Fig 1.
Three-dimensional 3-Tesla MR Neurography of the healed sacrotuberous ligament following complete division and grafting.
A: Sagittal oblique multiplanar intermediate-weighted MR image demonstrates continuity of the healed sacrotuberous ligament (STL) (white arrow) after previous complete division, indicative of spontaneous healing. The gray arrow indicates the healed division site. B: Sagittal oblique multiplanar intermediate-weighted MR images demonstrate continuity of a STL allograft (white arrow). C: Two-dimensional 3-Tesla MR Neurography of the healed STL following complete division and grafting, at level of Alcock’s canal. Axial intermediate-weighted MR image demonstrates the anteroposterior dimensions of the healed STL (white arrow) after previous complete division. D: Axial intermediate-weighted MR image the anteroposterior dimensions of the STL allograft (white arrow).
Fig 2.
Patient prone. Note scars from previous spinal cord 17 stimulator surgery. The right and left asterisk is the site of the tender pudendal 18 nerve at the posterior border of the sacrotuberous ligament.
Fig 3.
Pre-operative pudendal nerve 3T MR neurography.
Axial high spatial resolution T2-weighted MR image with fat suppression demonstrate abnormally hyperintense and thickened pudendal nerves bilaterally (arrows).
Fig 4.
Intra-operative photographs of sacrotuberous ligament and pudendal nerve, right side, with patient in prone position.
A: Bilateral markings to indicate the sacrotuberous ligament (STL) (vertical lines) connecting the sacrum (dashed lines) to the ischial tuberosity (dashed circles), with the proposed angled incision from the ischiorectal fossa (arrows), then crossing the STL. B: The intact STL (arrow) is noted between the gluteus maximus muscle fibers. C: A blue vessel loop is about the pudendal nerve (arrow) exiting the STL. D: The blackened, cauterized, edges of the STL (arrows) are separated about 1.5 to 2.0 cm after division of the ligament.
Fig 5.
Post-operative pudendal nerve three-dimensional 3-Tesla MR Neurography of the sacrotuberous ligament 3 months (A) and 8 months (B) following sacrotuberous ligament division.
A: Sagittal oblique multiplanar T2-weighted MR images with fat suppression demonstrate the continuous left sacrotuberous ligament (STL) (asterisks) with healing division site (white arrow). The gray arrow demonstrates the pudendal nerve subjacent to the STL. B: Sagittal oblique multiplanar T2-weighted MR images with fat suppression demonstrate the continuous right sacrotuberous ligament (STL) (asterisks) with healing division site (white arrow). The gray arrow demonstrates the pudendal nerve subjacent to the STL. C: Sagittal oblique multiplanar intermediate-weighted MR images demonstrate the continuous left STL (asterisks) with healed division site (white arrow). The gray arrow demonstrates the pudendal nerve subjacent to the STL. D: Sagittal oblique multiplanar intermediate-weighted MR images demonstrate the continuous left STL (asterisks) with healed division site (white arrow). The gray arrow demonstrates the pudendal nerve subjacent to the STL.
Fig 6.
Post-operative pudendal nerve 3T MR neurography.
Axial high spatial resolution T2-weighted MR image with fat suppression demonstrate near complete resolution of pudendal nerve engorgement (arrows) and decreased signal hyperintensity, consistent with interval improvement of symptoms.