Surgery for Meralgia Paresthetica Treatment & Management

Updated: Jul 08, 2019
  • Author: Ira Kornbluth, MD, MA, FAAPMR; Chief Editor: William L Jaffe, MD  more...
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Treatment

Approach Considerations

Treatment for meralgia paresthetica is directed toward identification and relief of the compressive force on the lateral femoral cutaneous nerve (LFCN). In many instances, the nerve spontaneously heals if the compression is relieved. If symptoms continue, anti-inflammatory medications, local injection, and other nonsurgical modalities may be considered. If these methods fail, surgery may be an option.

No absolute contraindications are recognized for LFCN 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 LFCN. 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), and anticonvulsant agents (eg, gabapentin) 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 TCAs 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. [23, 24] Long-term neurotoxic agents (eg, phenol) are not recommended, because of the possibility of adverse effects (eg, dysesthesias).

In most instances, the injection is performed just inferior to the inguinal ligament and 1 cm medial to the anterior superior iliac spine (ASIS). However, the physician should recognize that the nerve pathway can vary significantly and should therefore adjust the location of the injection accordingly. Ultrasonography (US) can be helpful for guiding injection therapy. [25]

Pulsed radiofrequency (RF) neuromodulation has been described as a means of treating intractable meralgia paresthetica. [26] In a small case series (N = 5), Ghai et al assessed the use of extended-duration (8 minutes) pulsed RF of the LFCN in patients with refractory meralgia paresthetica. [27] Four of the five patients were followed for 1-2 years, and one was followed for 6 months. In all five, substantial and long-lasting symptom relief was noted, along with an increase in daily life activities. The need for medications was reduced or eliminated, and there were no complications. Further study will be required to determine the clinical value of extended-duration pulsed RF in this setting.

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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, [28] but further study is required to investigate this issue in greater depth. A subsequent review by Payne et al concluded that there was not yet sufficient evidence to recommend either of these treatment methods over the other. [29]  

A study by Schwaiger et al suggested that the decompression/neurolysis approach should be the primary surgical procedure of choice for treatment of meralgia paresthetica if conservative treatment fails. [30] A study by de Ruiter et al found that the intraneural changes noted in persistent meralgia paresthetica may be largely irreversible, supporting neurectomy as an alternative to neurolysis for primary surgical treatment and not only for secondary treatment after failure of neurolysis. [22]

Before the procedure, the patient should be counseled about the potential risks and outcomes to be expected (see Complications).

Surgery may be performed with the patient under local or general anesthesia.

A small incision is made just distal to the site where the LFCN intersects the inguinal ligament. The nerve is exposed, and any compressive force is identified. The surgical procedure (neurolysis alone, neurolysis with transposition, or transection) is then performed. Which of these procedures is most effective and which should be attempted first are topics of some debate. [31]

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.

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Complications

Surgical complications include the following:

  • Infection
  • Excess bleeding
  • Failure to relieve symptoms
  • Worsening of pain

In addition, 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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