Abstract
The T12 to S4 spinal nerves form the lumbosacral plexus in the retroperitoneum, providing sensory and motor innervation to the pelvis and lower extremities. The lumbosacral plexus has a wide range of anatomic variations and interchange of fibers between nerve anastomoses. Neuropathies of the lumbosacral plexus cause a broad spectrum of complex pelvic and lower extremity pain syndromes, which can be challenging to diagnose and treat successfully. In their workup, selective nerve blocks are employed to test the hypothesis that a lumbosacral plexus nerve contributes to a suspected pelvic and extremity pain syndrome, whereas therapeutic perineural injections aim to alleviate pain and paresthesia symptoms. While the sciatic and femoral nerves are large in caliber, the iliohypogastric and ilioinguinal, genitofemoral, lateral femoral cutaneous, anterior femoral cutaneous, posterior femoral cutaneous, obturator, and pudendal nerves are small, measuring a few millimeters in diameter and have a wide range of anatomic variants. Due to their minuteness, direct visualization of the smaller lumbosacral plexus branches can be difficult during selective nerve blocks, particularly in deeper pelvic locations or larger patients. In this setting, the high spatial and contrast resolution of interventional MR neurography guidance benefits nerve visualization and targeting, needle placement, and visualization of perineural injectant distribution, providing a highly accurate alternative to more commonly used ultrasonography, fluoroscopy, and computed tomography guidance for perineural injections. This article offers a practical guide for MR neurography–guided lumbosacral plexus perineural injections, including interventional setup, pulse sequence protocols, lumbosacral plexus MR neurography anatomy, anatomic variations, and injection targets.
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References
Sequeiros RB, Sinikumpu JJ, Ojala R, Jarvinen J, Fritz J. Pediatric musculoskeletal interventional MRI. Top Magn Reson Imaging. 2018;27(1):39–44.
Fritz J, Sequeiros RB, Carrino JA. Magnetic resonance imaging-guided spine injections. Top Magn Reson Imaging. 2011;22(4):143–51.
Fritz J, Dellon AL, Williams EH, Rosson GD, Belzberg AJ, Eckhauser FE. Diagnostic accuracy of selective 3-T MR neurography-guided retroperitoneal genitofemoral nerve blocks for the diagnosis of genitofemoral neuralgia. Radiology. 2017;285(1):176–85.
Dalili D, Isaac A, Fritz J. MRI-guided sacroiliac joint injections in children and adults: current practice and future developments. Skelet Radiol. 2023;52(5):951–65.
Dalili D, Fritz J, Isaac A. 3D MRI of the hand and wrist: technical considerations and clinical applications. Semin Musculoskelet Radiol. 2021;25(3):501–13.
Khodarahmi I, Fritz J. The value of 3 Tesla field strength for musculoskeletal magnetic resonance imaging. Invest Radiol. 2021;56(11):749–63.
Khalilzadeh O, Fayad LM, Ahlawat S. 3D MR neurography. Semin Musculoskelet Radiol. 2021;25(3):409–17.
Khodarahmi I, Keerthivasan MB, Brinkmann IM, Grodzki D, Fritz J. Modern low-field MRI of the musculoskeletal system: practice considerations, opportunities, and challenges. Invest Radiol. 2023;58(1):76–87.
Poh F, Xi Y, Rozen SM, Scott KM, Hlis R, Chhabra A. Role of MR neurography in groin and genital pain: ilioinguinal, iliohypogastric, and genitofemoral neuralgia. AJR Am J Roentgenol. 2019;212(3):632–43.
Del Grande F, Guggenberger R, Fritz J. Rapid musculoskeletal MRI in 2021: value and optimized use of widely accessible techniques. AJR Am J Roentgenol. 2021;216(3):704–17.
Fritz J, Guggenberger R, Del Grande F. Rapid musculoskeletal MRI in 2021: clinical application of advanced accelerated techniques. AJR Am J Roentgenol. 2021;216(3):718–33.
Lin DJ, Walter SS, Fritz J. Artificial intelligence-driven ultra-fast superresolution MRI: 10-fold accelerated musculoskeletal turbo spin echo MRI within reach. Invest Radiol. 2023;58(1):28–42.
Murthy S, Fritz J. Metal artifact reduction MRI in the diagnosis of periprosthetic hip joint infection. Radiology. 2023;306(3):e220134.
Sonnow L, Gilson WD, Raithel E, Nittka M, Wacker F, Fritz J. Instrument visualization using conventional and compressed sensing SEMAC for interventional MRI at 3T. J Magn Reson Imaging. 2018;47(5):1306–15.
Fritz J, Fritz B, Thawait GK, Raithel E, Gilson WD, Nittka M, et al. Advanced metal artifact reduction MRI of metal-on-metal hip resurfacing arthroplasty implants: compressed sensing acceleration enables the time-neutral use of SEMAC. Skeletal Radiol. 2016;45(10):1345–56.
Khodarahmi I, Bonham LW, Weiss CR, Fritz J. Needle heating during interventional magnetic resonance imaging at 1.5- and 3.0-T field strengths. Invest Radiol. 2020;55(6):396–404.
Khodarahmi I, Rajan S, Sterling R, Koch K, Kirsch J, Fritz J. Heating of hip arthroplasty implants during metal artifact reduction MRI at 1.5- and 3.0-T field strengths. Invest Radiol. 2021;56(4):232–43.
Dalili D, Ahlawat S, Isaac A, Rashidi A, Fritz J. Selective MR neurography-guided anterior femoral cutaneous nerve blocks for diagnosing anterior thigh neuralgia: anatomy, technique, diagnostic performance, and patient-reported experiences. Skeletal Radiol. 2022;51(8):1649–58.
Dalili D, Isaac A, Rashidi A, Astrom G, Fritz J. Image-guided sports medicine and musculoskeletal tumor interventions: a patient-centered model. Semin Musculoskelet Radiol. 2020;24(3):290–309.
Fritz J, Niemeyer T, Clasen S, Wiskirchen J, Tepe G, Kastler B, et al. Management of chronic low back pain: rationales, principles, and targets of imaging-guided spinal injections. Radiographics. 2007;27(6):1751–71.
Fritz J, Weiss CR. The state-of-the-art of interventional magnetic resonance imaging: part 1. Top Magn Reson Imaging. 2018;27(1):1–2.
Filippiadis D, Efthymiou E, Tsochatzis A, Kelekis A, Prologo JD. Percutaneous cryoanalgesia for pain palliation: current status and future trends. Diagn Interv Imaging. 2021;102(5):273–8.
Reinpold W, Schroeder AD, Schroeder M, Berger C, Rohr M, Wehrenberg U. Retroperitoneal anatomy of the iliohypogastric, ilioinguinal, genitofemoral, and lateral femoral cutaneous nerve: consequences for prevention and treatment of chronic inguinodynia. Hernia. 2015;19(4):539–48.
Rab M, Ebmer J, Dellon AL. Anatomic variability of the ilioinguinal and genitofemoral nerve: implications for the treatment of groin pain. Plast Reconstr Surg. 2001;108(6):1618–238.
Anloague PA, Huijbregts P. Anatomical variations of the lumbar plexus: a descriptive anatomy study with proposed clinical implications. J Man Manip Ther. 2009;17(4):e107–14.
Daniels SP, Viers CD, Blaichman JI, Ross AB, Tang JY, Lee KS. US-guided musculoskeletal interventions of the body wall and core with MRI and US correlation. Radiographics. 2021;41(7):2011–28.
Cesmebasi A, Yadav A, Gielecki J, Tubbs RS, Loukas M. Genitofemoral neuralgia: a review. Clin Anat. 2015;28(1):128–35.
Bonham LW, Herati AS, McCarthy EF, Dellon AL, Fritz J. Diagnostic and interventional magnetic resonance neurography diagnosis of brachytherapy seed-mediated pudendal nerve injury: a case report. Transl Androl Urol. 2020;9(3):1442–7.
Fritz J, Dellon AL, Williams EH, Belzberg AJ, Carrino JA. 3-Tesla high-field magnetic resonance neurography for guiding nerve blocks and its role in pain management. Magn Reson Imaging Clin N Am. 2015;23(4):533–45.
Fritz J, Fritz B, Dellon AL. Sacrotuberous ligament healing following surgical division during transgluteal pudendal nerve decompression: a 3-Tesla MR neurography study. Plos One. 2016;11(11):e0165239.
Storlie NR, Abbasi H. Self-reported female orgasm following serial sacroiliac joint injections. Cureus. 2021;13(7):e16737.
Labat JJ, Riant T, Robert R, Amarenco G, Lefaucheur JP, Rigaud J. Diagnostic criteria for pudendal neuralgia by pudendal nerve entrapment (Nantes criteria). Neurourol Urodyn. 2008;27(4):306–10.
Lefaucheur JP, Labat JJ, Amarenco G, Herbaut AG, Prat-Pradal D, Benaim J, et al. What is the place of electroneuromyographic studies in the diagnosis and management of pudendal neuralgia related to entrapment syndrome? Neurophysiol Clin. 2007;37(4):223–8.
Fritz J, Chhabra A, Wang KC, Carrino JA. Magnetic resonance neurography-guided nerve blocks for the diagnosis and treatment of chronic pelvic pain syndrome. Neuroimaging Clin N Am. 2014;24(1):211–34.
Fritz J, Bizzell C, Kathuria S, Flammang AJ, Williams EH, Belzberg AJ, et al. High-resolution magnetic resonance-guided posterior femoral cutaneous nerve blocks. Skeletal Radiol. 2013;42(4):579–86.
Joshi DH, Thawait GK, Del Grande F, Fritz J. MRI-guided cryoablation of the posterior femoral cutaneous nerve for the treatment of neuropathy-mediated sitting pain. Skeletal Radiol. 2017;46(7):983–7.
Feigl GC, Dreu M, Ulz H, Breschan C, Maier C, Likar R. Susceptibility of the genitofemoral and lateral femoral cutaneous nerves to complications from lumbar sympathetic blocks: is there a morphological reason? Br J Anaesth. 2014;112(6):1098–104.
Fritz J, Zolnoun D, Lee DA. Anatomic variability of the lateral femoral cutaneous nerve: Value of 3T MRI in identifying anomaly for surgical intervention. Microsurgery. 2017;37(2):165–8.
Dalili D, Ahlawat S, Rashidi A, Belzberg AJ, Fritz J. Cryoanalgesia of the anterior femoral cutaneous nerve (AFCN) for the treatment of neuropathy-mediated anterior thigh pain: anatomy and technical description. Skeletal Radiol. 2021;50(6):1227–36.
Kapural L, Naber J, Neal K, Burchell M. Cooled radiofrequency ablation of the articular sensory branches of the obturator and femoral nerves using fluoroscopy and ultrasound guidance: a large retrospective study. Pain Physician. 2021;24(5):E611–7.
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Dalili, D., Isaac, A. & Fritz, J. Selective MR neurography–guided lumbosacral plexus perineural injections: techniques, targets, and territories. Skeletal Radiol 52, 1929–1947 (2023). https://doi.org/10.1007/s00256-023-04384-7
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DOI: https://doi.org/10.1007/s00256-023-04384-7