Surgical management of the pelvic plexus and lower abdominal nerves

Nerves of the pelvic plexus and lower abdominal wall can lead to chronic neuralgias owing to a variety of causes, including iatrogenic injury, trauma, tumors, and primary nerve entrapment. Differentiating among the various neural etiologies can be a challenging task. Here, we present a large series of patients who underwent surgical treatment of these nerves, with an emphasis on diagnostic and therapeutic considerations.

Between 1970 and 2006, the senior authors (DGK and DHK) surgically treated 264 cases of neuralgia of the pelvic plexus and nerves. A retrospective analysis of the patients' history, physical, diagnostic examinations, and follow-up was performed.

Twenty-five cases of solely ilioinguinal neuralgia and 24 cases of combined ilioinguinal neuralgias were treated. Of these, iatrogenic injury was the most common etiology. One hundred forty-five patients underwent surgical exploration for either femoral nerve injury (119 patients) or lateral femoral cutaneous compression (26 patients). Seventy-five percent of patients had femoral nerve injuries attributable to trauma (iatrogenic versus penetrating injuries), and the remaining 25% of patients had cystic masses or tumors. Fifty-two masses of the pelvic plexus were treated, including neurofibromas (68%), schwannomas (18%), malignant nerve sheath tumors (5%), and non-neural sheath tumors (9%).

Effective surgical management of these complex neuralgias depends on a solid understanding of the surgical anatomy and proper diagnosis. Electromyography and local anesthetic blocks not only can provide insight into the diagnosis but also have predictive value in assessing which patients may benefit from neurectomy or neurolysis.