Surgery for Meralgia Paresthetica Treatment & Management
- Author: Ira Kornbluth, MD, MA, FAAPMR; Chief Editor: William L Jaffe, MD more...
Treatment for meralgia paresthetica is directed toward identification and relief of the compressive force on the lateral femoral cutaneous nerve. In many instances, the nerve spontaneously heals if the compression is relieved. If symptoms continue, anti-inflammatory medications, local injection, and other nonsurgical modalities can be considered. If these methods fail, surgery may be an option.
No absolute contraindications are recognized for lateral femoral cutaneous nerve surgery. Relative contraindications include any comorbidities that place the patient at increased general surgical risk.
Meralgia paresthetica is a benign condition; in conservatively treated patients, complications are limited to persistent symptoms despite treatment. No weakness or disabling features should occur from this entity.
Devising a strategy to identify and relieve the compressive force should be the first step in the treatment of meralgia paresthetica. For example, a tool belt or tight clothing could induce or exacerbate symptoms. In obese patients, weight loss alone may prove to be very beneficial. Patients should be advised to avoid prolonged sitting because this may increase pressure on the nerve. Abnormal postures and movements should be addressed. Modalities such as heat, ice, and electrical stimulation can be used for symptomatic relief as appropriate.
Use of nonsteroidal anti-inflammatory drugs (NSAIDs), tricyclic antidepressants ([TCAs]; eg, amitriptyline [Elavil]), and anticonvulsant agents (eg, gabapentin [Neurontin]) may be helpful in providing some degree of symptomatic relief. NSAIDs have the potential to cause gastrointestinal ulcerations, damage renal and liver function, and exacerbate hypertension. Anticonvulsant medications can precipitate seizures, cause excess fatigue, or induce weight gain. Common effects of tricyclic antidepressants are dry mouth and urinary retention
Alternatively, local injections using steroid and local anesthetic preparations may reduce symptoms by decreasing any inflammatory component and disrupting the pain circuit.[20, 21] In most instances, the injection is performed just inferior to the inguinal ligament and 1 cm medial to the anterior superior iliac spine. However, the physician should recognize that the nerve pathway can vary significantly and should therefore adjust the location of the injection accordingly. Long-term neurotoxic agents such as phenol are not recommended because of the possibility of adverse effects such as dysesthesias.
In cases resistant to conservative measures, surgical options may be considered. The decision to pursue surgery depends on the extent and nature of the symptoms. Neurolysis alone, neurolysis with transposition of the nerve, and transection of the nerve are the most commonly performed surgical procedures for meralgia paresthetica. A prospective observational study by de Ruiter et al suggested that neurectomy may achieve better pain relief than neurolysis does, but further study will be required to investigate this issue in greater depth.
Before the procedure, the patient should be counseled about the potential risks and outcomes to be expected. Complications include infection, excess bleeding, failure to relieve symptoms, and the worsening of pain. Surgery may be performed with the patient under local or general anesthesia.
A small incision is made just distal to the site where the lateral femoral cutaneous nerve intersects the inguinal ligament. The nerve is exposed, and any compressive force is identified. Neurolysis, neurolysis with transposition, and transection are the most commonly performed surgical procedures. Which surgical procedure is most effective and which should be attempted first are topics of some debate.
Commonly, neurolysis or neurolysis with transposition is considered prior to transection because transection results in permanent numbness in the nerve distribution. Transection may be the only option if the nerve has been severely damaged or if multiple branches are affected. On the other hand, the rate of symptom recurrence may be higher with the neurolytic procedures than with transection. In transections, the surgeon should ensure that the proximal portion of the nerve is within the pelvis to minimize the formation of a painful neuroma.
Complete lysis is achieved by freeing the nerve at the tendinous arc from the iliac fascia; anteriorly, at the inguinal ligament; posteriorly, at a sling of fascia; and, distally, at the deep fascia of the thigh along each division.
Surgical complications include bleeding and infection; however, permanent anesthesia of the anterolateral thigh is an expected consequence of transection, and neuromas may develop.
Some surgical site tenderness is expected for a few days and can be managed with analgesics. Range of motion and function should not be restricted after surgery.
The patient should have thorough neurologic examinations immediately after the procedure and serial examinations for several months afterward to evaluate whether the procedure helped alleviate the symptoms of meralgia paresthetica and to identify any complications.
Craig E. Lateral femoral cutaneous neuropathy. Frontera WR, Silver JK. Essentials of Physical Medicine and Rehabilitation. Boston: Hanley & Belfus; 2001. 279-82.
Preston DC, Shapiro BE. Lateral femoral cutaneous neuropathy. Electromyography and Neuromuscular Disorders: Clinical-Electrophysiologic Correlations. Boston: Butterworth-Heinemann; 1997. 477.
Sunderland S. Anatomical features of nerve trunks in relation to nerve injury and nerve repair. Clin Neurosurg. 1970. 17:38-62. [Medline].
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].
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].
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].
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].
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].
Seror P, Seror R. Meralgia paresthetica: clinical and electrophysiological diagnosis in 120 cases. Muscle Nerve. 2006 May. 33(5):650-4. [Medline].
Williams PH, Trzil KP. Management of meralgia paresthetica. J Neurosurg. 1991 Jan. 74(1):76-80. [Medline].
van Eerten PV, Polder TW, Broere CA. Operative treatment of meralgia paresthetica: transection versus neurolysis. Neurosurgery. 1995 Jul. 37(1):63-5. [Medline].
Ivins GK. Meralgia paresthetica, the elusive diagnosis: clinical experience with 14 adult patients. Ann Surg. 2000 Aug. 232(2):281-6. [Medline].
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].
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].
Nahabedian MY, Dellon AL. Meralgia paresthetica: etiology, diagnosis, and outcome of surgical decompression. Ann Plast Surg. 1995 Dec. 35(6):590-4. [Medline].
Shimizu S. A novel approach to the diagnosis and management of meralgia paresthetica. Neurosurgery. 2008 Oct. 63(4):E820. [Medline].
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].
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].
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].
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].
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].
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].
Alberti O, Wickboldt J, Becker R. Suprainguinal retroperitoneal approach for the successful surgical treatment of meralgia paresthetica. J Neurosurg. 2008 Oct 31. [Medline].