Anatomical basis of transgluteal approach for pudendal neuralgia and operative technique

Abstract

Pudendal neuralgia is an entrapment syndrome whose both anatomic landmarks and operative technique remain relatively unfamiliar to neurosurgeons. To provide an outline of operative steps that is important to correct application of this approach. Surgical illustrations are included. The different figures detail the important steps of the operation. We perform a transmuscular approach leading to the sacrotuberous ligament, which is opened sagittally. The pudendal nerve and internal pudendal artery are found to be enclosed by a fascia sheath. The pudendal nerve swings around the sacrospinous ligament sacrospinous ligament with tension. Both distal branches of the pudendal nerve can be followed, especially the rectal branch running medially. After the section of the sacrospinous ligament, the pudendal nerve can be transposed frontally to the ischial spine within the ischiorectal fat. During this maneuver, significant venous bleeding may be encountered as perineural satellite veins dilatation can accompany or surround the pudendal nerve. It is important to avoid overpacking to limit compression injury to the pudendal nerve using judiciously small pieces of hemostatic device and soft cottonoid with light pressure. Then, the obturator fascia and the membranous falciform process of the sacrotuberous ligament that extend toward the ischioanal fossa must be incised. Transgluteal approach is a safe technique and we demonstrate that this approach can be performed safely minimizing pain, size of incision, surgical corridor, and trauma to adjacent muscles of buttock.