Surgical Interventions for Lumbosacral Plexus Injuries: A Systematic Review

Abstract

Background: Nerve reconstruction techniques for lumbosacral plexus (LSP) injuries vary. There are no clear treatment guidelines available, and summative evaluations of the literature discussing these surgeries are lacking. For these reasons, this investigation aimed to systematically review and consolidate all available literature discussing surgical interventions for LSP injuries and cohesively present patient-reported and objective postoperative outcomes. Methods: The authors conducted a systematic review using PubMed, Embase, Web of Science, ProQuest Dissertations and Theses Global (via Proquest.com), and ClinicalTrials.gov databases according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. After title and abstract screening, identified articles were read in full and selected for inclusion based on prespecified criteria. Results: Our literature search identified 8683 potential citations, and after duplicate removal, abstract screening, and full-text review, 62 studies remained meeting inclusion and exclusion criteria. Outcomes were extracted according to the location of injury and type of surgical repair. Injuries were classified into isolated femoral nerve injuries, isolated obturator nerve injuries, isolated sciatic nerve injuries, and multilevel LSP injuries. Surgical treatment was further classified into exploration with neurolysis, direct repair, nerve grafting, and nerve transfer surgery. Conclusions: Although results vary based on the location of the injury and the surgical technique used, nerve grafts and transfers demonstrated reasonable success in improving functional and pain outcomes. Overall, isolated femoral and obturator nerve injuries had the best outcomes reported with surgical treatment. Furthermore, incomplete sciatic nerve and multilevel LSP injuries had more reported surgical options and better outcomes than complete sciatic nerve injuries.

Differentiating Lumbar Spinal Etiology from Peripheral Plexopathies

“…Following these procedures to expose the targeted nerve, surgeons typically opt for neurolysis to mitigate pain symptoms related to the pathology of that peripheral nerve, which often is the femoral, obturator, and the sciatic nerve when considering LS plexopathies [ 103 ]. As discussed above, pathologies related to these nerves often result in deambulation and the radiation of burning pain [ 7 , 58 ].…”

“…This peripheral approach to treatment, when targeting the femoral nerve in patients experiencing LS plexopathy, has been found to attain positive results with various patients, including a reduction in severe pain and restored motor function to the gluteal muscles [ 102 , 106 ]. Furthermore, in studies following patients with plexopathy affecting on the obturator nerve, and thus experiencing limited hip adduction, it was determined that neurolysis on the obturator nerve improved hip adduction from Medial Research Council (MRC) grade 2 to MRC grade 5 along with a reduction in pain [ 103 , 107 ].…”

“…Further, repair strategies used in LS plexopathies with extensive neuronal damage include procedural nerve grafts to restore function to affected peripheral nerves ( Figure 5 A) [ 60 , 103 ]. Nerve grafts can either entail an end-to-end nerve suture or suturing an autologous donor nerve to replace the damaged portion of the recipient nerve [ 108 , 109 ].…”

“…Nerve grafts can either entail an end-to-end nerve suture or suturing an autologous donor nerve to replace the damaged portion of the recipient nerve [ 108 , 109 ]. Various case reports highlight the effectiveness of this strategy, namely restoring the functionality of the femoral, obturator, and sciatic nerves, as well as for multilevel injuries involving nerve roots [ 102 , 103 , 107 , 110 , 111 ]. Across these various procedures, it was reported that related motor and sensory function was successfully restored, including hip adduction, hip flexion, and knee extension [ 102 , 103 , 107 , 110 , 111 ].…”