BACKGROUND AND OBJECTIVES: En bloc sacrectomy is associated with sacral root transection causing loss of urinary bladder, rectum, and sexual function. The aim of the study was to determine the position of the pudendal branches (sensorimotor) and pelvic splanchnic nerves (parasympathetic) on the sacral roots relative to the sacrum, and the minimal and maximal defects in the sacral roots that can be reconstructed by grafting after various types of sacrectomy. METHODS: Five cadaveric pelves were dissected bilaterally. The lengths and widths of the S1-S4 roots and their branches were measured. Then, the minimal and maximal defects between the proximal and distal stumps of the sacrificed roots were measured following 3 models of sacrectomy (below S2, below S1, and total sacrectomy). RESULTS: The mean distance of the splanchnic nerves from the S2 and S3 anterior sacral foramina was 17.7 ± 7.3 and 23.6 ± 11.1 mm, respectively, and the mean distance of the pudendal S2 and S3 branches was 36.8 ± 13.7 and 30.2 ± 10.8 mm, respectively. The mean widths of the S2 and S3 roots were 9.3 ± 1.9 and 5.4 ± 1.2 mm, respectively. The mean maximal defects in S2 and S3 roots after various types of sacrectomies were between 61.8 ± 16.3 and 100.7 ± 14.3 mm and between 62.7 ± 20.2 and 84.7 ± 25.1 mm, respectively. There were no statistically significant differences between sides or sexes for all obtained measurements. CONCLUSION: The reconstruction of the S2-S3 roots is anatomically feasible after partial or total sacrectomies in which the resection of the soft tissue does not extend further than approximately 1.5 to 2 cm ventrally from the sacrum.

Center for Endoscopic Surgical and Clinical Anatomy 2nd Faculty of Medicine Charles University Prague Czech Republic

Department of Anatomy 2nd Faculty of Medicine Charles University Prague Czech Republic

Department of Plastic Surgery Oxford University Hospitals NHS Foundation Trust Oxford UK

Department of Spinal Surgery Oxford University Hospitals NHS Foundation Trust Oxford UK

Nuffield Department of Clinical Neuroscience University of Oxford Oxford UK

Nuffield Department of Surgical Sciences University of Oxford Oxford UK

See more in PubMed

Zoccali C, Skoch J, Patel AS, Walter CM, Maykowski P, Baaj AA. Residual neurological function after sacral root resection during en-bloc sacrectomy: a systematic review. Eur Spine J. 2016;25(12):3925-3931.

Payer M. Neurological manifestation of sacral tumors. Neurosurg Focus. 2003;15(2):e1.

Lam J, deSouza RM, Laycock J, et al. Patient-reported bladder, bowel, and sexual function after cauda equina syndrome secondary to a herniated lumbar intervertebral disc. Top Spinal Cord Inj Rehabil. 2020;26(4):290-303.

Armas-Salazar A, Garcia-Jeronimo AI, Villegas-Lopez FA, Navarro-Olvera JL, Carrillo-Ruiz JD. Clinical outcomes report in different brachial plexus injury surgeries: a systematic review. Neurosurg Rev. 2022;45(1):411-419.

Nichols DS, Fenton J, Cox E, et al. Surgical interventions for lumbosacral plexus injuries: a systematic review. Plast Reconstr Surg Glob Open. 2022;10(8):e4436.

Gomez-Amaya SM, Barbe MF, de Groat WC, et al. Neural reconstruction methods of restoring bladder function. Nat Rev Urol. 2015;12(2):100-118.

Zheng G, Xiao S, Zhang Y, Zhang X, Wang Z, Wang Y. A case study using total en bloc sacrectomy and neuroanastomosis for sacral tumor. Eur Spine J. 2014;23(9):1963-1967.

Berra LV, Armocida D, Palmieri M, et al. Sacral nerves reconstruction after surgical resection of a large sacral chordoma restores the urinary and sexual function and the anal continence. Neurospine. 2022;19(1):155-162.

Baader B, Herrmann M. Topography of the pelvic autonomic nervous system and its potential impact on surgical intervention in the pelvis. Clin Anat. 2003;16(2):119-130.

Day EP, Johnston BR, Bazarek SF, et al. Anatomical location of the vesical branches of the inferior hypogastric plexus in human cadavers. Diagnostics (Basel). 2024;14(8):794.

Yoshimura N, Chancellor MB. Neurophysiology of lower urinary tract function and dysfunction. Rev Urol. 2003;5(Suppl 8):S3–S10.

Dekutoski MB, Clarke MJ, Rose P, et al. Osteosarcoma of the spine: prognostic variables for local recurrence and overall survival, a multicenter ambispective study. J Neurosurg Spine. 2016;25(1):59-68.

Koch K, Varga PP, Ronai M, Klemencsics I, Szoverfi Z, Lazary A. Complication pattern of sacral primary tumor resection: a study on the risk factors of surgical site infection and bowel or bladder dysfunction and their associations with length of hospital stay. Asian Spine J. 2023;17(5):851-861.

Ye F, Su H, Xiong H, et al. Applied anatomy of female pelvic plexus for nerve-sparing radical hysterectomy(NSRH). BMC Womens Health. 2023;23(1):533.

Lin H, Xu Z, Liu Y, Chen A, Hou C. The effect of severing L6 nerve root of the sacral plexus on lower extremity function: an experimental study in rhesus monkeys. Neurosurgery. 2012;70(1):170-177; discussion 177.

Zhu L, Zhang F, Yang D, Chen A. The effect of severing a normal S1 nerve root to use for reconstruction of an avulsed contralateral lumbosacral plexus: a pilot study. Bone Joint J. 2015;97-B(3):358-365.

Morozov A, Barret E, Veneziano D, et al. A systematic review of nerve-sparing surgery for high-risk prostate cancer. Minerva Urol Nephrol. 2021;73(3):283-291.

Zhu L, Zhou ZB, Shen D, Chen AM. Ipsilateral S2 nerve root transfer to pudendal nerve for restoration of external anal and urethral sphincter function: an anatomical study. Scientific Rep. 2019;9(1):13993.

Tiwari E, Porreca DS, Braverman AS, et al. Nerve transfer for restoration of lower motor neuron-lesioned bladder, urethral and anal sphincter function. Part 4: effectiveness of the motor reinnervation. Am J Physiol Regul Integr Comp Physiol. 2024;326(6):R528-R551.

Barbe MF, Braverman AS, Salvadeo DM, et al. Bladder reinnervation by somatic nerve transfer to pelvic nerve vesical branches does not reinnervate the urethra. Neurourol Urodyn. 2020;39(1):181-189.

Gomez-Amaya SM, Barbe MF, Brown JM, et al. Bladder reinnervation using a primarily motor donor nerve (femoral nerve branches) is functionally superior to using a primarily sensory donor nerve (genitofemoral nerve). J Urol. 2015;193(3):1042-1051.

Souza Trindade JC, Viterbo F, Petean Trindade A, Favaro WJ, Trindade-Filho JCS. Long-term follow-up of treatment of erectile dysfunction after radical prostatectomy using nerve grafts and end-to-side somatic-autonomic neurorraphy: a new technique. BJU Int. 2017;119(6):948-954.

Tuite GF, Polsky EG, Homsy Y, et al. Lack of efficacy of an intradural somatic-to-autonomic nerve anastomosis (Xiao procedure) for bladder control in children with myelomeningocele and lipomyelomeningocele: results of a prospective, randomized, double-blind study. J Neurosurg Pediatr. 2016;18(2):150-163.

Baradaran A, El-Hawary H, Efanov JI, Xu L. Peripheral nerve healing: so near and yet so far. Semin Plast Surg. 2021;35(3):204-210.

Millesi H. Techniques for nerve grafting. Hand Clin. 2000;16(1):73-91, viii.

Riedl O, Koemuercue F, Marker M, Hoch D, Haas M, Deutinger M. Sural nerve harvesting beyond the popliteal region allows a significant gain of donor nerve graft length. Plast Reconstr Surg. 2008;122(3):798-805.

Dong RP, Zhang Q, Yang LL, Cheng XL, Zhao JW. Clinical management of dural defects: a review. World J Clin Cases. 2023;11(13):2903-2915.

DeLaney TF, Liebsch NJ, Pedlow FX, et al. Long-term results of Phase II study of high dose photon/proton radiotherapy in the management of spine chordomas, chondrosarcomas, and other sarcomas. J Surg Oncol. 2014;110(2):115-122.

Chhabra AM, Rice SR, Holtzman A, et al. Clinical outcomes and toxicities of 100 patients treated with proton therapy for chordoma on the proton collaborative group prospective registry. Radiother Oncol. 2023;183:109551.

Gidley PW, Herrera SJ, Hanasono MM, et al. The impact of radiotherapy on facial nerve repair. Laryngoscope. 2010;120(10):1985-1989.