Laparoscopic Catheter Implantation for Targeted Therapy Delivery in the Treatment of Pudendal Neuralgia and Other Intrapelvic Causes Of Neuropathic Pain

Video Objective To describe the technique and propose a tentative care pathway for the use of the targeted delivery of ropivacaine via implanted catheter to alleviate post-decompression neuropathic pain in patients with intrapelvic nerve entrapments (INE) in four successful initial cases. Setting Tertiary care center: specialized Neuropelveology center; this video features an initial proof-of-concept case series. Interventions Despite the high success rate of laparoscopic neuronavigation (LANN) in the surgical treatment of INE, 52% of patients experience residual pain, likely resulting from axon demyelination and Schwann cell degeneration. During axonal injury, sodium channels are upregulated, resulting in a massive influx of sodium, causing neuralgia, mechanosensitivity, and hyperalgesia. Genetic/pharmacologic blockade of these channels has neuroprotective and analgesic effects. Building on these insights, we hypothesized that the inhibition of sodium channels with ropivacaine in the entrapped nerve may alleviate post-decompression pain in patients undergoing LANN. Four patients (one male, three female) diagnosed with INE in our Neuropelveology clinic in Sao Paulo and undergoing LANN detrapment were included. The first three cases had a catheter implanted at the site where the INE was relieved; the catheter was connected to a medication pump or a subcutaneous port. The fourth case was a salvage procedure, in which the patient had failed to experience pain relief following one prior hip replacement, one hip prosthesis revision, and one previous LANN detrapment of the intrapelvic portion of the sciatic nerve. Optimal pain control was obtained in all the four patients. A proposed care pathway for INE is presented and discussed. Conclusion Preliminary observations indicate that the targeted delivery of ropivacaine via implanted catheter and pump/port may effectively control post-decompression neuropathic pain and completely obviate the use of opioid analgesics without the risk of dependence or cognitive side effects.