Management of Vascular Entrapment with Coexisting Fibrosis on the Sacral Nerve Roots

Abstract

Study Objective To demonstrate decompression of sacral nerves from aberrant vessels and fibrous tissue located on the plexus. Design Video presentation of two cases. Setting Tertiary center specializing in advanced gynecologic surgery and neuropelveology. Patients or Participants Case 1: A 43-year-old gravidity 1 parity 1 female patient presented with dysmenorrhea, dyspareunia and pudendal pain with dysuria. Gynecological examination revealed deep infiltrative endometriosis with rectovaginal nodule and partial obliteration of pouch of Douglas. She had a history of laparoscopic endometriosis surgery with left oophorectomy and was treated with intravascular coil embolization for pelvic congestion syndrome. Case 2: A 41-year-old gravidity 1 parity 1 female patient presented with chronic pelvic pain and left sided sciatic pain with chronic dysesthesia in the dermatome of sciatic nerve without any motor deficit of lower extremity. Gynecological examination revealed deep infiltrative endometriosis and full obliteration of pouch of Douglas. She had a history of multiple laparoscopic and laparotomic operations for endometriosis. Interventions Robot-assisted laparoscopic sacral nerve decompression and dissection of cul-de-sac with rectal nodule shaving (case1) and laparoscopic sacral nerve decompression and dissection of cul-de-sac (case 2). Measurements and Main Results Patients were evaluated at 3rd and 6th month postoperatively. Both patients report significant pain reduction with visual analog scale score. Conclusion Since lumbosacral plexus is located over the sacral bone, it can be compressed easily by an abnormal structure (abnormal vessels, fibrous tissue, tumor, etc.) located on the plexus. Deep infiltrative endometriosis may affect retroperitoneal tissue by causing fibrosis. An abnormal vessel, which is located on the sacral plexus may entrap the roots much easier with coexisting fibrosis. On six moths follow up the visual analog scale score of case 1 and 2 decreased from 10 to 4 and 10 to 3, respectively. Patients are still under surveillance.