What is the management of lumbosacral plexopathy?

Management of Lumbosacral Plexopathy

The management of lumbosacral plexopathy requires MRI of the lumbosacral plexus as the primary diagnostic tool, followed by etiology-specific treatment that may include pain management with pregabalin for neuropathic pain, immunotherapy for inflammatory causes, and surgical intervention for compressive lesions. 1, 2

Diagnostic Approach

Initial Imaging

• MRI of the lumbosacral plexus is the preferred imaging modality due to its superior soft-tissue contrast and ability to visualize intraneural anatomy in cases of nontraumatic lumbosacral plexopathy 1
• MRI with and without IV contrast is recommended as it can detect and characterize various etiologies of lumbosacral plexopathy 1
• Imaging should be delayed approximately 1 month following trauma to allow for resolution of blood and soft-tissue edema 1
• Standard MRI of the pelvis without dedicated plexus imaging is not supported by evidence for evaluating lumbosacral plexopathy 1

Electrodiagnostic Studies

• Electrodiagnostic testing helps distinguish plexopathy from radiculopathy and confirms abnormalities across multiple nerve distributions 2, 3
• There is a significant correlation between nerve signal abnormality on MRI and findings of active radiculopathy on electromyography 1

Treatment Based on Etiology

Neuropathic Pain Management

• Pregabalin has demonstrated efficacy for neuropathic pain, including that associated with spinal cord injury, with dosages ranging from 150-600 mg/day 4
• Patients may experience pain reduction as early as week 1 of treatment, which can persist throughout therapy 4
• Other medications for neuropathic pain include antidepressants, opioids, and other anticonvulsants 5

Inflammatory/Immune-Mediated Plexopathy

• For idiopathic lumbosacral plexopathy (also known as lumbosacral plexitis), treatment typically includes analgesics, neuropathic pain medications, and short-term corticosteroids 5
• In severe cases, long-term corticosteroids and immunosuppressive agents may be required 5
• Intravenous immunoglobulin (IVIg) has shown dramatic improvement in some cases of postoperative lumbosacral plexopathy 6
• However, there is currently no evidence from randomized controlled trials supporting any specific immunotherapy for idiopathic lumbosacral plexopathy 7

Tumor-Related Plexopathy

• For plexopathy secondary to metastatic disease, radiation therapy and/or systemic chemotherapy may provide relief of pain and improvement of neurologic deficits 8
• CT of the pelvis is reported to be the most accurate method for documenting tumor involvement of the lumbosacral plexus 8

Traumatic Plexopathy

• Penetrating and open injuries to the plexus often require early surgical exploration 1
• Blunt and closed injuries may be managed nonoperatively or surgically depending on the location and severity 1
• It is crucial to determine if a nerve is completely ruptured (requiring early operative management) or stretched but intact 1

Rehabilitation

• Physical therapy and rehabilitation are important components of management for all types of lumbosacral plexopathy 5, 3

Clinical Monitoring and Prognosis

• Recovery from idiopathic lumbosacral plexopathy is typically slow (6 to 36 months) and often incomplete 5
• Regular follow-up is essential to monitor progression and adjust treatment accordingly 3
• Approximately 71% of patients with lumbosacral plexopathy have a change in management resulting from MRI findings, highlighting the importance of accurate diagnosis 1

Common Pitfalls to Avoid

• Failing to distinguish between plexopathies and radiculopathies, which typically follow a single dermatome distribution 2
• Not recognizing that lateral disc herniations may cause plexopathy that is not detected on standard lumbar spine MRI 2
• Delaying appropriate imaging in traumatic cases; imaging should be performed approximately 1 month after injury 1