Anatomical feasibility of performing a nerve transfer from the femoral branch to bilateral pelvic nerves in a cadaver: a potential method to restore bladder function following proximal spinal cord injury

Laboratory investigation

Restricted access

Object

Nerve transfers are an effective means of restoring control to paralyzed somatic muscle groups and have recently been shown to be effective in denervated detrusor muscle in a canine model. A cadaveric study was performed to examine the anatomical feasibility of transferring femoral muscular nerve branches to vesical branches of the pelvic nerve as a method of potentially restoring innervation to control the detrusor muscle in humans.

Methods

Twenty cadavers were dissected bilaterally to expose pelvic and femoral muscular nerve branches. Ease of access and ability to transfer the nerves were assessed, as were nerve cross-sectional areas.

Results

The pelvic nerve was accessed at the base of the bladder, inferior to the ureter, and accompanied by inferior vesical vessels. Muscular branches of the femoral nerve to the vastus medialis and intermedius muscles (L-3 and L-4 origins) were followed distally for 17.4 ± 0.8 cm. Two muscle branches were split from the femoral nerve trunk, and tunneled inferior to the inguinal ligament. One branch was moved medially toward the base of the bladder and linked to the ipsilateral pelvic nerve. The second branch was tunneled superior to the bladder and linked to the contralateral pelvic nerve. The cross-sectional area of the pelvic nerve vesical branch was 2.60 ± 0.169 mm2 (mean ± SEM), and the femoral nerve branch at the suggested transection site was 4.40 ± 0.41 mm2.

Conclusions

Use of femoral nerve muscular branches from the vastus medialis and intermedius muscles for heterotopic nerve transfer of bilateral pelvic nerves is surgically feasible, based on anatomical location and cross-sectional areas.

Abbreviation used in this paper:SCI = spinal cord injury.

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 March 29, 2013; DOI: 10.3171/2013.2.SPINE12793.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Identification of the pelvic nerve and its vesical branch to the bladder within the pelvic cavity. Lateral view, with pubis (pubic bone) and sacral vertebrae (SV) indicated as landmarks. A: Diagram of male pelvis showing the relationship of the vesical branch of the pelvic nerve to the bladder, ureter, and ductus deferens (DD). S1, S2, S3 = sacral ventral rami 1, 2, and 3. B: Pelvic cavity of a female cadaver showing similar relationships. Arrows within the black box indicate the path of the pelvic nerve (PN), shown passing over wooden sticks. One branch passes to the bladder (the vesical branch of the pelvic nerve) and a second passes to the vaginal area in this cadaver. The rectum is removed. Inset shows enlargement of boxed area, and shows the relationship of the PN to the pelvic ganglia (PG). C: The pelvic cavity of a second cadaver showing similar relationships. Arrows in box indicate the path of the pelvic nerve and show 1 branch passing to the bladder (the vesical branch of the pelvic nerve) that then splits into a branch to the ureter and 2 branches to the detrusor wall. A second branch is shown passing to the vaginal area that splits into 2 branches. The rectum is removed. B = bladder. D: Enlargement of box shown in C, with a wooden stick now elevating the branches of the pelvic nerve.

  • View in gallery

    Relationship of the pelvic nerve (PN) to the inferior vesical vessels, ductus deferens (DD), and inferior epigastric vessels. Lateral view, legs are located on the right side of these panels. The parietal peritoneum was separated manually from the visceral peritoneum and viscera. Upper: The vesical branch of the pelvic nerve (large arrow) was identified at the base of the bladder (B) in the retroperitoneal space. A suture was tied around the pelvic nerve for identification purposes. The suture is shown pulled inferiorly over the pubic bone (right side of panel). Pertinent landmarks such as the inferior epigastric artery and vein, DD, and reflected rectus abdominis muscle are indicated. Lower: Diagram of the same figure showing the same landmarks.

  • View in gallery

    Transfer of a muscular branch of the left femoral nerve (FN) to the left (ipsilateral) pelvic nerve. A: The branches of the left femoral nerve in the left anterior thigh were exposed. B: Branches of the left femoral nerve were cleared of fat. A branch to the vastus medialis muscle was teased out from the femoral nerve trunk. A surgical cloth was placed under the nerve branches to aid visualization. C: This muscular branch of the left femoral nerve was moved superiorly in the subcutaneous space. Asterisk indicates a loop of gut. D: The cut branch was tunneled inferior to the inguinal ligament into the abdominal cavity's retroperitoneal space. The location of the bladder is indicated with a dashed line. E: The cut muscular branch of the left femoral nerve had enough length to be easily anastomosed with the left pelvic nerve on the bladder wall. Inset shows higher magnification of transferred femoral nerve and femoral-pelvic nerve “reanastomosis” site (white arrows). F: Diagram of image shown in E and of surgical procedure. DD = ductus deferens. Asterisk indicates the same loop of gut in each panel, as demarcated first in C.

  • View in gallery

    Transfer of a muscular branch of the left femoral nerve to the right (contralateral) pelvic nerve. Anterior view, similar to Fig. 3. A: Another muscular branch of the femoral nerve was identified and tunneled inferior to the inguinal ligament into the abdominal cavity's retroperitoneal space. The left femoral nerve branch is moved across the abdomen, superior to the bladder, to the contralateral (right) pelvic nerve. The tunnel is indicated by dashed lines. 1 = first transferred nerve (ipsilateral transfer); 2 = second transferred nerve (contralateral transfer). DD = ductus deferens; m = muscle. B: Similar but enlarged image as shown in A. The cut muscular branch of the left femoral nerve (2) was placed adjacent to the transected right pelvic nerve (PN, left arrow). C: Diagram of A. D: Diagram of B.

  • View in gallery

    Illustration of the transfer of muscular braches of the left femoral nerve to both the left and right dominant branches of the pelvic nerves, innervating the urinary bladder using an anterior pelvic extraperitoneal approach. The transferred nerves are passed through a subcutaneous tunnel on the left inner thigh to allow for functional electrical stimulation of the transferred nerves with standard transepidermal nerve stimulators and electrodes.

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