In some cases is impossible to access to the more proximal sciatic nerve, the bony and more proximal sciatic nerve, the bony and ligamentous rim of the greater sciatic notch ligamentous rim of the greater sciatic notch can be nibbled or drilled away to gain accesscan be nibbled or drilled away to gain access

In some cases is impossible to access to the In some cases is impossible to access to the more proximal sciatic nerve, the bony and more proximal sciatic nerve, the bony and ligamentous rim of the greater sciatic notch ligamentous rim of the greater sciatic notch can be nibbled or drilled away to gain accesscan be nibbled or drilled away to gain access

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Surgical TechniquesSurgical Techniques

Intraoperative electrophysiological recording Intraoperative electrophysiological recording

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Surgical Approach Surgical Approach

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Surgical Approach Surgical Approach

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Surgical Approach Surgical Approach

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Surgical Approach Surgical Approach

Sciatic nerve Sciatic nerve

Neurolysis Neurolysis

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Surgical Approach Surgical Approach

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Surgical Approach Surgical Approach

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Intrabdominal Graft Intrabdominal Graft

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Surgical Approach Surgical Approach

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Surgical Approach Surgical Approach

Psoas Psoas

Femoral nerve Femoral nerve

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Neurolysis Neurolysis

30 days later30 days later

Results Results

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3 months later 3 months later

Results Results

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Posterior Approach Posterior Approach

Sacrectomy Sacrectomy

Nerve graftingNerve grafting

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Sciatic NerveSciatic Nerve

Classic Technique Classic Technique

Our ApproachOur Approach

Surgical Approach Surgical Approach

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Sciatic Sciatic NerveNerve

Surgical Approach Surgical Approach

Neurolysis Neurolysis

Aesthetic results Aesthetic results www.hgiocoli.com

Sciatic Nerve TumorSciatic Nerve Tumor

Surgical Approach Surgical Approach

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Follow-upFollow-up

Sciatic Sciatic NerveNerve

Surgical Approach Surgical Approach

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Pelvis TumorPelvis Tumor

Tumor Tumor

Incision Incision

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Pelvis TumorPelvis Tumor

Tumor Tumor

Extirpation Extirpation

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Pelvis TumorPelvis Tumor

Tumor Tumor

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Femoral nerve Femoral nerve

Anterior ApproachAnterior Approach

Total extirpation Total extirpation

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Posterior ApproachPosterior Approach

Sciatic nerve Sciatic nerve

Tumor Tumor

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Pelvis TumorPelvis Tumor

Total extirpation Total extirpation

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5 months later 5 months later

ResultsResults

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Femoral SurgeryFemoral Surgery

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Femoral SurgeryFemoral Surgery

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Femoral SurgeryFemoral Surgery

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Distal and Proximal Stump Distal and Proximal Stump Common Peroneal NerveCommon Peroneal Nerve

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Common Peroneal NerveCommon Peroneal Nerve

ResultsResults

Grafts Grafts

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Tibial Nerve Palsy Tibial Nerve Palsy

Incision Incision

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Tibial Nerve Palsy Tibial Nerve Palsy Neuroma Neuroma

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Tibial Nerve Palsy Tibial Nerve Palsy

Nerve Grafting Nerve Grafting

Results Results

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PosteriorPosterior Tibial NerveTibial Nerve

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NeurolysisNeurolysis

PosteriorPosterior Tibial NerveTibial Nerve

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PosteriorPosterior Tibial NerveTibial Nerve

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GraftsGrafts

PosteriorPosterior Tibial NerveTibial Nerve

StumpsStumpswww.hgiocoli.com

Results After 29 patientsResults After 29 patients

GoodGood FearFear BadBadMaleMale FemaleFemale

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Thank you !! Thank you !! www.hgiocoli.com