Anomalous formation and branching pattern of the sciatic and pudendal nerves

Multiple nerve variations were observed in the right gluteal region of a 62 year old female which includes origin, course and branching pattern of the sciatic and pudendal nerves. The sciatic nerve was formed by the L4, L5, S1 and S2 in the pelvis, whereas the pudendal nerve was contributed by the S3, S4 and S5. The pudendal was divided into medial and lateral divisions in the gluteal region. The lateral division had joined the sciatic nerve. High division of the pudendal nerve was observed and all its branches originated from the medial division of the pudendal nerve. The inferior rectal nerve passed through the sacrospinous ligament and formed a loop around the ischial spine. The dorsal nerve of the clitoris passed between the sacrospinous and sacrotuberous ligaments. Since iatrogenic injuries to these nerves may occur during surgery, a thorough knowledge of the variation anatomy of the sciatic and pudendal nerves can help to reduce post-operative complications. Moreover, variation anatomy knowledge might guide the radiologist, surgeons and other health professionals to diagnose and treat various neuralgia related to the perineum and gluteal region

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Trifecta nerve complex: potential anatomical basis for microsurgical denervation of the spermatic cord for chronic orchialgia.

PURPOSE: We identified structural abnormalities in the spermatic cord nerves that may explain how microsurgical denervation of the spermatic cord provides pain relief in patients with chronic orchialgia. MATERIALS AND METHODS: We retrospectively reviewed a prospective database to compare spermatic cord biopsy specimens from 56 men treated with a total of 57 procedures for microsurgical denervation of the spermatic cord for chronic orchialgia vs a control group of men without pain treated with cord surgery, including varicocelectomy in 4 and radical orchiectomy in 6. Tissue biopsies were obtained from mapped regions of the spermatic cord in all cases. Biopsies stained with hematoxylin and eosin were examined by an independent pathologist. Three human cadaveric spermatic cords were dissected to confirm localization of the nerve distribution identified on pathological mapping. RESULTS: We identified a median of 25 small diameter (less than 1 mm) nerve fibers in the spermatic cord. Of the 57 procedures for orchialgia 48 (84%) showed wallerian degeneration in 1 or more of these nerves but only 2 of 10 controls (20%) had such degeneration (p = 0.0008). In decreasing order of nerve density the 3 primary sites (trifecta nerve complex) of these changes were the cremasteric muscle fibers (19 nerves per patient), perivasal tissues and vasal sheath (9 nerves per patient), and posterior cord lipomatous/perivessel tissues (3 nerves per patient). Cord nerve distribution mapped by the biopsies was confirmed by cadaveric dissection. CONCLUSIONS: In men with chronic orchialgia there appears to be wallerian degeneration in reproducible patterns in the spermatic cord nerve fibers. Transection of these nerves may explain the effect of the denervation procedure.