OverviewOctober 1, 2024
Prof. Prof. DK Prof. Dr. med. Marc Possover, MD, PhD
Unrecognized Neurologic Complications of Sacropexies: A retrospective cases study
SUMMARY
Sacral radiculopathies are rare but significant complications of sacrocolpopexy or rectopexy for pelvic organ prolapse. Despite limited literature on pelvic nerve injuries, this study aims to raise awareness and emphasize the importance of precise surgical techniques and early diagnosis to improve patient outcomes. In this cohort, we examined 38 patients (29 women, 9 men) presented in our center between 2011 and 2023 with sacral radiculopathies secondary to sacropexy. All underwent laparoscopic nerve decompression without mesh explantation, with one-year follow-up. Pain was evaluated using the Visual Analog Scale (VAS), and motor deficits were assessed with the Medical Research Council (MRC) Scale.
The S2 nerve root was most affected. Non-neurogenic sacral radiculopathies (84%) typically presented later than neurogenic cases, which caused immediate neuropathic pain and motor deficits, with limited sensory recovery. Non-neurogenic sacral radiculopathies, often associated with fibrosis, showed significant pain improvement post-decompression (VAS 7–10/10 to 1–4/10 in 76% of cases). Secondary sacral radiculopathies are frequently misdiagnosed as spinal pathologies due to their delayed onset and complex presentation. This study underscores the role of neuropelveological expertise in accurate diagnosis and management. Laparoscopic nerve decompression proved effective, avoiding the risks of mesh removal.
Improved diagnostic approaches and precision in surgical techniques are critical to mitigating sacral radiculopathies after sacropexy. Neuropelveology plays a vital role in preventing chronic pain and neurological deficits, highlighting the need for early intervention and specialized expertise to enhance patient outcomes.
INTRODUCTION
Sacral radiculopathies are rare but severe complications following sacrocolpopexy or rectopexy procedures for pelvic organ prolapse. These surgeries, widely regarded as standard treatments, rely on mesh fixation at the sacral promontory to ensure long-term stability. While the surgical benefits are well-documented, the risk of pelvic nerve injuries often remains overlooked and is sparsely addressed in the literature 1,2. Previous studies have repeatedly highlighted the risk of injuries to the sacral plexus nerves 3, yet detailed analyses of their causes, clinical presentation, and management strategies are lacking. This gap frequently leads to misdiagnosis and delayed treatment, significantly affecting patients' quality of life. This study aims to shed light on this rare but impactful complication. Based on a retrospective analysis of 38 patients, it identifies key clinical patterns, diagnostic challenges, and the efficacy of minimally invasive decompression of the affected nerves. Emphasis is placed on the role of surgical technique, primarily the positioning of the mesh, as a critical risk factor. Our goal is to increase awareness of these complications, optimize diagnostic and therapeutic approaches, and highlight the importance of clinical neuropelveology in pelvic surgery. Through the findings of this study, we provide new insights into the pathophysiology and management of sacral radiculopathies, offering surgeons the valuable tools to address and prevent these rare complications promptly.
AIM OF THE STUDY
This study analyzed 38 patients (29 women and 9 men) who presented with symptoms of sacral radiculopathy secondary to sacropexy procedures at our Center for Neuropelveology between 2011 and 2023 (Table 1).
Table 1: Overall data, distribution by gender, and lateral distribution of radiculopathies.
Patient demographics, clinical presentations, and surgical outcomes were retrospectively reviewed. All patients underwent laparoscopic nerve decompression without mesh explantation. This surgery prioritizes on nerve release rather than resecting the mesh or fibrotic tissue. The procedure involves metuclous explosure of the affected region of the sacral root and restoration it to its normal anatomical zone, most often distally. Once the nerve root is exposed at the sacral plexus, it is traced retrograde, up to the sacral foramen. The fibrosis is transected longitudinally, following the surface of the nerve. If part of the mesh is in contact with or very close to the nerve, that portion of the mesh is resected, but complete removal of the mesh is not performed. During dissection, it is crucial to avoid attempting the complete removal of perineural fibrosis, as this would result in the formation of new fibrosis, leading to the recurrence of pain several months later. The longitudinal opening of the fibrotic sheath along the nerve is generally sufficient to release it. Naturally, if the dissection reveals a staple or suture in contact or close proximity to the nerve, these are removed. To prevent the formation of new fibrosis, it is imperative that the dissection be performed without the use of sutures or clips and achieving absolute hemostasis.
Postoperative follow-up evaluations were conducted at one year to assess pain relief and functional recovery. Pain intensity was quantified using the Visual Analog Scale (VAS), while motor deficits were evaluated through clinical examination. All participants voluntarily approached our center for diagnosis and treatment for pelvic neuropathy/radiculopathy and signed informed consent forms for surgery and publication of case details. The study was conducted following the Declaration of Helsinki and has approved by our local local ethics committee.
RESULTS
Among the 38 patients analyzed, 29 were women who underwent sacrocolpopexy, and 9 were men following rectopexy (Fig. 1).
Figure 1: Gender Distribution of Patients: Illustrates the proportion of women and men among the patients
We encountered no major complications either intraoperatively or postoperatively, particularly no issues with hemorrhage or conversions to laparotomy. Right-sided radiculopathies predominated in women (26 cases), whereas left-sided radiculopathies were more common in men (5 cases) (Fig. 2).
Figure 2: Lateral Distribution of Radiculopathies: Depicts the distribution of radiculopathies by side (right-sided, left-sided, bilateral).
It is noteworthy that not a single patient was referred to our center with the diagnosis of "sacral radiculopathy." Instead, patients presented with the following diagnoses:
Additionally, 16 patients had previously undergone surgical discectomy with or without osteosynthesis.
All patients were classified preoperatively as suffering from:
Six patients presented with neuropathic low back/gluteal /leg pain immediately or within a few days after the pexy, accompanied by the following neurological deficits:
Following laparoscopic nerve decompression, pain scores decreased from 8–10/10 to 5–7/10 at the one-year follow-up. While some improvement in motor function was observed, sensory deficits showed no significant recovery at one year (Fig.3).
Figure 3: Pain Reduction Outcomes (VAS evolution) after Nerve Decompression in neurogenic versus non-neurogenic groups decompression.
Thirty-two patients reported painful S2 radiculopathy with pain localized to the lower back and buttocks, fifteen of them with radiations to the foot and toes. All of them had perianal pain and a hypersensitivity of the bladder (not a hyperactivity – urodynamic testing inconspicuous!) with pollakiuria and urgencies.
None of these patients demonstrated sensorimotor deficits during the neuropelveological evaluation. Pain onset occurred at a mean of 4 months post-procedure (range: 1 month to 7 years). Four patients had previously undergone surgical revision involving partial or total mesh resection.
At one-year follow-up, 76% of these patients reported a reduction in pain scores from 7–10/10 on the Visual Analog Scale (VAS) to 1–4/10. However, four patients experienced no benefit from laparoscopic nerve decompression.
A review of the operative reports for all promontofixation procedures included in this study revealed the names of the surgeons and their affiliated clinics or hospitals. Despite this, a search on PubMed identified no publications or reports from these surgeons addressing such complications. This highlights a significant gap in the reporting of these adverse events and underscores the uncertainty surrounding their true incidence.
DISCUSSION
Sacral radiculopathy, particularly involving the S2 nerve root, is a rare but significant complication following rectopexy or sacrocolpopexy procedures. Despite frequent mentions of the risk of pelvic nerve injuries in the literature, detailed reports and analyses of these complications remain scarce. This paradox - acknowledged risk with minimal documentation - can be attributed to several factors. First, the infrequency of such complications within individual surgical practices may discourage publication. Second, surgeons might be reluctant to disclose complications associated with their procedures. Third, the recognition of these complications is inherently challenging. Indeed, when direct injury to the sacral plexus occurs, such as inadvertent suturing of a sacral nerve root during mesh fixation to the sacrum, diagnosis tends to be more straightforward. Patients typically present with immediate postoperative gluteal pain radiating to the leg (sciatic pain), accompanied by gait disturbances and numbness, prompting re-evaluation of the surgical intervention. In contrast, sacral plexus irritation secondary to fibrosis presents a more complex diagnostic challenge. Scar tissue formation around the mesh may occur months or even years after the initial surgery. Consequently, patients experiencing sciatica long after rectopexy or sacrocolpopexy are often referred to orthopedic specialists and misdiagnosed with lumbar spine pathology. The delay in considering complications from remote pelvic surgeries further postpones accurate diagnosis and treatment.
This study emphasizes the importance of recognizing these complications and raises awareness among surgeons performing pelvic reconstructive procedures. Surgeons must consider sacral radiculopathy as a potential complication of rectopexy or sacrocolpopexy and develop the neuropelveological expertise necessary for timely and accurate diagnosis. Without such expertise, many patients may remain undiagnosed and untreated, enduring prolonged pain and disability.
The therapeutic approach to these complications requires careful consideration. While mesh explantation might seem a logical solution, it is often ineffective in cases of fibrosis-induced nerve entrapment. Mesh removal does not necessarily relieve the entrapped nerve and carries the risk of recurrent pelvic organ prolapse and intestinal injury. Additionally, resecting fibrotic tissue may injure or transect the nerves, and potentially exacerbating scarring. From a neuropelveological standpoint, the optimal treatment involves laparoscopic nerve decompression without removing the mesh or scar tissue, except in cases of infection, where explantation is indicated.
Over the past two decades, the incidence of this complication has declined in our practice but has not been eradicated. Since our initial report of 59 cases in 2011, we have managed an additional 38 patients with sacral radiculopathy at our center. This cohort included nine men following rectopexy (five with left S2 radiculopathy, three with right-sided radiculopathy, and one with bilateral involvement) and 29 women (three with left-sided radiculopathy and 26 with right-sided radiculopathy after sacrocolpopexy). Six patients presented with neurogenic S2 radiculopathy, characterized by Trendelenburg gait and plantar flexion weakness of the toes. Delayed nerve decompression in these cases likely resulted in Wallerian degeneration - a process occurring within days to weeks after nerve injury - leading to irreversible neurogenic damage. Although some pain reduction was achieved (mean pain score decreased from 8–10/10 to 5–7/10), full neurological recovery was not observed. Conversely, patients with non-neurogenic radiculopathy (i.e., without axonal damage) experienced significant pain relief, with 76% reporting a reduction in VAS scores from 7–10/10 to 1–4/10 at one-year follow-up.
Our findings challenge conventional views on the mechanisms of sacral plexus injury during promontofixation. Traditional recommendations emphasize avoiding lateral mesh fixation to prevent nerve injuries, as sacral nerve roots are laterally positioned relative to the sacrum. However, our study demonstrates that S2 radiculopathy often results from excessively distal fixation. While the S1 nerve root is lateral at the level of the internal iliac vessels, the S2 nerve root is closer to the midline and more caudal. Therefore, the primary risk arises not from lateral fixation but from improper caudal placement. These findings highlight the critical importance of precise surgical technique to avoid injury to deeper sacral roots.
This study underscores the necessity of increasing awareness, refining diagnostic strategies, and optimizing surgical techniques to minimize the risk of these debilitating complications. Advancing clinical knowledge in neuropelveology and fostering interdisciplinary collaboration are essential to ensure that these complications are promptly recognized and effectively managed. In cases of primary nerve injury, early recognition and timely nerve decompression are imperative to prevent chronic intractable neuropathic pain and associated neurological deficits, including gait and balance disorders.
CONCLUSION
The findings illustrate the dual challenges of diagnosing and managing sacral radiculopathies post-sacropexy. Direct nerve injuries are often identified early due to acute symptoms, whereas fibrotic entrapment presents diagnostic difficulties due to its delayed onset. This study emphasizes the importance of neuropelveological expertise for early diagnosis and surgical intervention to minimize irreversible damage especially in primary surgical nerve injuries. Management should prioritize nerve decompression without mesh explantation unless infection is present. Resecting fibrotic tissue risks recurrent scarring and further complications. Awareness of this rare but impactful complication is crucial for surgeons performing sacropexy procedures. This study emphasizes the need for education in clinical neuropelveology among gynecologists and visceral surgeons.
REFERENCES