Intrapelvis Entrapment Lemos Peng Pelvineurology 2018
Intrapelvis Entrapment Lemos Peng Pelvineurology 2018
Intrapelvis Entrapment Lemos Peng Pelvineurology 2018
Original article
Abstract: It has been well-established that a large portion of the lumbosacral plexus is located intra-abdominally, in the retroperitoneal space.
However, most of the literature descriptions of lesions on this plexus refer to its extra-abdominal parts whereas its intra-abdominal portions
are often neglected.The objective of this review paper is to describe the laparoscopic anatomy of intrapelvic nerve bundles, as well as the
findings and advances already achieved by Neuropelveology practitioners.
Abreviations:
- LANN – Laparoscopic Neuronavigation
- LION – Laparoscopic Implantation of Neuroprosthesis
INTRODUCTION Figure 1. –
Laparoscopic view the
It is well established that a large portion of the lum- left abdominal wall
bosacral plexus is located intra-abdominally in the exhibiting the Ilio-
retroperitoneal space1. However, descriptions of lesions on Hypogastric (IHN),
this plexus in most of the literature refer to its extra-abdom- Ilio-Inguinalis (IIN)
inal course. The intra-abdominal location and the potential and Genito-Femoralis
(GFN) Nerves, with
entrapment of nerves from lumbosacral plexus at these sites
the overlying peri-
are often neglected in the literature2. toneal intact (A) and
In 2007, Possover et al.3 described the Laparoscopic exposed (B) [PM –
Neuronavigation (LANN) technique, opening the doors to Psoas Muscle; LO –
accessing the retroperitoneal portion of the lumbosacral Left Ovary; IPL –
plexus through a safe, minimally invasive, and objective Infundibulopelvic
way. Since then, multiple causes of intrapelvic nerve en- Ligament; LFA – Left
trapments have been described and a new field in Medicine Femoral Artery
– Neuropelveology – was created.
In this paper, we will review the laparoscopic anatomy of
the intrapelvic nerve bundles, describe the symptoms and
signs associated with intrapelvic neuropathies, as well as
the diagnosis and treatment rationale of these conditions.
Femoral nerve
The femoral nerve is the largest motor and sensory nerve
of the lumbar plexus. It emerges from the postero-lateral Figure 2. – The Left Femoral Nerve (FN) entering the retroperi-
aspect of the psoas muscle and leaves the abdomen through toneal space on the posterolateral aspect of the Psoas Muscle
the femoral canal (Figure 2) to innervate the quadriceps (PM). (LC – Left Colon)
Nerves of the Obturator Space crossing about two thirds of the distance between the
The obturator nerve enters the obturator space at the level sacrum and the uterine cervix or the prostate, its fibers
of the pelvic brim and leaves the pelvis through the obtura- spread to join the pelvic splanchnic nerves (described be-
tor canal. It gives sensory branches to the skin of the medial low) to form the inferior hypogastric plexus (Figure 4). The
thigh and motor branches to the hip adductors (Figure 3-A). hypogastric nerves carry the sympathetic signals to the in-
The lumbosacral trunk and the distal portions of the S1, ternal urethral and anal sphincters, rectum and bladder,
S2, S3 and S4 nerve roots merge into the obturator space which cause detrusor relaxation and bladder contraction,
and form the sciatic and pudendal nerves (Figure 3-B). thus promoting continence. They also carry proprioceptive
The sciatic nerve is formed by the L4 and L5 fibers of the and nociceptive afferent signals from the pelvic viscera9.
lumbosacral trunk and fibers from the S1, S2 and S3 nerve
roots and leaves the pelvis through the greater sciatic notch.
It gives out sensory branches to the upper gluteal region,
postero-lateral thigh, leg, ankle and foot. It also controls the
hip extensors, abductors and rotators, knee flexors, and all
the muscles for the ankle and foot.
The pudendal nerve is formed by fibers of the 2nd, 3rd and
4 nerve roots and leaves the pelvis in the interligamentous
th
Nerves of the Presacral and Pararectal Spaces Figure 5. – The Sacral Nerve Roots (S2-S4) can be found juxta-
The superior hypogastric plexus, which is formed by laterally to the Hypogastric Fascia (HGF) and give origin to the
fibers from para-aortic sympathetic trunk and gives rise to Pelvic Splanchnic Nerves (PSN), which run anteriorly and distally
the hypogastric nerves. The hypogastric nerves run over the to merge the Hypogastric Nerve and form the Inferior Hypogastric
hypogastric fascia in an anterior and distal direction. After Plexus (IHP).
7
4-Lemos - Laparoscopic.qxp_treatment 05/03/18 12:11 Pagina 8
Nucelio Lemos, Kinshuk Kumar, Christine Plöger-Schor, Philip Peng, Allan Gordon
INTRAPELVIC NERVE ENTRAPMENT SYNDROME identified at the tractography is infiltrated with 0.5mL to
Definition and Clinical Features 1mL of lidocaine 0.5%. If a reduction of 50% or more in
Nerve entrapment syndrome, or compression neuropathy, pain (VAS) is observed, the test is considered positive
is a clinical condition caused by compression on a single (Figure 7).
nerve or nerve root. The symptoms and signs include pain,
tingling, numbness, and muscle weakness on the affected
nerve’s dermatome and myotome11. Intrapelvic nerve en-
trapments are, therefore, entrapments of the intrapelvic por-
tions of the nerves described in the previous sessions and
will produce clinical features related to the affected nerves.
The above definition refers to the entrapment of somatic
nerves. Autonomic nerve entrapment will produce visceral
and vegetative symptoms, such as urinary frequency or ur-
gency, dysuria, rectal pain, suprapubic and/or abdominal
cramps and chills. However, as described, above, the sacral
nerve roots give origin to both somatic and parasympathet-
ic nerves. Therefore, entrapments of these roots will pro-
duce somatic (such as pain along the dermatome) and vis-
ceral (such as urinary and bowel dysfunction) clinical pic-
tures.
In a concise manner, the main symptoms of intrapelvic
nerve entrapments are:
– Sciatica associated with urinary symptoms (urgency, fre-
quency, dysuria) without any clear orthopedic cause
(spinal or deep gluteal nerve entrapment);
– Gluteal pain associated with perineal, vaginal or penile
pain;
– Dysuria and/or painful ejaculation;
– Refractory urinary symptoms;
– Refractory pelvic and perineal pain.
It is important to emphasize that, due to the distance be-
tween both plexuses, intrapelvic nerve entrapments will
usually cause unilateral symptoms.
Diagnostic Workup
Once the hypothesis of an intrapelvic entrapment is
Figure 7. – (A) Ultrasound image of the interligamentous plane at
raised, it is mandatory to perform the topographic diagno- the ischial spine where the pudendal artery and nerve are located
sis, which is the determination of the exact point of entrap- between the sacrospinous and sacrotuberous ligaments. (B) Color
ment. So far, careful neuropelveological evaluation, com- Doppler of the same picture showed the pudendal artery.
bined with a detailed medical history and neurological ex- Reprinted with permission from Philip Peng Educational Series
amination is the most reliable method for this.
To increase objectivity and accuracy of the diagnosis, we
have been examining the use of high definition pelvic MRI
and sacral plexus tractography, which is a technique for
functional MRI of peripheral nerves12. Asymmetries and Endometriosis
Etiology of intrapelvic entrapments
structures that could entrap the plexus are identified at MRI The first report of intrapelvic nerve entrapment was
and those specific portions are investigated on tractography made by Denton and Sherill13, who described a case of
for any gaps in neural activity (Figure 6). cyclic sciatica due to endometriosis in 1955. After that,
some other case reports and small series were published,
until 2011, when Possover et al2 described the largest series
so far, with 175 patients, all treated laparoscopically.
In endometriotic entrapments, the symptoms tend to be
cyclic, worsening during the premenstrual and menstrual
days and ameliorating or even disappearing during the
post-menstrual period2,14-15.
Evaluation consists of preoperative identification of the
symptoms and determination of the topographical localiza-
tion of the lesions mainly by clinical evaluation, although
Figure 6. – A: contrasted MRI showing enlarged vessels (VA) in radiological examination (MRI) is sometimes required.
direct contact with S1 nerve root. B: Tractography showing a sig- Treatment is achieved by exploring all suspect segments of
nal gap in S1.(Courtesy of Dr. Suzan M. Goldman, MD, PhD & the plexus through laparoscopic approach, with radical re-
Homero Faria) moval of all endometriotic foci and fibrosis2,14-15 (Figure 8).
The true incidence of endometriosis involving the sacral
Our results so far are very promising, but the accuracy of plexus is unknown, as this presentation of the disease is of-
this method still needs to be investigated. Therefore, for ten neglected. On average, patients undergo four surgical
further assurance, our next step is a diagnostic block, guid- procedures seeking to treat the pain before receiving the
ed by ultrasound or fluoroscopy and performed by an inter- right diagnosis2. Moreover, about 40% of women with en-
vention pain specialist; the exact point where a signal gap is dometriosis refer unilateral pain on the inferior limb16 and,
8
4-Lemos - Laparoscopic.qxp_treatment 05/03/18 12:11 Pagina 9
sels can entrap the nerves of the sacral plexus against the
pelvic sidewalls, producing symptoms such as sciatica, or
refractory urinary and anorectal dysfunction2,21 (Figure 10).
Vascular Entrapment Figure 11. – Muscular entrapment of the right S2 and S3 nerve
roots. Observe the transected piriformis muscle bundle (PM) origi-
Pelvic congestion syndrome is a well-known cause of nating from the sacral bone medially from the sacral nerve roots
cyclic pelvic pain. Patients commonly present with pelvic and, therefore, crushing the nerves every time the muscle contracts.
pain without evidence of inflammatory disease. The pain is
worse during the premenstrual period and pregnancy, and is
exacerbated by fatigue and standing20. Neoplasms
However, what is much less known is the fact that dilated Tumors can also entrap the nerves or nerve roots. Tumors
or malformed branches of the internal or external iliac ves- can be primary neural tumors, such as Schwanomas, or
9
4-Lemos - Laparoscopic.qxp_treatment 05/03/18 12:11 Pagina 10
Nucelio Lemos, Kinshuk Kumar, Christine Plöger-Schor, Philip Peng, Allan Gordon
metastatic tumors, such as pelvic lymph nodes, entrapping around 50% will experience more than 50% reduction in
the nerves in pelvic malignancies (Figure 12). pain and about 20% will not improve or, in some cases, ex-
perience worsening of their pain. Approximately 25% of
patients will present with post-decompression neuropathic
pain and 17% will present neuropathic strength loss, both
of which tend to be transient; the former will last, on aver-
age, 5.5 months and the latter will last 2.5 months24.
Patients who present with transient post-decompression
pain, persistent post-neuropathic pain or worsening of
symptoms, should be treated like patients with primary
neuropathic pain, as described in the following session.
Oxycodone 20 to 60 mg / day
must be clinically treated by an interprofessional pain team Morphine Sulfate 20 to 90 mg / day
composed of a pain physician (usually an anesthesiologist Methadone 150 to 400 mg / day
or neurologist), a physiotherapy team (pelvic and motor), Transdermal Fentanyl Up to 75 mg / day
and a mental healthcare team (psychologist and psychia-
trist). The pain specialist will prescribe and adjust the phar- Capsaicin
macological treatment and, in cases where poor response to
Local anesthetics
Anti-inflammatories
medical treatment is observed, perform the appropriate in-
tervention (e.g. anesthetic blocks, pulsed radiofrequency).
As a rule, once a nerve entrapment has been diagnosed, the main goals of physical therapy are to reduce pain, train
Etiology of intrapelvic entrapments
decompression (usually surgical) is mandatory, since the pelvic floor muscles, and provide education about dys-
chronic ischemia can lead to endoneurial degeneration23. function and lifestyle interventions. This includes teaching
Therefore, the longer the time between the beginning of awareness of the pelvic muscle group, the correct way to
symptoms and detrapment, the lower the chance of success. contract the pelvic muscles, coordination, motor control,
Surgical decompression will lead to complete resolution strength, endurance, and relaxation of the muscula-
of pain and other symptoms in about 30% of the patients; ture28,29,30.
10
4-Lemos - Laparoscopic.qxp_treatment 05/03/18 12:11 Pagina 11
In order to reduce the patient’s pain after surgical nerve techniques are best described in the myofascial pain chap-
decompression, cryotherapy has proven to be an effective ter.
therapeutic resource when applied to the vaginal canal. It is Pulsed Radio Frequency (RFP) is an alternative tech-
recommended to fill a non-sterile glove finger (or a con- nique to conventional radiofrequency, and its advantage
dom) with ice and insert it into the patient’s vagina for less would be a longer pain relief without neural damage.
than 20 minutes. During RFP application, a high frequency, pulsed current is
Electrical stimulation is also an important resource in the generated and this allows the heat generated in the tissue to
treatment of pain. It stimulates the rapidly conducting dissipate during the latency periods, not exceeding 45°C,
myelinated gross nerve fibers, triggering at the central level which would be a neurodestructive temperature42. Thus, by
the descending inhibitory analgesic systems on the noci- maintaining the temperature only up to 42°C, there is no
ceptive transmission conducted by the non-myelinated neural destruction, and, therefore, can be applied even in
fibers of small caliber, thus generating pain reduction31,32. mixed nerves (i.e. both sensory and motor). The mecha-
Manual therapy techniques for myofascial release should nism of action of the RFP is related to the electric field
be applied when there are signs of muscular tension of the formed, which would alter painful signaling in a neuromod-
pelvic floor, with the presence of trigger points, due to pain ulatory form, but has not yet been fully elucidated42,43. The
caused by nerve compression. The technique involves firm RFP can be applied distally to the nerve responsible for the
massage on the levator anus muscle with sliding move- patient’s pain, or proximal, at its exit in the intervertebral
ments towards the origin and insertion, punctual pressure at foramen.
the trigger points at the limit of the patient’s pain, in addi- The Dorsal Root Ganglia (DRG) block corresponding to
tion to perpendicular movements to the muscle fiber33. the nerve responsible for the pain can be performed with lo-
The techniques described for strengthening and aware- cal anesthetic, guided by fluoroscopy. If the blockage alle-
ness of pelvic floor musculature include biofeedback, and viates at least 50% of the pain, it is possible to apply RFP
electrostimulation. These represent an important form of thereafter38.
prevention and treatment for pelvic floor dysfunction. Phenol Neurolysis has been described in several targets,
Biofeedback is one of the most used resources for urogy- especially to treat cancer pain, but also for non-cancer pain,
necological physiotherapy, since it has no side effects. This and may bring prolonged pain relief. Care must be taken
technique allows the objective awareness of the physiolog- not to inject near motor nerves, because of the risk of flac-
ical function that is unconscious in the individual, facilitat- cid paralysis. Chemical neuritis is another possible compli-
ing the correct learning of the pelvic floor muscle contrac- cation, although uncommon44.
tion. It can also be used for training and hypertrophy of the Cryoablation is a technique that promotes prolonged
muscles. In addition, biofeedback assists in patient motiva- analgesia. The application of tissue cold blocks nerve con-
tion during treatment, improving adherence to the physio- duction is similar to the local anesthetic. Long-term analge-
therapy program34,35. sia is due to freezing, which damages the nerve structure
Electrical stimulation, when applied in the vaginal canal and causes Wallerian degeneration. However, since the
acts passively, and has an important effect on the proprio- myelin sheath and endoneurium remain intact, the nerve
ceptive awakening along with stimulating the correct learn- can regenerate after a period of time. One of its advantages
ing of the perineal contraction. In addition, it has shown ef- over other neurolysis techniques, such as phenol for exam-
fective therapeutic results in patients with pelvic floor dys- ple, is the absence of post-procedure neuritis39.
function, contributing to training of strength and muscular The main complications described with these procedures
endurance, increasing the number of activated motor units are similar to those experienced with any injection, includ-
and generating hypertrophy of the fibers. These benefits ing hematoma, infection and nerve damage.
promote a strong and rapid contraction of the muscles, in-
creasing urethral pressure and preventing urine loss during
an abrupt increase in intra-abdominal pressure36. In cases where medical and intervention pain treatment
Neuromodulation
treatment of pelvic and perineal neuropathic pain. This is tion electrodes can be used to specifically modulate the af-
true especially for patients in whom conservative treatment
did not bring the expected relief from pain, or for those
whom the adverse effects of medications are intolerable.
The percutaneous blockade of specific nerves serves both
diagnostic and therapeutic roles. In addition to the local
anesthetic, it is quite common to add depot steroid for the
anti-inflammatory and membrane-stabilizing effect.
Imaged guidance with ultrasound37,38, computed tomogra-
phy, or fluoroscopy39 enhanced the accuracy, reduce the
volume of injectate and potentially minimize the complica-
tion rates.
If the pain relief is temporary, it is possible to apply more
lasting techniques, such as radiofrequency, cryoablation, or
neurolysis by chemical agents, such as phenol.
In the case of neuralgia caused by nervous incarceration
by a muscle, there is the possibility of infiltration of this
muscle with local anesthetic at first, followed by specific
physiotherapy40,41. If this muscle contracts again, resulting
Figure 13. – LION Electrode placed on right sciatic and pudendal
again in nervous compression, it is possible to inject bo-
nerves (PM – Psoas Muscle; IS – Ischial Spine; SN – Sciatic
tulinum toxin, for a more prolonged relaxation. These Nerve; SSL – Sacrospinous Ligament)
11
4-Lemos - Laparoscopic.qxp_treatment 05/03/18 12:11 Pagina 12
Nucelio Lemos, Kinshuk Kumar, Christine Plöger-Schor, Philip Peng, Allan Gordon
fected nerve, producing very encouraging results when 8. Wallner C, van Wissen J, Maas CP, Dabhoiwala NF, DeRuiter
compared to the more commonly available epidural neuro- MC, Lamers WH. The contribution of the levator ani nerve and
modulation5,45. the pudendal nerve to the innervation of the levator ani muscles;
The laparoscopic implantation of neuroprosthesis – the a study in human fetuses. Eur Urol. 2008 Nov, 54 (5), 1136-42.
9. DeGroat WC, Yoshimura N. Anatomy and Physiology of the
LION procedure – was first reported by Possover in 2009
Lower Urinary Tract. In: Handbook of Clinical Neurology 3rd
as a rescue procedure in patients with local complications Series. Ed. Elsevier. Oxford, UK, 2015.
of a Brindley procedure45. Due to its successful results and 10. Possover M, Baekelandt J, Flaskamp C, Li D, Chiantera V.
decreased invasiveness, it was then used as a primary pro- Laparoscopic neurolysis of the sacral plexus and the sciatic
cedure in spinal cord-injured patients, aiming to improve nerve for extensive endometriosis of the pelvic wall. Minim
locomotion and bladder function46. Long term data has Invasive Neurosurg. 2007 Feb; 50 (1), 33-6.
shown improvement in voluntary motor function and sensi- 11. Bouche P. Compression and entrapment neuropathies. Handb
tivity, suggesting positive effects on neuroplasticity47 Clin Neurol. 2013, 115, 311-66.
(Figure 13). 12. van der Jagt PK, Dik P, Froeling M, Kwee TC, Nievelstein
RA, ten Haken B, Leemans A. Architectural configuration and
microstructural properties of the sacral plexus: a diffusion ten-
CONCLUSION sor MRI and fiber tractography study. Neuroimage. 2012 62
(3), 1792-9. doi:10.1016/j.neuroimage.2012.06.001.
Laparoscopy provides minimally invasive access with 13. Denton RO, Sherrill JD. Sciatic syndrome due to endometrio-
optimal visualization to virtually all abdominal portions of sis of sciatic nerve. South Med J. 1955 Oct; 48 (10), 1027-31.
the lumbosacral plexus, which are also subject to entrap- 14. Lemos N, Kamergorodsky G, Ploger C, Castro R, Schor E, Girão
ment neuropathies. Therefore. when facing sciatica, gluteal M. Sacral nerve infiltrative endometriosis presenting as perimen-
or perineal pain without any obvious spinal or deep gluteal strual right-sided sciatica and bladder atonia: case report and de-
causes, the examiner should always remember that the en- scription of surgical technique. J Minim Invasive Gynecol. 2012
May-Jun; 19 (3), 396-400. doi: 10.1016/j.jmig.2012.02.001.
trapment could be in the intrapelvic portions, especially 15. Lemos N, D’Amico N, Marques R, Kamergorodsky G, Schor
when urinary or anorectal symptoms are present. E, Girão MJ. Recognition and treatment of endometriosis in-
The laparoscopic approach to the intrapelvic bundles of volving the sacral nerve roots. Int Urogynecol J. 2016 Jan, 27
the lumbosacral nerves opened a myriad of possibilities to (1), 147-50.
assess and treat this neglected portion of the plexus, by 16. Missmer SA, Bove GM. A pilot study of the prevalence of leg
means of nerve decompression or selective neuromodula- pain among women with endometriosis. J Body Mov Ther.
tion. 2011 Jul, 15 (3), 304-8. doi: 10.1016/j.jbmt.2011.02.001.
17. Pacchiarotti A, Milazzo GN, Biasiotta A, Truini A, Antonini
G, Frati P, Gentile V, Caserta D, Moscarini M. Pain in the up-
DISCLOSURES per anterior-lateral part of the thigh in women affected by en-
dometriosis: study of sensitive neuropathy. Fertil Steril. 2013
Nucelio Lemos received research grants from Medtronic Inc. Jul; 100 (1), 122-6. doi: 10.1016/j.fertnstert.2013.02.045.
and Laborie Inc, travel grants from Medtronic Inc. and Boston 18. Amarenco G, Lanoe Y, Perrigot M, Goudal H. [A new canal
Scientific and proctorship grants from Medtronic Inc. None of syndrome: compression of the pudendal nerve in Alcock’s
these grants are, however, directly related to the current publica- canal or perinal paralysis of cyclists]. Presse Med., 1987 Mar
tion. 7, 16 (8), 399.
Philip Peng received equipment support from Sonosite Fujifilm 19. Possover M, Lemos N. Risks, symptoms, and management of
Canada. pelvic nerve damage secondary to surgery for pelvic organ
Allan Gordon is the recipient of a multi sited Research Grant the prolapse: a report of 95 cases. Int Urogynecol J. 2011 Dec, 22
CIHR SPOR Pain Grant as well as several other CIHR funded re- (12), 1485-90. doi: 10.1007/s00192-011-1539-4.
search grants. He has also received an operating grant from 20. Ganeshan A, Upponi S, Hon LQ, Uthappa MC, Warakaulle
Allergan for several BOTOX® related projects. DR, Uberoi R. Chronic pelvic pain due to pelvic congestion
syndrome: the role of diagnostic and interventional radiology.
Cardiovasc Intervent Radiol. 2007 Nov-Dec, 30 (6), 1105-11.
REFERENCES 21. Lemos N, Marques RM, Kamergorodsky G, Ploger C, Schor E,
1. Gray, Henry. 1918. Anatomy of the Human Body. IX. Girão M. Vascular entrapment of the sciatic plexus causing cata-
Neurology. 6d. The Lumbosacral Plexus. menial sciatica and urinary symptoms. In: 44th Annual Meeting
2. Possover M, Schneider T, Henle KP (2011) Laparoscopic ther- of the International Continence Society (ICS), 2014, Rio de
apy for endometriosis and vascular entrapment of sacral Janeiro. Neurourology and Urodynamics. Hoboken, NJ: Willey,
plexus. Fertil Steril, 95 (2), 756-8. 2014, v. 33. p. 999-1000. doi: 10.1016/j.jbmt.2011.02.001.
3. Possover M, Chiantera V, Baekelandt J (2007) Anatomy of the 22. Possover M. The sacral LION procedure for recovery of blad-
Sacral Roots and the Pelvic Splanchnic Nerves in Women der/rectum/sexual functions in paraplegic patients after ex-
Using the LANN Technique. Surg Laparosc Endosc Percutan plantation of a previous Finetech-Brindley controller. J Minim
Tech, 17 (6), 508-10. Invasive Gynecol. 2009, Jan-Feb, 16 (1), 98-101.
4. Whiteside JL, Barber MD, Walters MD, Falcone TA (2003) 23. Rempel D, Dahlin L. Pathophysiology of Nerve Compression
Anatomy of ilioinguinal and iliohypogastric nerves in relation Syndromes: Response of Peripheral Nerves to Loading. J
to trocar placement and low transverse incisions. Am J Obstet Bone Joint Surg Am., 1999 Nov, 81 (11), 1600-10 .
Gynecol, 180 (6), 1574-8. 24. Lemos et al. Intrapelvic nerve entrapments – a neglected cause
5. Possover M. Use of the LION procedure on the sensitive of perineal pain and urinary symptoms. In: “Scientific
branches of the lumbar plexus for the treatment of intractable Programme, 45th Annual Meeting of the International
postherniorrhaphy neuropathic inguinodynia. Hernia. 2013 Continence Society (ICS), 6-9 October 2015, Montreal,
Jun; 17 (3), 333-7. doi: 10.1007/s10029-011-0894-x. Canada.” Neurourol Urodyn. 2015 Aug, 34 Suppl 3: S53-S55.
6. Grigorescu BA, Lazarou G, Olson TR, Downie SA, Powers K, doi: 10.1002/nau.22830.
Greston WM, Mikhail MS. Innervation of the levator ani mus- 25. Finnerup N, Attal N, Haroutounian S, McNicol E, Baron R,
cles: description of the nerve branches to the pubococcygeus, Dworkin R et al. Pharmacotherapy for neuropathic pain in
iliococcygeus, and puborectalis muscles. Int Urogynecol J adults: a systematic review and meta-analysis. The Lancet
Pelvic Floor Dysfunct. 2008 Jan, 19 (1), 107-16. Neurology. 2015, 14 (2), 162-173.
7. Barber MD, Bremer RE, Thor KB, Dolber PC, Kuehl TJ, 26. Haanpää M, Attal N, Backonja M, Baron R, Bennett M,
Coates KW. Innervation of the female levator ani muscles. Am Bouhassira D et al. NeuPSIG guidelines on neuropathic pain
J Obstet Gynecol., 2002 Jul, 187 (1), 64-71. assessment. Pain. 2011, 152 (1), 14-27.
12
4-Lemos - Laparoscopic.qxp_treatment 05/03/18 12:11 Pagina 13
27. Attal N, Cruccu G, Baron R, Haanpää M, Hansson P, Jensen T 39. Trescot AM. Cryoanalgesia in Interventional Pain Manage-
et al. EFNS guidelines on the pharmacological treatment of ment. Pain Physician. 2003, 6, 345-360.
neuropathic pain: 2010 revision. European Journal of 40. Ingber RS. Iliopsoas myofascial dysfunction: a treatable cause
Neurology. 2010, 17 (9), 1113-e88. of “failed” low back syndrome. Arch Phys Med Rehabil. 1989,
28. Bo K, Berghmans B, Morkved S, Van Kampen M. Evidence- 70 (5), 382-6.
Based Physical Therapy for the Pelvic Floor. 2nd Ed. China: 41. Lewit K. Manipulative Therapy in Rehabilitation of the Motor
Elsevier; 2007. System. In: John P. Butler (ed). Myofascial Pain and
29. Weiss JM. Pelvic floor miofascial trigger points: manual ther- Dysfunction. Volume 2. The Trigger Point Manual
apy for interstitial cystitis and the urgency-frequency syn- Butterworths, London. Lippincott Williams & Wilkins, 1985.
drome. J Urol. 2001, Dec, 166: 2226-2231. p. 138, 276, 315.
30. Stockdale CK, Lawson HW. 2013 Vulvodynia Guideline up- 42. Rozen D, Parvez U. Pulsed radiofrequency of lumbar nerve
date. J Low Genit Tract Dis. 2014 Apr, 18 (2), 93-100. doi: roots for treatment of chronic inguinal herniorraphy pain. Pain
10.1097/LGT.0000000000000021. Physician. 2006, 9 (2), 153-6.
31. Robinson AJ, Snyder-Mackler L. Eletrofisiologia clínica: 43. Cahana A, Zundert JV, Macrea L, van Kleef M, Sluijter M.
eletroterapia e teste fisiológico. 3 ed. Porto Alegre: Artmed; Pulsed Radiofrequency: Current Clinical and Biological
2010. Literature Available. Pain Medicine. 2006, 7 (5), 411-23.
32. Fitzwater JB, Kuehl TJ, Schrier JJ. Electrical stimulation in 44. Weksler N, Klein M, Gurevitch B, Rozentsveig V, Rudich Z,
the treatment of pelvic pain due to levanto rani spasm. J Brill S, et al. Phenol neurolysis for severe chronic nonmalig-
Reprod Med. 2003, 48, 573-577. nant pain: is the old also obsolete? Pain Med. 2007, 8 (4),
33. Srinivasan AK, Kaye JD, Moldwin R. Myofascial dysfunction 332-7.
associated with chronic pelvic pain: management 45. Possover M. Laparoscopic management of endopelvic etiolo-
strategies. Curr Pain Headache Rep. 2007, Oct, 11 (5), 359- gies of pudendal pain in 134 consecutive patients. J Urol.
64 2009 Apr; 181 (4), 1732-6. doi: 10.1016/j.juro.2008.11.096.
34. Fitz FF, Resende APM, Stüpp L, Costa TF, Sartori MGF, 46. Possover M, Schurch B, Henle K. New strategies of pelvic
Girão MJBC, Castro RA. Efeito da adição do biofeedback ao nerves stimulation for recovery of pelvic visceral functions
treinamento dos músculos do assoalho pélvico para tratamento and locomotion in paraplegics. Neurourol Urodyn. 2010, 29,
da incontinência urinária de esforço. Rev Bras Ginecol Obstet. 1433-1438.
2012, 34 (11), 505-10. 47. Possover M. Recovery of sensory and supraspinal control of
35. Moreno, AL. Fisioterapia em Uroginecologia. São Paulo: leg movement in people with chronic paraplegia: a case se-
Manole, 2004. ries. Arch Phys Med Rehabil. 2014 Apr, 95 (4), 610-4.
36. Palma, P (ed). Urofisioterapia aplicações clínicas das técnicas
fisioterapêuticas nas disfunções miccionais e do assoalho
pélvico. Campinas/SP: Personal Link Comunicações; 2009.
37. Bendtsen TF, Lönnqvist PA, Jepsen KV, Petersen M, Knudsen
L, Børglum J. Preliminary results of a new ultrasound-guided
approach to block the sacral plexus: the parasacral parallel
shift. Br J Anaesth. 2011 Aug, 107 (2), 278-80. doi: Correspondence to:
10.1093/bja/aer216. Nucelio Lemos, MD PhD
38. Peng PWH, Tumber PS. Ultrasound-Guided Interventional Mailing Address: Rua Jose de Magalhaes, 373 ap904.
Procedures for Patients with Chronic Pelvic Pain – A São Paulo – SP. Brazil.
Description of Techniques and Review of Literature. Pain CEP: 04026-090 Phone: +55-11-98162-8136
Physician. 2008, 11, 215-224. email: nucelio@gmail.com
CORRIGENDUM
In the article
Y. Sekiguchi, H. Inoue, B. Liedl, M. Haverfield, P. Richardson, A.Yassouridis, L. Pinango, F. Wagenlehner, D. Gold. Is Chronic
Pelvic Pain in the female surgically curable by uterosacral/cardinal ligament repair? Pelviperineology 2017; 36: 74-78
page 76
INSTEAD OF:
All patients signed informed consent and the principles of the Helsinki Declaration were followed.
CORRIGENDUM:
ETHICS. This was a prospective case study audit. Prior to undertaking this study, each unit obtained EC approval for use of the
TFS instrument in prolapse and incontinence surgery as standard hospital practice. All patients signed informed consent and the
principles of the Helsinki Declaration were followed.
13