Integrating tractography in pelvic surgery: a proof of concept
Abstract
Objective: To show the interest of tractography in pelvic surgery by a demonstrative case of neurofibroma re-
sected by robotic assisted laparoscopy.
Summary background data: Although diffusion tensor magnetic resonance imaging, along with tractography
algorithms, is increasingly included in image guided neurosurgery methods, it is less frequently used for the
peripheral nervous system such as the pelvic sacral plexus. We report one observation demonstrating the interest
of such image data for pelvic surgery.
Methods: A 12-years-old girl with neurofibromatosis presented with a growing left pelvic neurofibroma on re-
peated pelvic MRI with an increased SUV (2.83) on PET scan. A diffusion tensor pelvic MRI was performed
before and after robotically assisted tumoral resection, and a tractography algorithm was applied on both
images.
Results: The pre-operative tractogram showed the nervous nature of the tumor in close contact with the left
sacral plexus. Section of a nerve trunk encased in the neurofibroma was mandatory for the resection and well
documented by the 3D enhanced vision provided by the robot. Post-operatively, the patient showed a slight
paresthesia and dysesthesia of the left leg calf and of the plantar vault (left S2 territory), without any motor
deficit. The post-operative tractogram showed a thinning of the left S2 sacral root and the disappearance of right
aberrant nervous tracts.
Conclusions: This clinical case validates the ability of pelvic tractography to deliver a proper imaging of the
sacral nervous network and emphasizes the potential usefulness of this approach in pelvic surgery management,
with perspectives of image-guided surgery.