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Surgery for Meralgia Paresthetica Treatment & Management

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

Approach Considerations

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.

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Medical Therapy

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.

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Surgical Therapy

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,[22] 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.[23]

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.

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Long-Term Monitoring

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.

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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
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  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].

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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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