Intraoperative Nerve Stimulation as an Approach for the Surgical Treatment of Genitofemoral Neuralgia

Abstract

BACKGROUND Genitofemoral neuralgia is a pain syndrome that involves injury to the genitofemoral nerve and is frequently iatrogenic. We report intraoperative nerve localization using ultrasound, nerve stimulation, and the cremasteric reflex in the surgical treatment of genitofemoral neuralgia. CASE REPORT A 49-year-old man with a history of extracorporeal membrane oxygenation with cannulation sites in bilateral inguinal regions presented with right groin numbness and pain following decannulation. His symptoms corresponded to the distribution of the genitofemoral nerve. He had a Tinel's sign over the midpoint of his inguinal incision. A nerve block resulted in temporary resolution of his symptoms. Due to the presence of a pacemaker, peripheral nerve neuromodulation was contraindicated. He underwent external neurolysis and neurectomy of the right genitofemoral nerve. Following direct stimulation and ultrasound for localization, the nerve was further localized intraoperatively using nerve stimulation with monitoring for the presence of the cremasteric reflex. At his 1-month postoperative visit, his right medial thigh pain had resolved and his right testicular pain 50% improved; his residual pain continued to improve at last evaluation 3 months after surgery. CONCLUSIONS We report the successful use of nerve stimulation and the cremasteric reflex to aid in identification of the genitofemoral nerve intraoperatively for the treatment of genitofemoral neuralgia.

Figure 1.

(A) Using ultrasound guidance, an arterial line marker was placed to mark the location of the genitofemoral nerve at the level of the right groin. (B) The skin entry site (black arrow) was consistent with the midpoint of the prior ECMO incision and the site of his Tinel’s sign on examination.

Figure 2.

The right genital branch of the genitofemoral nerve is isolated and shown looped above forceps (*) following intraoperative nerve stimulation and observation of the cremasteric reflex. The nerve was identified overlying the spermatic cord (a solid black line is shown parallel to its location). A ground electrode is shown under the body of the forceps (black arrow). The right scrotum, which is not included in this intraoperative photo, was located just beyond the solid arrowhead at the inferior and medial aspect of the surgical field.