Feasibility of a femoral nerve motor branch for transfer to the pudendal nerve for restoring continence: a cadaveric study

Laboratory investigation

Restricted access

Object

Nerve transfers are an effective means of restoring control to paralyzed somatic muscle groups and, recently, even denervated detrusor muscle. The authors performed a cadaveric pilot project to examine the feasibility of restoring control to the urethral and anal sphincters using a femoral motor nerve branch to reinnervate the pudendal nerve through a perineal approach.

Methods

Eleven cadavers were dissected bilaterally to expose the pudendal and femoral nerve branches. Pertinent landmarks and distances that could be used to locate these nerves were assessed and measured, as were nerve cross-sectional areas.

Results

A long motor branch of the femoral nerve was followed into the distal vastus medialis muscle for a distance of 17.4 ± 0.8 cm, split off from the main femoral nerve trunk, and transferred medially and superiorly to the pudendal nerve in the Alcock canal, a distance of 13.7 ± 0.71 cm. This was performed via a perineal approach. The cross-sectional area of the pudendal nerve was 5.64 ± 0.49 mm2, and the femoral nerve motor branch at the suggested transection site was 4.40 ± 0.41 mm2.

Conclusions

The use of a femoral nerve motor branch to the vastus medialis muscle for heterotopic nerve transfer to the pudendal nerve is surgically feasible, based on anatomical location and cross-sectional areas.

Article Information

Address correspondence to: Michael R. Ruggieri Sr., Ph.D., Temple University School of Medicine, 3400 North Broad Street, 715 OMS, Philadelphia, Pennsylvania 19140-5104. email: rugg@temple.edu.

Please include this information when citing this paper: published online July 15, 2011; DOI: 10.3171/2011.6.SPINE11163.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Location of the pudendal nerve. A: Diagram showing the location of the pudendal nerve (PN) in the Alcock canal (pudendal canal) located medial to the ischial tuberosity (IT) and lateral to the anus (An). After exiting the Alcock canal, the pudendal nerve divides into several branches that course to the anus, external urethral complex (U; nerve indicated by small arrows), and clitoris. The location of the femoral nerve (FN) on the anterior thigh is also indicated in the diagram. B: Photograph of the pudendal nerve (held by a needle driver) as it exits the pudendal canal. Its path toward the urethra (U) is indicated by the small arrows. The location of the ischial tuberosity (IT) is indicated by a large arrow. C: Enlarged photograph of the pudendal nerve as it exists the Alcock canal. Its path toward the urethra is indicated by the arrows. Note the several small branches from the pudendal nerve as it nears its terminal targets.

  • View in gallery

    Location of the femoral nerve and branches. A: Diagram showing the location of the femoral nerve (FN) and several of its branches in the anteromedial thigh prior to removal of the subcutaneous fascia. Note its relationship to the great saphenous vein (Gr Saph V). B: Photograph of a female cadaver showing the femoral nerve (elevated by forceps) exiting the femoral triangle medial to the rectus femoris (RF) and coursing inferiorly on the anterior thigh toward the knee. The medial relationship of the great saphenous vein to the femoral nerve is indicated. C: Enlarged photograph indicating the medial relationship of the femoral artery (FA) and great saphenous vein (Gr Saph V) to the femoral nerve (elevated by forceps), and the lateral relationship of the rectus femoris (RF) muscle to the nerve.

  • View in gallery

    Feasibility of transferring a motor branch of the femoral nerve to the pudendal nerve. A: Photograph of anterior thigh showing the location of a motor branch of the femoral nerve (FN, indicated by 2 string loops, and the surgeon's hand). The location of the pudendal nerve (PN) within the perineum and its proximity to the femoral nerve are shown. B: Photograph of the anterior thigh and perineal regions showing the transfer of the femoral nerve branch (FN, string loop and arrow) from its anterior thigh position to the pudendal nerve (PN, string loop and arrow). C: Diagram showing the transfer of a femoral nerve branch to the proximal pudendal nerve as it exists from the Alcock (pudendal) canal. D: Photograph showing the transfer of a large branch of the femoral nerve from its original anterior location (Fem N, indicated by the dashed line at the right margins of image), medially across the thigh, to the site of the proximal pudendal nerve in the Alcock canal (small clip and large gray arrow). Large black arrow and metal marker indicate the location of ischial tuberosity (IT). An = anus.

References

  • 1

    Anderson KD: Targeting recovery: priorities of the spinal cord-injured population. J Neurotrauma 21:137113832004

  • 2

    Barbe MFRuggieri MR Sr: Innervation of parasympathetic postganglionic neurons and bladder detrusor muscle directly after sacral root transection and repair using nerve transfer. Neurourol Urodyn 30:5996052011

  • 3

    Boger ABhadra NGustafson KJ: Bladder voiding by combined high frequency electrical pudendal nerve block and sacral root stimulation. Neurourol Urodyn 27:4354392008

  • 4

    Browne EZSnyder CC: Intercosto-sacral neural anastomosis. Surg Forum 22:4744761971

  • 5

    Carlsson CASundin T: Reconstruction of efferent pathways to the urinary bladder in a paraplegic child. Rev Surg 24:73761967

  • 6

    Gustafson KJZelkovic PFFeng AHDraper CEBodner DRGrill WM: Fascicular anatomy and surgical access of the human pudendal nerve. World J Urol 23:4114182005

  • 7

    Huittinen VM: Lumbosacral nerve injury in fracture of the pelvis. A postmortem radiographic and patho-anatomical study. Acta Chir Scand Suppl 429:3431972

  • 8

    Johnston L: Human spinal cord injury: new and emerging approaches to treatment. Spinal Cord 39:6096132001

  • 9

    Kilvington B: Report C. An investigation on the regeneration of nerves, with regard to surgical treatment of certain paralysis. Br Med J 1:24179889901907

  • 10

    Livshits ACatz AFolman YWitz MLivshits VBaskov A: Reinnervation of the neurogenic bladder in the late period of the spinal cord trauma. Spinal Cord 42:2112172004

  • 11

    Mariano TYBoger ASGustafson KJ: The feline dorsal nerve of the penis arises from the deep perineal nerve and not the sensory afferent branch. Anat Histol Embryol 37:1661682008

  • 12

    Matta JMSaucedo T: Internal fixation of pelvic ring fractures. Clin Orthop Relat Res 24283971989

  • 13

    Patil A: Intercostal nerves to spinal nerve roots anastomosis (spinal cord bypass) and Harrington rod fusion in traumatic paraplegia—technical note. Acta Neurochir (Wien) 57:2993031981

  • 14

    Rao CRBruce AWLywood DWRobertson DM: Reinnervation of the neurogenic bladder with somatic motor nerves. Invest Urol 9:59631971

  • 15

    Ruggieri MRBraverman ASD'Andrea LBetz RBarbe MF: Functional reinnervation of the canine bladder after spinal root transection and genitofemoral nerve transfer at one and three months after denervation. J Neurotrauma 25:4014092008

  • 16

    Ruggieri MRBraverman ASD'Andrea LMcCarthy JBarbe MF: Functional reinnervation of the canine bladder after spinal root transection and immediate somatic nerve transfer. J Neurotrauma 25:2142242008

  • 17

    Ruggieri MRBraverman ASD'Andrea LSimpkiss BKozin SHPontari MA: Functional reinnervation of the canine bladder after spinal root transection and immediate end-onend repair. J Neurotrauma 23:112511362006

  • 18

    Schmidek HHSmith DAKristiansen TK: Sacral fractures. Neurosurgery 15:7357461984

  • 19

    Shafik A: Neuronal innervation of urethral and anal sphincters: surgical anatomy and clinical implications. Curr Opin Obstet Gynecol 12:3873982000

  • 20

    Standring S: Gray's Anatomy: The Anatomical Basis of Clinical Practice ed 40EdinburghChurchill Livingstone/Elsevier2008

  • 21

    Trumble HC: Experimental reinnervation of the paralyzed bladder. Med J Aust 1:1181935

  • 22

    Tung THMartin DZNovak CBLauryssen CMackinnon SE: Nerve reconstruction in lumbosacral plexopathy. Case report and review of the literature. J Neurosurg 102:1 Suppl86912005

  • 23

    Vorstman BSchlossberg SKass L: Investigations on urinary bladder reinnervation. Historical perspective and review. Urology 30:89961987

  • 24

    Xiao CG: Reinnervation for neurogenic bladder: historic review and introduction of a somatic-autonomic reflex pathway procedure for patients with spinal cord injury or spina bifida. Eur Urol 49:22292006

  • 25

    Xiao CGde Groat WCGodec CJDai CXiao Q: “Skin-CNS-bladder” reflex pathway for micturition after spinal cord injury and its underlying mechanisms. J Urol 162:9369421999

TrendMD

Cited By

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 89 89 8
Full Text Views 46 46 0
PDF Downloads 39 39 0
EPUB Downloads 0 0 0

PubMed

Google Scholar