Dr. Héctor Giócoli's own methods and results for lumbosacral plexus surgery

1. Lumbosacral
Plexus Surgery
Hector Giocoli, MD
Buenos Aires - Argentina

2. Characteristics
 Low incidence: Rarely reported lesions, witch, if
posttraumatic, may remain undiagnosed because of
the variable destination of the patients in emergency
 Difficult level diagnosis: Patients witch different
parenchimal or visceral lesions, with different
problems witch hinder motility (And frequently
affected by severe pain)
 Difficult surgical treatment:
 Analogous lesions in the brachial plexus are
normally treated, and results are quite well known.
 In this anatomical district surgical approach is not
so comfortable and familiar
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3. Etiology
Traumatic Events
• Herniorrhaphy
 Obstetrical trauma • Appendectomy
• Hysterectomy
 Surgery • Lumbar sympatectomy
• Lateral approach to the
 Abdominal surgery spine
 Gynecological procedures
 Tumors
 Intrapelvic
 Terminal branches
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4. Anatomy
Lumbar Plexus
 Spinal roots L2, L3, and L4
(L1 and L5)
 Located in the corner
between vertebral bodies
and lateral apophisis
 Covered by
 Ascending iliac and cava
veins, and by psoas muscle
 By aorta and common iliac
arteries on the right side
 By iliac arterial and venous
plexuses on the left
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5. Anatomy
Lumbar Plexus Subserved
Muscle are:
 Abdominal
 Psoas
 Iliac
 Pectineus
 Sartorius
 Quadriceps femoris
 Adductors of the thigh
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6. Anatomy
Sacral Plexus
 Spinal roots L5, S1,
and L2 (L4)
 Lies on the sacro iliac
junction
 Medial to psoas muscle
between it and the column
 Hypogastric artery
intermigles the nerve trunks
and asending veins cover
the plexus
 The lumbosacral trunk is
given by components from
L4 and from L5
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7. Anatomy
Sacral Plexus
Subserved Muscle are:
 Glutei
 Obturator
 Piriform
 Gemelli
 Quadratus
 Muscle or posterior thigh
 Anterior tibial
 Peroneal foot abductors
and extensors
 Triceps surae and plantar
flexors
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8. Surgical Techniques
 Anterior: extraperitoneal
 Lateral: extraperitoneal
 Anterior: transperitoneal
 Posterior: sacrectomy
In some cases is impossible to access to the
more proximal sciatic nerve, the bony and
ligamentous rim of the greater sciatic notch can
be nibbled or drilled away to gain access
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9. Surgical Techniques
Intraoperative electrophysiological recording
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10. Surgical Approach
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11. Surgical Approach
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12. Surgical Approach
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13. Surgical Approach
Neurolysis
Sciatic nerve
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14. Surgical Approach
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15. Surgical Approach
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16. Intrabdominal Graft
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17. Surgical Approach
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18. Surgical Approach
Psoas
Neurolysis
Femoral nerve
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19. Results
30 days later
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20. Results
3 months later
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21. Posterior Approach
Sacrectomy
Nerve grafting
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22. Surgical Approach
Sciatic Nerve
Classic Technique Our Approach
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23. Surgical Approach
Sciatic Nerve
Neurolysis
Aesthetic results
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24. Surgical Approach
Sciatic Nerve Tumor
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25. Surgical Approach
Sciatic Nerve
Follow-up
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26. Pelvis Tumor
Tumor
Incision
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27. Pelvis Tumor
Tumor
Extirpation
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28. Pelvis Tumor
Tumor
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29. Anterior Approach
Total extirpation
Femoral nerve
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30. Posterior Approach
Sciatic nerve
Tumor
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31. Pelvis Tumor
Total extirpation
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32. Results
5 months later
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33. Femoral Surgery
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34. Femoral Surgery
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35. Femoral Surgery
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36. Distal and Proximal Stump
Common Peroneal Nerve
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37. Common Peroneal Nerve
Results
Grafts
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38. Tibial Nerve Palsy
Incision
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39. Tibial Nerve Palsy
Neuroma
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40. Tibial Nerve Palsy
Results
Nerve Grafting
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41. Posterior Tibial Nerve
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42. Posterior Tibial Nerve
Neurolysis
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43. Posterior Tibial Nerve
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44. Posterior Tibial Nerve
Stumps Grafts
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45. Results After 29 patients
Male Female Good Fear Bad
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46. Tha nk
y o u !!
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