Targeting nerve safety: an innovative era in minimally invasive sciatic and sacral surgery with real-time neuromonitoring for sensorimotor protection and foot drop prevention

BACKGROUND: This study assesses a novel laparoscopic decompression technique supported by real-time multimodal neuromonitoring to improve surgical safety in sciatic and sacral nerve entrapments and to prevent motor deficits such as foot drop. The approach aims to address suspected neurovascular conflicts along the pelvic sidewall and sacral plexus. METHODS: A prospective observational study was performed between June 2023 and April 2024. Ten female patients with chronic pelvic neuropathic pain (including sciatica, pudendal neuralgia, and/or dyspareunia) unresponsive to at least one year of conservative treatment underwent laparoscopic nerve exploration and decompression of suspected pelvic nerve entrapments. Multimodal neuromonitoring involved transcranial motor evoked potentials (TcMEP), somatosensory evoked potentials (SEP), bulbocavernosus reflex (BCR), free-run EMG, and triggered EMG. Changes in neuromonitoring were recorded and correlated with postoperative neurological examinations and pain outcomes over a period of up to 12 months. RESULTS: Neurovascular conflict was identified in seven out of 10 patients (70%). After decompression, TcMEP amplitudes improved, BCR responses increased, and SEP signals remained stable, supporting the preservation of sensory pathways. No patient experienced new postoperative neurological deficits. Pain scores decreased significantly, and improvements were maintained throughout follow-up, with meaningful gains in daily functioning and a reduction in neuropathic symptom burden. CONCLUSIONS: Laparoscopic nerve decompression assisted by real-time multimodal neuromonitoring appears feasible and safe for selected patients with refractory pelvic neuropathic pain. In this preliminary series, neuromonitoring provided actionable intraoperative feedback that may help optimise the extent of decompression while minimising the risk of motor impairment. These data support further multicentre evaluation to confirm efficacy, refine indications, and standardise monitoring-guided algorithms.