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Surgery for Meralgia Paresthetica

  • Author: Ira Kornbluth, MD, MA, FAAPMR; Chief Editor: William L Jaffe, MD  more...
 
Updated: Jun 19, 2015
 

Background

Meralgia paresthetica is a common but underrecognized condition that is manifested by pain, numbness, and tingling in the anterior and lateral parts of the thigh. Bernhardt first described symptoms corresponding to meralgia paresthetica in 1878. In 1885, Hagar correctly suggested that lateral femoral cutaneous nerve compression was the source of this symptom complex; surgical correction of meralgia paresthetica also dates back to Hagar at this time. (See the image below.) A decade later, Roth coined the term meralgia paresthetica from the Greek words meros (thigh) and algos (pain). Anecdotally, Sigmund Freud is said to have diagnosed himself and his son with this condition.

The lateral femoral cutaneous nerve provides senso The lateral femoral cutaneous nerve provides sensory innervation to the anterolateral thigh. Courtesy of Essentials of Physical Medicine and Rehabilitation, Hanley & Belfus Publishers, 2001, used with permission.

 

Entrapment of the lateral femoral cutaneous nerve results in pain and sensory abnormalities in the anterolateral thigh. The lateral femoral cutaneous nerve is a pure sensory nerve that typically receives its innervation from the L2-3 lumbar nerve roots and includes sudomotor fibers. Sudomotor changes, such as mild sweating in the nerve distribution, may be evident, although this is uncommon. Because the lateral femoral cutaneous nerve is purely sensory, no associated motor or reflex findings should be present.[1, 2]

As physicians and patients become increasingly aware of meralgia paresthetica and as new medications and surgical techniques develop, the diagnosis and initiation of a treatment plan will be made more rapidly. Patients and physicians alike would benefit from an algorithm guiding diagnosis and treatment.

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Anatomy

The lateral femoral cutaneous nerve typically arises from lumbar nerve roots, specifically those at the L2-3 levels, although the nerve can arise from different combinations of the L1-3 nerve roots. The lateral femoral cutaneous nerve pierces the psoas, travels across the iliacus toward the anterior superior iliac spine, and then enters the anterolateral thigh by passing under, through, or above the inguinal ligament.

In most individuals, the lateral femoral cutaneous nerve crosses into the anterolateral thigh approximately 1 cm medial to the anterior superior iliac spine. However, the relation of the lateral femoral cutaneous nerve to the anterior superior iliac spine is quite variable. The nerve may cross into the anterolateral thigh as much as 2 cm lateral or 6 cm medial to the anterior superior iliac spine. A bifurcation into anterior and posterior divisions occurs approximately 5-12 cm below the anterior superior iliac spine.

Cadaver dissections have demonstrated that anatomic variations are also found in the origin of the lateral femoral cutaneous nerve. As many as 30% of lateral femoral cutaneous nerves may be derived partially or entirely from adjacent genitofemoral or femoral nerves.

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Pathophysiology

Along its course, the lateral femoral cutaneous nerve is vulnerable to compression at several sites. The nerve emerges from the psoas muscle, intersects with the inguinal ligament, curves around the anterior superior iliac spine, and exits from the fascia lata. Meralgia paresthetica most commonly occurs from compression of the nerve as it exits the pelvis.[3, 4]

Peripheral nerve injuries are described in terms of the nature of the insult and the associated prognosis. Thus, a compressive force results in a neuropraxic injury to the nerve, which is characterized by the loss of myelin without affecting the axon or its axonal sheath. Neuropraxic injuries have the best prognosis and may heal over hours to months, depending on the severity. Loss of the axon or its axonal sheath constitutes a more severe nerve injury and a worse prognosis for healing, because the nerve undergoes wallerian degeneration or destruction of the nerve fibers distal to the injury site.[5]

If the injury involves only the axons and spares the axonal sheath (axonotmesis), the patient may make a full, but likely slow, recovery. If the axonal sheath is affected such that the nerve is in discontinuity (neurotmesis), then the prognosis for spontaneous recovery is poor. Most commonly, compressive forces tend to result in neuropraxic injuries, and relief of the compressive force initiates the healing process.

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Etiology

Metabolic conditions, such as diabetes, alcoholism, and thyroid disorders, can contribute to the development of a neuropathy in the lateral femoral cutaneous nerve and other peripheral nerves. In most instances, the etiology of meralgia paresthetica involves excessive pressure on the nerve at various sites of possible entrapment. Pressure may be from internal causes such as obesity, pregnancy, or pelvic tumors.

There is a higher incidence of obesity in patients with meralgia paresthetica, which strongly suggests that obesity is an independent risk factor.[6] Alternatively, external causes such as tight belts worn around the waist may be identified as the culprit.[7, 8] In addition, the lateral femoral cutaneous nerve may be injured iatrogenically from local trauma during surgical procedures. Hip replacement, iliac crest bone grafting, appendectomy, inguinal lymph node dissection, aortofemoral bypass, uterine surgery, cesarean section, and quadriceps surgery have all been implicated as causative for meralgia paresthetica.

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Epidemiology

The prevalence of meralgia paresthetica has been estimated at 3 cases per 10,000 individuals, and this condition has been reported in up to 35% of patients referred for evaluation of leg discomfort. However, these symptoms are often not recognized or they may be mistaken for other conditions such as lumbar radiculopathy. In a large case series,[9] the presumptive diagnosis by the referring physician was meralgia paresthetica in 47 of 120 patients (39%). This condition has been described in toddlers and elderly persons, but most cases occur in patients aged 30-65 years. Whether a sex predominance exists is unclear. Meralgia paresthetica is usually unilateral but may be bilateral in as many as 50% of cases.

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Prognosis

The outcome of meralgia paresthetica depends largely on whether the diagnosis and treatment plan are achieved within a reasonable time frame. The prognosis from conservative management alone is quite good because the condition often is self-limited. In 277 patients treated conservatively by Williams and Trzil, 91% had satisfactory symptom relief.[10] In the worst-case scenario, patients treated conservatively had persistent symptoms such as pain, numbness, burning, hyposensitivity, and tingling in the anterolateral thigh.

Controversial issues include the efficacy of surgery and the selection of a surgical procedure. van Eerten et al[11] noted complete symptom relief in 3 of 10 patients who underwent neurolysis and in 9 of 11 patients who had a transection. Similarly, 23 of 24 patients who had a transection in Williams and Trzil's series had complete relief of their presenting symptoms. Ivins reported results for 8 patients who underwent neurolysis; 4 experienced relief of symptoms, of which 2 had recurrence of their symptoms.[12] Siu and Chandran reported results from a case series of 45 decompressive procedures in 42 patients who underwent neurolysis: 43% reported complete relief, 40% reported partial relief, and 17% reported no relief.[13]

Although transection is more likely to produce complete relief, it likely will cause permanent anesthesia of the anterolateral thigh.

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Contributor Information and Disclosures
Author

Ira Kornbluth, MD, MA, FAAPMR Managing Partner, SMART Pain Management

Ira Kornbluth, MD, MA, FAAPMR is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, Physiatric Association of Spine, Sports and Occupational Rehabilitation, American Society of Interventional Pain Physicians

Disclosure: Nothing to disclose.

Coauthor(s)

Phillip J Marone, MD, MSPH Clinical Professor, Department of Orthopedic Surgery and Department of Rehabilitation Medicine, Jefferson Medical College of Thomas Jefferson University

Phillip J Marone, MD, MSPH is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Medical Association, American Orthopaedic Society for Sports Medicine, Philadelphia County Medical Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

B Sonny Bal, MD, JD, MBA Professor, Department of Orthopedic Surgery, University of Missouri-Columbia School of Medicine

B Sonny Bal, MD, JD, MBA is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Received none from Bonesmart.org for online orthopaedic marketing and information portal; Received none from OrthoMind for social networking for orthopaedic surgeons; Received stock options and compensation from Amedica Corporation for manufacturer of orthopaedic implants; Received ownership interest from BalBrenner LLC for employment; Received none from ConforMIS for consulting; Received none from Microport for consulting.

Chief Editor

William L Jaffe, MD Clinical Professor of Orthopedic Surgery, New York University School of Medicine; Vice Chairman, Department of Orthopedic Surgery, New York University Hospital for Joint Diseases

William L Jaffe, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American College of Surgeons, Eastern Orthopaedic Association, New York Academy of Medicine

Disclosure: Received consulting fee from Stryker Orthopaedics for speaking and teaching.

Additional Contributors

Miguel A Schmitz, MD 

Miguel A Schmitz, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, Arthroscopy Association of North America, North American Spine Society

Disclosure: Nothing to disclose.

References
  1. Craig E. Lateral femoral cutaneous neuropathy. Frontera WR, Silver JK. Essentials of Physical Medicine and Rehabilitation. Boston: Hanley & Belfus; 2001. 279-82.

  2. Preston DC, Shapiro BE. Lateral femoral cutaneous neuropathy. Electromyography and Neuromuscular Disorders: Clinical-Electrophysiologic Correlations. Boston: Butterworth-Heinemann; 1997. 477.

  3. Sunderland S. Anatomical features of nerve trunks in relation to nerve injury and nerve repair. Clin Neurosurg. 1970. 17:38-62. [Medline].

  4. de Ridder VA, de Lange S, Popta JV. Anatomical variations of the lateral femoral cutaneous nerve and the consequences for surgery. J Orthop Trauma. 1999 Mar-Apr. 13(3):207-11. [Medline].

  5. Schestatsky P, Lladó-Carbó E, Casanova-Molla J, Alvarez-Blanco S, Valls-Solé J. Small fibre function in patients with meralgia paresthetica. Pain. 2008 Oct 15. 139(2):342-8. [Medline].

  6. Mondelli M, Rossi S, Romano C. Body mass index in meralgia paresthetica: a case-control study. Acta Neurol Scand. 2007 Aug. 116(2):118-23. [Medline].

  7. Fargo MV, Konitzer LN. Meralgia paresthetica due to body armor wear in U.S. soldiers serving in Iraq: a case report and review of the literature. Mil Med. 2007 Jun. 172(6):663-5. [Medline].

  8. Moucharafieh R, Wehbe J, Maalouf G. Meralgia paresthetica: a result of tight new trendy low cut trousers ('taille basse'). Int J Surg. 2008 Apr. 6(2):164-8. [Medline].

  9. Seror P, Seror R. Meralgia paresthetica: clinical and electrophysiological diagnosis in 120 cases. Muscle Nerve. 2006 May. 33(5):650-4. [Medline].

  10. Williams PH, Trzil KP. Management of meralgia paresthetica. J Neurosurg. 1991 Jan. 74(1):76-80. [Medline].

  11. van Eerten PV, Polder TW, Broere CA. Operative treatment of meralgia paresthetica: transection versus neurolysis. Neurosurgery. 1995 Jul. 37(1):63-5. [Medline].

  12. Ivins GK. Meralgia paresthetica, the elusive diagnosis: clinical experience with 14 adult patients. Ann Surg. 2000 Aug. 232(2):281-6. [Medline].

  13. Siu TL, Chandran KN. Neurolysis for meralgia paresthetica: an operative series of 45 cases. Surg Neurol. 2005 Jan. 63(1):19-23; discussion 23. [Medline].

  14. Grossman MG, Ducey SA, Nadler SS, Levy AS. Meralgia paresthetica: diagnosis and treatment. J Am Acad Orthop Surg. 2001 Sep-Oct. 9(5):336-44. [Medline].

  15. Nahabedian MY, Dellon AL. Meralgia paresthetica: etiology, diagnosis, and outcome of surgical decompression. Ann Plast Surg. 1995 Dec. 35(6):590-4. [Medline].

  16. Shimizu S. A novel approach to the diagnosis and management of meralgia paresthetica. Neurosurgery. 2008 Oct. 63(4):E820. [Medline].

  17. Suh DH, Kim DH, Park JW, Park BK. Sonographic and electrophysiologic findings in patients with meralgia paresthetica. Clin Neurophysiol. 2013 Jul. 124 (7):1460-4. [Medline].

  18. Chhabra A, Del Grande F, Soldatos T, Chalian M, Belzberg AJ, Williams EH, et al. Meralgia paresthetica: 3-Tesla magnetic resonance neurography. Skeletal Radiol. 2013 Jun. 42 (6):803-8. [Medline].

  19. Park BJ, Joeng ES, Choi JK, Kang S, Yoon JS, Yang SN. Ultrasound-guided lateral femoral cutaneous nerve conduction study. Ann Rehabil Med. 2015 Feb. 39 (1):47-51. [Medline].

  20. Tumber PS, Bhatia A, Chan VW. Ultrasound-guided lateral femoral cutaneous nerve block for meralgia paresthetica. Anesth Analg. 2008 Mar. 106(3):1021-2. [Medline].

  21. Hurdle MF, Weingarten TN, Crisostomo RA, Psimos C, Smith J. Ultrasound-guided blockade of the lateral femoral cutaneous nerve: technical description and review of 10 cases. Arch Phys Med Rehabil. 2007 Oct. 88(10):1362-4. [Medline].

  22. de Ruiter GC, Kloet A. Comparison of effectiveness of different surgical treatments for meralgia paresthetica: Results of a prospective observational study and protocol for a randomized controlled trial. Clin Neurol Neurosurg. 2015 Jul. 134:7-11. [Medline].

  23. Alberti O, Wickboldt J, Becker R. Suprainguinal retroperitoneal approach for the successful surgical treatment of meralgia paresthetica. J Neurosurg. 2008 Oct 31. [Medline].

 
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The lateral femoral cutaneous nerve provides sensory innervation to the anterolateral thigh. Courtesy of Essentials of Physical Medicine and Rehabilitation, Hanley & Belfus Publishers, 2001, used with permission.
 
 
 
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