Anatomy of the superior hypogastric plexus and its relevance to anterior lumbar interbody fusion

J Neurosurg Spine 43:19–25, 2025

This cadaveric study details the anatomy of the superior hypogastric plexus (SHP) at L5–S1, its variations, and implications for anterior lumbar interbody fusion (ALIF). The authors recommend left-sided SHP retraction to minimize nerve injury and retrograde ejaculation; if unfeasible, midline splitting and lateral mobilization are advised.

• The study examined the anatomy of the superior hypogastric plexus (SHP) at the L5–S1 level and its relevance to anterior lumbar interbody fusion (ALIF) surgery.

• Injury to the SHP during ALIF can cause retrograde ejaculation (RE) in males and sexual dysfunction in females.

• The SHP typically overlays the midline at L5–S1 with a slight leftward shift and is covered by connective tissue beneath the peritoneum.

• Three morphological types of SHP were found: single cord, plexiform, and fiber; the plexus divides into hypogastric nerves below the aortic bifurcation.

• Retraction of the SHP to the left side is generally more feasible (up to 15.3 mm) than to the right (up to 5.3 mm); left-sided retraction is recommended.

• If left retraction is not possible, splitting the SHP at the midline and retracting both components laterally is advised.

• Careful SHP mobilization and avoidance of electrocautery are crucial to reduce risk of RE and sexual dysfunction in ALIF patients.

• The findings highlight the importance of detailed SHP anatomy knowledge for safer ALIF, especially with minimally invasive approaches.