Professional Documents
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Pelvic 45
Thais Khouri Vanetti, Alexandra Tavares Raffaini Luba,
Fabrcio Dias Assis, and Charles Amaral de Oliveira
Despite the paucity of literature on the genitofemoral nerve Chronic inguinal and perineal pain and paresthesias may be
(GFN), impairment of this nerve, which may result in chronic due to GFN pathology [1]. Postoperative neuropathies after
pain, is not uncommon but rather likely under-recognized. major pelvic surgeries are rare, with a total estimated inci-
Blunt trauma or pelvic operations such as inguinal hernior- dence of 1.9 %; postoperative GFN neuropathy is estimated
rhaphy, C sections, and others are often accompanied by at 0.3 % [6]. Magee first reported the syndrome of genito-
chronic inguinal and perineal pain and paresthesias, which femoral neuralgia in 1942 [7], but it remains a rarely encoun-
may be due to GFN pathology [1]. tered (or diagnosed) clinical entity. The most common
The GFN, iliohypogastric nerve (IHN), and ilioinguinal clinical presentation of GFN entrapment consists of intermit-
nerve (IIN) originate from similar levels of the spinal nerves; tent or constant pain, burning dysesthesia, and sensory
therefore, it is often clinically difficult to determine which changes in the inguinal region (Fig. 45.1), with radiation of
nerve is causing the pain. The major differential diagnosis of the pain to the skin of the genitalia (scrotum, vagina, labia
GFN is ilioinguinal neuralgia. Diagnostic blocks can aid in majora) and upper middle thigh (Fig. 45.2) [1]. Female
making this diagnosis. The femoral branch of the GFN is patients usually present with dyspareunia and pelvic pain,
also known as the lumboinguinal nerve. and GFN neuralgia can be misdiagnosed as interstitial cysti-
tis or pudendal neuralgia (Fig. 45.3). The pain is exacerbated
by activities such as walking and hyperextension of the thigh
and is ameliorated by recumbent position and thigh flexion
T.K. Vanetti, MD, FIPP (*) [1]. Paresthesia and persistent pain in the lower abdomen or
Singular Centro de Controle da Dor, pelvic region, including the lateral scrotum or labia majora
Campinas, So Paulo, Brazil and the anterior proximal thigh, may also represent GFN
Instituto do Cncer do Estado de So Paulo,
Rua Doutor Arnaldo 251, So Paulo 01246-000, So Paulo, Brazil
e-mail: thavanetti@yahoo.com.br Table 45.1 Occupation/exercise/trauma history relevant to genito-
femoral nerve entrapment
A.T. Raffaini Luba, MD
Singular Centro de Controle da Dor, Compression Hematoma and adhesions
Campinas, So Paulo, Brazil associated with surgery
Lumbar plexus abnormalities Psoas abscess, psoas entrapment [2]
Instituto do Cncer do Estado de So Paulo, (see Chap. 49)
Rua Doutor Arnaldo 251, So Paulo 01246-000, So Paulo, Brazil
Mechanical Pubic symphysis irritation
Santa Casa de So Paulo, So Paulo, Brazil Late pregnancy
e-mail: alexaraffaini@yahoo.com
Trauma Lumbar sympathetic neurolytics
F.D. Assis, MD, FIPP Celiac plexus neurolytics
Medical Director, Singular Centro de Controle da Dor,
Surgery Trans-obturator sling surgery for
Campinas, So Paulo, Brazil
incontinence [3]
e-mail: FABRICIOASSIS@TERRA.COM.BR
Inguinal hernia repair [4]
C.A. de Oliveira, MD, FIPP
Hysterectomy and cesarean section
Singular Centro de Controle da Dor,
[5]
Campinas, So Paulo, Brazil
e-mail: charles@singular.med.br Entrapment Surgical scar, adhesions
Subcostal nerve
Iliohypogastric nerve
Genitofemoral
nerve (cut)
Lumbosacral trunk
Femoral nerve
T7
T8
Thoracoabdominal
T9 nerves
T10
Anterior cutaneous T11
nerves
areas including the pelvic region, groin, scrotum or labia ilioinguinal nerve was solely responsible for cutaneous
majora, and anterior proximal thigh area. innervation of the genital branch of the genitofemoral nerve
The genital branch of the GFN accompanies the psoas in 28 % of the dissections and shared innervation with the
muscle. In males, it passes inside the internal inguinal ring genital branch of the genitofemoral nerve in 8 % [10].
together with the spermatic cord, supplying motor fibers to the
cremaster muscle and sensation to the lateral scrotum. In
females, it accompanies the round ligament, innervating the Entrapment
mons pubis and the labia majora. The femoral branch (also
known as the lumboinguinal nerve) is located caudally and The GFN may be entrapped during its association with the
laterally to the genital branch and travels with the external iliac psoas muscle and in the pelvis, by a spasm of the muscle, or
artery beneath the inguinal ligament, piercing the fascia latae by the presence of intramuscular hematoma, abscess, or
and entering the femoral sheath to innervate the skin of the adhesions. During the retroperitoneal course of this nerve, it
anterior proximal thigh in the femoral triangle (Fig. 45.6) [9]. may also become entrapped by a retroperitoneal hematoma
Though the course of this nerve and its branches is sim- or lymphoma [13]. A more common cause of entrapment is
ilar in men and women, anatomical studies suggest great surgery involving the pelvis or inguinal area, including C
variability among individuals, with only about 37 % of section, appendectomy, and inguinal hernia repair, particu-
individual innervation patterns conforming to the conven- larly when done laparoscopically [4]. Pain may begin months
tional description [10]. The location where the genital and or years after surgery, due to gradual scar tissue formation at
femoral branches split is typically reported just superior to the surgical site [10]. On its passage above the pubic ramus,
the inguinal ligament, but variations are common [11]. the genitofemoral nerve is vulnerable to surgical trauma.
Additionally, in males, the relation between the genital Albeit less common, this nerve can also be compressed and
branch and the spermatic cord varies considerably; it can injured during the final stages of pregnancy [14].
travel outside the spermatic cord, dorsally, ventrally, or
inferiorly [12]. In a cadaver dissection study, the genital
branch of the GFN was found in 28 % of subjects to arise Physical Examination
from the IIN nerve and hence from T12, L1, and L2 [10].
Special attention to the great variation of the nerves in Careful neurological sensory examination may demonstrate
the groin region (ilioinguinal, iliohypogastric, and genito- sensory changes in the border zone between the abdomen
femoral) is warranted, because of the free communication and thigh, groin, anterior proximal thigh, and lateral scrotum
between these branches. According to a cadaver study, the or labia majora. Tender points may be found on the internal
45 Genitofemoral Nerve Entrapment: Pelvic 483
appendectomy, and C-section hernia repairs with mesh the utmost care must be taken in relation to important
placement or done laparoscopically are all causes of GFN spermatic cord structures (testicular artery) and peritoneal
entrapment. Retroperitoneal surgery and pregnancy are cavity transgression.
also causes.
Treatment of the underlying conditions that caused the
nerve entrapment should be incorporated into treatment. Fluoroscopy-Guided Technique
Physical therapy can provide mobilization and strengthening
to decrease spasm and dysfunction; desensitization therapy With the patient in the supine position, the area of maximal
can be used for treating hyperpathic or allodynic areas. If the tenderness (just lateral to the pubic tubercle) is identified by
perpetuating factor is nerve compression by a surgical scar, it fluoroscopy (Fig. 45.7). After a sterile skin prep and local
is possible to remove the scar tissue, thereby releasing the anesthetic infiltration subcutaneously, a 22-gauge needle is
nerve. If compression is caused by muscle hypertrophy, the advanced to the periosteum. The use of a PNS will facilitate
treatment of choice is to inject local anesthetic to enable identification of the nerve (Fig. 45.8). One cc of local anes-
muscle relaxation and, if necessary, botulinum toxin for lon- thetic and deposteroid is then injected.
ger-lasting relaxation. Early recognition and treatment of Another technique for GFN diagnosis and treatment is the
surgical complications such as hematoma will also help limit dorsal root ganglion (DRG) local anesthetic block at T12, L1,
the extent of nerve injury. and L2, ipsilateral to the pain (Fig. 45.9). The T12 DRG should
be included because it is common for the ilioinguinal and gen-
itofemoral nerves to communicate. If the injection results in
Injection Technique significant pain relief (at least 50 % improvement), but is
short-lived, cryoneuroablation or pulsed radio frequency may
As noted above, it can be challenging to distinguish geni- be applied posteriorly to these ganglia (see below) [11].
tofemoral from ilioinguinal and iliohypogastric neuralgia,
due to the adjacent areas of innervation and the consider-
able anatomical variation. One common diagnostic Ultrasound-Guided Technique
approach is to first perform diagnostic blocks of the ilioin-
guinal and/or iliohypogastric nerves as appropriate, given Another approach is to perform a selective injection of the
the patients symptoms, preferably using ultrasound guid- genital branch of the GFN under ultrasound guidance.
ance for maximum accuracy. If these blocks successfully
create appropriate areas of numbness without decreasing
the pain, then a follow-up block may be performed of L1
and L2 as a selective nerve root block or paravertebral
block. If this block relieves the pain, it is likely a result of
an entrapment of the GFN. This process has the disadvan-
tage of requiring two or three distinct procedures with the
attendant time and risk. A block which successfully
relieves the pain symptoms may be followed up with cryo-
neuroablation or pulsed radiofrequency treatment (see
below) [11].
Landmark-Guided Technique
CT-Guided Technique
Neurolytic Techniques
Cryoneuroablation
a b
Fig. 45.11 Composite cross-sectional ultrasound image of the internal (superficial) and external iliac artery (deep) (Image courtesy of Thiago
inguinal ring. Dotted line represents the internal inguinal ring; (a) male, Nouer Frederico, MD)
(b) female, CR cremaster, RL round ligament, ART femoral artery
a b
Fig. 45.12 Cross-sectional ultrasound image of the internal inguinal male, (b) female, CR cremaster, RL round ligament, ART femoral artery
ring filled with local anesthetic and needle tip near the cremaster or (superficial) and external iliac artery (deep), (Image courtesy of Thiago
round ligament. Dotted line represents the internal inguinal ring; (a) Nouer Frederico, MD)
multiple sites, primarily at the GFN but occasionally also at cryoneuroablation, and these consecutive cryoneuroablations
the ilioinguinal nerve. All patients had post-procedure numb- yielded longer-lasting results. Interestingly, she has observed
ness of the scrotum, with increased function and increased that the pain does not return to the same area that was treated,
ability to lift and carry objects; three patients underwent repeat suggesting an element of unmasking (see Chap. 1).
45 Genitofemoral Nerve Entrapment: Pelvic 487
Phenol
Fig. 45.14 Cryoneuroablation probe positioned on the proximal geni- Weksler and colleagues [22] described injecting 4 % phenol
tofemoral nerve at L1 (Image courtesy of Andrea Trescot, MD) on to a variety of painful structures (including the GFN) in
35 patients; they noted good relief and no complications.
Radiofrequency Lesioning
Complications
Summary
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