Adrian KASTLER GRENOBLE JFR 2019Introduction Pelvi-perineal pain syndromes are very complex conditions with difficult diagnostic outcome These conditions are often refractory to specific pain medications with potential debilitating conditions and possible high socio economic impact. Existing treatment options are sparse and patients eventually develop chronic refractory pain CT guided infiltration of inguinofemoral, pudendal nerves, interiliac sympathetic plexus, hypogastric plexus and impar ganglion are procedures which should be known by the interventional radiologist, as they have both a diagnostic and therapeutic value The objectives are to describe the prerequisites to perform successful | CT-guided pelvic interventional proceduresOutline @ This poster will review the following anatomical targets: @ Pain of lumbar plexus origin : © Ilio-inguinal/hypogastric © Genito-femoral @ Lateral cutaneous nerve © Obturator Nerve © Pain of sacral plexus ori @ =Pudendal nerve in ® Posterior femoral cutaneous nerve © Pain of sympathetic lumbo-sacral origin : © Hypogastric, interiliac and impar ganglion— RUTTIDAP PICXUS (anterior groin pain) Innervation territory Ilio-inguinal and ilio- hypogastric common territory Lateral ilio-hypogastric u bracnch territory B Lateral cutaneous nerve territory u Femoral branch of genitofemoral nerve |Genital branch of genitofemoral neve Be© Iatrogenic + + + (found in 15-20% of cases oF inguinal crural hernia repair+ ++) Compression mecanisms (tight clot lateral cutaneous branch), Obesity Pregnancy Groin surgery and trauma Lumbar spine disorders 1g especially for the © Origin Both from La root (Common trunk in35% of eases) ‘hypogastric (i, ack tow) and Hainguinal (i, white stron) mise © Course Descent bein the parietal periteneum on the quadrats lumbarum muscle, perforate the transverse abdominal muscle TAM, Course between he TAM medially and the leser oblique muscle (LOM, red arrow) externally (facing the Anterior perk reaurow) aswes along the inguinal canal ta become subcutane © Branches For lt lateral cutaneous branch (black arrow head) © Tertitory and distribution: ‘Common ta and ALinguinal region (dark blue), pubic an groin region (green) libteanch: lateral and upper pact of thigh ight blue) ppendicis Surgery r Surgery 19 (46.4%) 5 (12.2%) 5 (12.2%) 5 (122%) 3 (73%) 2 (49%) resticular and Hernia Surgery rauma ‘Kastler etal, Radiology 2012 Srakeeth By fies them ac atellio-inguinal and Ilio-hypogastric Eero ea Planning CT (non enhanced) performed at level of ASIS to locate target : [1 and IH nerves (black arrow head) between Transverse abdominal muscle (black arrow) and lesser oblique muscle (white arrow) Infiltration : After accurate contrast media diffusion at defined target, Injection of a mixture of fast and slow acting anesthetic (a ml lidocaine hydrochloride 1% and 2 ml bupivacaine hydrochloride 0.25%, black arrow and arrow head) ialiowed by KENACORT. Radiofrequency @ Stimulation mode is used to confirm exact needle tip position adjacent to the nerve. @ Three go sec. RF in lesion mode are performed at 70, 80 and go °C Kastler et al. Radiology 2012 Kastler et al. Pain Physician 2012e@ Neurolysis wi Ilio-inguinal and Ilio-hypogastric a Infiltration improve symptoms for 1-2 months h RF produces a longer lasting result around 1 year Before Mean procedure " B 7 9 Te duration RF Group 775 12 43 16 39 42 125 Inf Group 7.46 48 61 65 69 69 1.22 ttest | p=0.212 | p<0.001 | p<0.001 | p<0.001 | p=0.007 | p=0.033 | p=0.006 | Kastler et al. Radiology 2012 Kastler et al. Pain Physician 2012Genito-Femoral Nerve @ = This nerve arises from the L2 root, possibly anastomosing with that of La penetrates the psoas muscle and emerges from it at the level of disc L3-L4 . It passes obliquely in front of this muscle, where it is visible beneath its sheath. It then usually divides into two branches: A femoralbranch (red arrow) thatfollows the external iliac artery to the external part of the femoral ring and emerges in Scarpa’s triangle in front of the femoral artery; after 2 to 3 cm it enters the cribriform fascia and innervates the anterior and superior region of the thigh A genital branch (black arrow)which enters the deep inguinal ring and follows the inguinal canal on the inside of and behind the funiculus. In the inguinal canal it gives rise to a motor branch (responsible for the cremasteric reflex) and terminal fibers intended for the skin of the scrotum or labia majora. If the genitofemoral nerve is affected, pain occurs in nerve areas anterior and superior region of the thigh for the femoral branch, and in the inguinal region and scrotum or labia majora for the genital branch). Interventional Radiology in Pain Treatment, Kastler, Springer 2006Genito-Femoral Nerve [eee Infiltration of the genito-femoral nerve under CT guidance Placement of the needle at the first site (femoral branch) in front of the femoral artery. Placement of the needle at the genito-femoral branch. Interventional Radiology in Pain Treatment, Kastler, Springer 2006Inguinal canal Infiltration | Testiculor vessels & panpiniform plows ‘Cremasteric vessels Remains of processus vials Internal spermatic fascia rere Ticinginl nerve ‘Cremasteric muscle Externd spermatic fasciaDouleur inguinale d’origine LombaireDouleur inguinale d’origine LombaireLateral femoral cutaneous Nerve This nerve arises mostly from the L2 root and partly from the L3 root of the lumbar spinal nerves. It emerges on the lateral margin of the psoas muscle and crosses the iliac muscle obliquely, reaching the anterosuperior iliac spine (ASIS) and passing under or through the inguinal ligament, which extends from the ASIS to the pubis. It innervates the skin of the anterolateral region of the thigh up to the knee, and through a posterior branch the lateral region of the major trochanter eT Fritz et al. Magn Reson Imaging Clin N Am 2015Obturator Nerve Dire eee ee Origin : Roots L2, L3, andL4 Course : Leaves the lumbar plexus and descends behind the psoas major on its medial aspect, then travels into the lesser pelvis, and finally exists the pelvis through the obturator canal ae The most accessible target is at the top of the obturator hiatus, patient in supine position aiira a |BSacral plexus (posterior groin pain)Pudendal Neuralgia (The most famous) Essential criteria (must all be present) * Pain in the territory of the pudendal nerve: from the anus to the penis or clitoris * Pain is predominantly experienced while sitting = The pain does not wake the patient at night = Pain with no objective sensory impairment = Pain relieved by diagnostic pudendal nerve block Complementary diagnostic criteria + Burning, shooting, stabbing pain, numbness * Allodynia or hyperpathia * Rectal or vaginal foreign body sensation (sympathalgia) = Worsening of pain during the day redominantly unilateral pain " Pain triggered by defecation = Presence of exquisite tenderness on palpation of the ischial spine * Clinical neurophysiology findings in men or nulliparous women Associated signs not excluding the diagnosis * Buttock pain on sitting * Referred sciatic pain * Pain referred to the medial aspect of the thigh = Suprapubic pain rinary frequency and/or pain on a full bladder * Pain occurring after ejaculation = Dyspareunia and/or pain after sexual intercourse = Erectile dysfunction * Normal clinical neurophysiologyPudendal Neuralgia (The most famous) + The pudendal nerve originates from the sacral plexus: it is formed from the fusion of the 2"4, 34 and 4" sacral nerves which merge in the pre-sacral region (first subsection) * The nerve then courses through the infrapiriform canal (second subsection) , where it can be entrapped between the sacrospinous and the sacrotuberous ligaments posterior to the ischial spine (site 2) Pudendal right plexus Sacrospinous ligament + After leaving the pelvis on its way through the pudendal canal (i.e. Alcock’ s canal) (third subsection ) accompanied by the pudendal Pudendal nerve arterial bundle within the internal obturator fascia forming an non-stretchabel aponeurotic tunnel where it can be constricted (site 2) Pudendal nerve (Site 1) Sacrotuberous ligamentPudendal Neuralgia (The most famous) CREE nee Target 2 posterior to the ischiatic spine Level of the ischial spine : - neurovascular pudendal bundle (arrowhead), ~ sacrospinous ligament (short arrow), - sacrotuberous ligament (long arrow), - the ischiatic nerve (curved arrow) Target 2 : the pudendal canal Pudendal fight plexus —}——__(_ ) ( Sacrospinous: ligament as Pudendal nerve Sacrotliberous ligament Ischiorectal fossa Level shows -neurovascular pudendal bundle (little nipple - arrowhead) - obturator internus muscle (short arrow) limited medially by its aponeurosis (long arrow)Pudendal Neuralgia Ey (The most famous) Target 1 posterior to the ischiatic spine *At target Site injection of : *amL of contrast to confirm the correct diffusion of the pudendal nerve in-between the sacrospinous and the sacrotuberous = yh r ligaments * 2 to 3 ml of a mixture of Lidocaine/Naropain #1.5 mL of CortivazolPudendal Neuralgia =a (The most famous) Target 2 : the pudendal canal *Needle is advanced through the gluteal muscles obturator internus muscle aponeurosis it is positionned at the pudendal canal, Injection of : *amL of contrast to confirm the correct moulding of the pudendal nerve in- between the sacrospinous and the sacrotuberous ligaments * 2 to 3 ml of a mixture of Lidocaine/Naropain *amL of KENACORTCorrect lodine diffusion ?Pudendal Neuralgia (The most famous) PNI between 2002 and 2016: | ‘Neuropathic pain in PN territory Increased pain i sitting position Noor lite night pain Possible symotoms (may or may not be present) Foreign body sensation Pain increase during defecation Inclusion Ys] | No 85 patients Gl (=I Exclusion + 61 females, 34 males, Le ens + Mean Age :52y.0 + Pain distribution : * Bilateral : 60 cases * Unilateral : 35 cases + 155 performed procedures Fig. 1. Flow chart representing patient selection and demographic data. Baseline 1 Month 3 Months 6 Months Clinical Success 63.2% (60/95) 50.5% (48/95) 25.2% (24/95) Psetscore ti zs cas VAS = visual analog scale SRI = self-reported improvement Kastler et al. 2017Posterior femoral cutaneous Nerve (The unknown differential diagnosis) Anatomical and Clinical Findings Origin : The PFCN arises from S1-S2-S3 andisa sensory nerve that is formed by the sacral plexus and carries only sensory fibers. Branches Inferior cluneal branches => lateral buttock area. Perineal branchPosterior femoral cutaneous Nerve (The lesser known differential diagnosis) ee Very few reports on CT procedures targeting this nerve are available. Fritz et al. Have reported the feasibility of PFCN blocks with high resolution MR neurography guidance. Eventhough MR guiddance is not a widely available technique, knowledge of this nerve is important in cases of failure of pudendal nerve infiltration, as it is a differential diagnosis worth knowing Fig. 3. Three-Tesla MR neurography-guided injection of the right posterior femoral cutaneous nerve. (A) Axial intermediate-weighted MR neurography image shows the right posterior femoral cutaneous nerve (white arrow) in the subgluteal space posterior to the sciatic nerve and the pudendal nerve medially in the pudendal canal (black arrow). (B) Axial intermediate-weighted turbo spin-echo MR image demonstrates the needle tip (black arrow) in the right subgluteal space next to the right posterior femoral cutaneous nerve (white arrow). (C) Axial ‘T2-weighted half-Fourier acquisition single-shot turbo spin-echo image demonstrates the injected local anes: thetic (black arrow) circumferentially surrounding the right posterior femoral cutaneous nerve (white arrow). Fritz et al. Skel radiol 2022 Fritz et al. Magn Reson Imaging Clin N Am 2015Posterior femoral cutaneous Nerve (The lesser known differential diagnosis) eee Ee tT onSciatical Pain reer ts ord Superior ‘pees! 2Sciatical Pain Piriformis Syndrome Piriformis syndrome can cause posterior hip pain, deep buttock pain, tingling down the back of thigh and leg Increase in sitting position Dynamic positive signs (Freiburg and Pace) ate TT Bry Ve \ s &£ siatic nerve ——~|Take Home Messages Important role of the Interventional Radiologist in helping with very complicated wide variety of clinical settings Lumbar plexus => Anterior Pain, @ Very frequent yet underdiagnosed condition = ilio- inguinal impairment Sacral Plexus => Posterior/perineal Pain e@ Most common = Pudendal Neuralgia e@ However, PFCN may be a differential CT guidance = best available guidance tool fora widerange of indications