Lumbosacral plexus and pudendal nerve magnetic resonance tractography: A systematic review of the clinical applications for pudendal neuralgia

Diffusion tensor imaging (DTI) is commonly used to establish three-dimensional mapping of white-matter bundles in the supraspinal central nervous system. DTI has also been the subject of many studies on cranial and peripheral nerves. This non-invasive imaging technique enables virtual dissection of nerves in vivo and provides specific measurements of microstructural integrity. Adverse effects on the lumbosacral plexus may be traumatic, compressive, tumoral, or malformative and thus require dedicated treatment. DTI could lead to new perspectives in pudendal neuralgia diagnosis and management.

We performed a systematic review of all articles or posters reporting results and protocols for lumbosacral plexus mapping using the DTI technique between January 2011 and December 2023.

Twenty-nine articles published were included. Ten studies with a total of 351 participants were able to track the lumbosacral plexus in a physiological context and 19 studies with a total of 402 subjects tracked lumbosacral plexus in a pathological context. Tractography was performed on a 1.5T or 3T MRI system. DTI applied to the lumbosacral plexus and pudendal nerve is feasible but no microstructural normative value has been proposed for the pudendal nerve. The most frequently tracking parameters used in our review are: 3T MRI, b-value of 800 s/mm², 33 directions, 3 × 3 × 3 mm³, AF threshold of 0.1, minimum fiber length of 10 mm, bending angle of 30°, and 3DT2 TSE anatomical resolution.

Increased use of DTI could lead to new perspectives in the management of pudendal neuralgia due to entrapment syndrome, whether at the diagnostic, prognostic, or preoperative planning level.

Prospective studies of healthy subjects and patients with the optimal acquisition parameters described above are needed to establish the accuracy of MR tractography for diagnosing pudendal neuralgia and other intrapelvic nerve entrapments.