Definition and Overview

A neurectomy is a surgical procedure wherein certain nerves are blocked or severed to relieve severe chronic pain and cramping in patients with endometriosis, adenomyosis, or vertigo. The procedure is used as the last resort if all other treatment methods, such as the use of NSAIDs or non-steroidal anti-inflammatory pain relievers, fail to provide long-lasting pain relief.

Who Should Undergo and Expected Results

There are two types of a neurectomy, both of which are performed to relieve pain symptoms. These are:

  • Presacral neurectomy
  • Vestibular neurectomy
    A presacral neurectomy is beneficial for all patients suffering from conditions that cause lower abdominal and pelvic pain. Some examples are:

  • Endometriosis – This condition can cause severe abdominal cramping/dysmenorrhea, painful sexual intercourse, pain during urination and when moving bowels, and excessive bleeding during and in between periods. It is also one of the most common causes of female infertility. Other symptoms include diarrhea, constipation, bloating, nausea, and fatigue.

  • Adenomyosis – This is a condition wherein the endometrial tissue develops in the muscular wall of the uterus.

Although a hysterectomy is commonly prescribed for the treatment of endometriosis and adenomyosis, a neurectomy is actually more effective. This is because even when the uterus is removed, the endometrial tissue sometimes gets left behind in other abdominal organs, such as the bowels or bladder. As a result, the patient will still experience pain and cramping. A neurectomy, however, completely blocks the nerves that go not just directly to the uterus but also around it.

A vestibular neurectomy, on the other hand, is performed on patients who suffer from chronic vertigo and conditions that cause it. One such example is Meniere’s disease, a condition that affects the inner ear. It is associated with frequent attacks of tinnitus and vertigo. When left untreated, it can cause progressive hearing loss.

How Does the Procedure Work?

Both types of neurectomy are performed by a neurosurgeon in a hospital operating room, with the patient under general anaesthesia.

It is normal for surgeons to conduct a test nerve block using a local anesthetic before the procedure. This helps to determine whether the procedure is likely to be effective in relieving the patient’s pain and whether some side effects will occur.

Presacral neurectomy

Due to its location, the pain affecting the pelvic area does not respond well to other non-invasive treatments. Thus, a lot of patients benefit from a presacral neurectomy.

In the past, the surgery involves making a large abdominal incision to access the pelvic area. Now, however, advanced surgical techniques allow surgeons to perform the procedure through a laparoscopy or using robotic technology, making it significantly less invasive. There have been no major differences observed between the long-term benefits of an open incision and laparoscopic surgery, with the latter reported to effectively relieve pain by an average of 90%. Also, the laparoscopic approach helps the patient recover faster and suffer less post-surgical discomfort. Patients who undergo traditional neurectomy may take six weeks to recover fully while those who choose the laparoscopic approach are often fully recovered by the second week following the procedure.

The procedure begins with the doctor making three small cuts just under the navel where special surgical tools are inserted. These include a laparoscope, a thin tube with a scope or camera attached at one end. Through these tools, the surgeon determines the exact point where the nerve tissue can be disrupted. This is usually at the sacral promontory or the point where the tailbones and the spine coincide.

Vestibular neurectomy

In a vestibular neurectomy, the surgeon accesses the vestibular nerve, also known as the balance nerve, and severs it. Since the vestibular nerve is easily accessible, the procedure is performed without affecting the cochlear nerve or the hearing nerve that runs from the ear going to the brain. Thus, it can relieve vertigo without affecting the patient’s hearing.

During a vestibular neurectomy, the patient is asked to lie supine with the head turned to the side and the affected ear on the upright side. The surgeon then makes an incision from the zygomatic root going to the temporal area. Once he gains access to the vestibular nerve, he cuts it at the farthest point away from the vestibular crest. In most cases, the Scarpa’s ganglion is also removed.

Possible Risks and Complications

There are various risks involved in undergoing a neurectomy. In a presacral neurectomy, there is some risk of nerve and blood vessel damage since the uterus is surrounded by several major blood vessels. Thus, surgical precision is extremely important.

Less serious complications include:

  • Urinary retention – This refers to the inability to urinate, a side effect expected to resolve less than a week after the procedure
  • Constipation – This usually resolves without treatment after two months

A vestibular neurectomy also comes with certain risks, such as:

  • Hearing loss
  • Dizziness
  • Tinnitus
  • Facial muscle weakness
  • Infection
  • Spinal fluid leakage

Patients are given strict instructions before and after the procedure to reduce these risks.

References:

  • Endolymphatic Sac Shunt, Labyrinthectomy and Vestibular Nerve Section in Meniere’s Disease. Meniere’s Disease. Otolaryngological Clinics of North America. October 2010. 43:5.

  • Chapter 35-Middle cranial fossa-vestibular neurectomy; Chapter 36-Retrolabyrinthine and rectosigmoid vestibular neurectomy. Otologic Surgery-Brackmann, Shelton and Arriaga. 3rd Edn.

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