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Meralgia Paresthetica

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Other Names

  • Meralgia Paresthetica (MP)
  • Entrapment of the Lateral Cutaneus Nerve of the Thigh
  • Entrapment of the Lateral Femoral Cutaneous Nerve
  • Entrapment of Nervus Cutaneous Femoris Lateralis
  • Bernhardt-Roth Syndrome
  • LCN (lateral cutaneous nerve) neuralgia
  • LFCN Neuropraxia

Background

History

  • MP first described by Hager in 1885 (need citation)
  • Named by Roth in 1895 (need citation)

Epidemiology

  • General
    • Average age is 30-40 years
    • Males greater than females
    • Cases are bilateral about 20% of the time[1]
  • Incidence
    • Rate of 32.6 - 43 cases per 100,000 patient years in the general population[2]
    • 247 cases per 100,000 patient years in individuals with diabetes mellitus[3]

Pathophysiology

Anatomy and distribution of lateral femoral cutaneous nerve
  • General
    • MP is characterized by nerve entrapment resulting in pain, paresthesias, and sensory loss within the distribution of the LFCN
    • Paucity of research makes diagnosis, treatment challenging

Etiology

  • Idiopathic or spontaneous
    • No clear cause often associated with multiple risk factors
    • Mechanical risk factors refers to increased abdominal pressure (pregnancy, obesity, belts, corsets, tight pants)
    • Metabolic risk factors include lead poisoning, Alcoholism, Hypothyroidism, and Diabetes
  • Iatrogenic
    • Associated with surgical procedures including hip arthroplasty, anterior hip resufracing, spinal surgery
    • Goulding et al estimated 81% of patients had LFCN neuropraxia following THA[4]
    • Gupta et al found 13/110 (12%) patients had LFCN neuropraxia following posterior lumbar spine surgery[5]
    • Mirovsky estimated about 20% of spine surgery cases develop LFCN neuropraxia[6]
    • Less commonly linked to iliac bone harvesting, open and laparoscopic appendectomy, cesarean section with epidural analgesics, and OBGYN surgery

Pathoanatomy


Risk Factors


Differential Diagnosis

Differential Diagnosis Hip Pain

Differential Diagnosis Thigh Pain


Clinical Features

  • History
    • A careful review of history to identify risk factors should be performed
    • Patients may characterize pain as burning, numbness, muscle aches, coldness, lightning pain, or buzzing
    • Location is typically primarily lateral thigh (73%), anterior thigh (26%)[13]
    • Symptoms may wax or wane
    • May be worse with prolonged standing and walking
    • May be alleviated with sitting
  • Physical Exam: Physical Exam Hip
    • There may be reproducible tenderness on the lateral aspect of the Inguinal Ligament where the nerve crosses
    • In some cases, hair loss may be evident due to recurrent friction or rubbing[14]
  • Special Tests

Evaluation

Ultrasound guided lateral femoral cutaneous nerve block

EMG/NCS

  • Findings
    • Somatosensory evoked potentials (81.3% sensitivity)[15]
    • Sensory nerve conduction (65.2% sensitivity)
  • Limitations
    • Increased body habitus

MRI

  • Magnetic Resonance Neurography (MRN) has been utilized
  • Chabara et al blinded two radiologists to 11 confirmed and 28 control cases[16]
    • Sensitivity: 71-73%
    • Specificity: 94-95%
    • PPV: 71-79%
    • NPV: 94%
    • Diagnostic Accuracy: 90-91%

Diagnostic Nerve Block

  • Consider diagnostic block where the LFCN exits the pelvis at the inguinal ligament
    • Approximate site of injection is 1cm medial and inferior to the ASIS or at the point of maximum pain

Classification

  • Idiopathic vs Iatrogenic

Management

Prognosis

  • Most cases cases of MP have a favorable course
    • 85% will recover with conservative treatment[17]

Nonoperative

  • General
    • Goal: If known, treat underlying cause (i.e. diabetes, occupational risks, etc)
    • Relative rest from offending activities
    • Protection of the affected area
  • Analgesics
  • Physical Therapy
  • Manual Therapy
    • Case reports and series suggest Active Release Techniques (ART), mobilization/ manipulation for the pelvis, myofascial therapy for the rectus femoris and illiopsoas, transverse friction massage of the inguinal ligament, stretching exercises for the hip and pelvic musculature, and pelvic stabilization/abdominal core exercises may help[18][19]
  • Kinesiology Taping
    • Kalichman et al found improvement in symptoms in a small pilot study[20]

Procedures

  • Acupuncture
    • Case series suggests benfit when combined with cupping[21]
  • Corticosteroid Injection
    • Taglifi injected 20 patients with EMG confirmed MP[22]
      • 16/20 (80%) had improvement at 1 week post injection
      • 100% of patients experienced a complete resolution of symptoms and significant improvements on the QOL scale
    • Tumber et al also demonstrated efficacy of CSI after 2 injections spaced out 3 weeks apart[23]
    • Note: Can be performed diagnostically/ therapeutically without corticosteroids
  • Pulsed Radiofrequency Ablation
    • 4 case reports have suggested efficacy[24]
  • Spinal Cord Stimulator
    • One case discusses a patient refractory to other treatments who was pain free after the insertion of a spinal cord stimulator[25]

Operative

  • Indications
    • Unknown
  • Technique
    • LFCN Neurolysis
    • LFCN Resection
  • Research
    • Early studies suggest resection is superior to neurolysis[26][27]

Rehab and Return to Play

Rehabilitation

  • Variable depending on etiology

Return to Play

  • Variable depending on etiology and management

Complications

  • Chronic pain
  • Inability to return to work
  • Inability to return to sport

See Also


References

  1. Ecker AD. Diagnosis of meralgia paresthetica. JAMA. 1985;253:976.
  2. 2.0 2.1 van Slobbe AM, Bohnen AM, Bernsen RM, et al. Incidence rates and determinants in meralgia paresthetica in general practice. J Neurol. 2004;251(3):294-297.
  3. 3.0 3.1 Parisi TJ, Mandrekar J, Dyck PJ, et al. Meralgia paresthetica: relation to obesity, advanced age, and diabetes mellitus. Neurology. 2011;77(16):1538-1542.
  4. Goulding K, Beaule PE, Kim PR, et al. Incidence of lateral femoral cutaneous nerve neuropraxia after anterior approach hip arthroplasty. Clin Orthop Relat Res. 2010;468(9):2397-2404.
  5. Gupta A, Muzumdar D, Ramani PS. Meralgia paraesthetica following lumbar spine surgery: a study in 110 consecutive surgically treated cases. Neurol India. 2004;52(1):64-66.
  6. Mirovsky Y, Neuwirth M. Injuries to the lateral femoral cutaneous nerve during spine surgery. Spine. 2000; 25:1266–1269.
  7. Macgregor J, Moncur JA. Meralgia paraesthetica-a sports lesion in girl gymnasts. Br J Sports Med. 1977;11(1):16-19.
  8. Otoshi K, Itoh Y, Tsujino A, et al. Case report: meralgia paresthetica in a baseball pitcher. Clin Orthop Relat Res. 2008;466(9):2268-2270.
  9. Ulkar B, Yildiz Y, Kunduracioglu B. Meralgia paresthetica: a long-standing performance-limiting cause of anterior thigh pain in a soccer player. Am J Sports Med. 2003;31(5):787-789.
  10. Szewczyk J, Hoffmann M, Kabelis J. Meralgia paraesthetica in a body-builder. Sportverletz Sportschaden. 1994;8(1):43-45.
  11. Kho KH, Blijham PJ, Zwarts MJ. Meralgia paresthetica after strenuous exercise. Muscle Nerve. 2005;31(6):761-763.
  12. Goldberg VM, Jacobs B. Osteoid osteoma of the hip in children. Clin Orthop Relat Res. 1975;106:41–47.
  13. Seror P, Seror R. Meralgia paresthetica: clinical and electrophysiological diagnosis in 120 cases. Muscle Nerve. 2006;33(5):650-654.
  14. Harney D, Patijn J. Meralgia paresthetica: diagnosis and management strategies. Pain Med. 2007;8:669–677
  15. Seror P. Somatosensory evoked potentials for the electrodiagnosis of meralgia paresthetica. Muscle Nerve. 2004;29(2):309-312.
  16. Chhabra A, Del Grande F, Soldatos T, et al. Meralgia paresthetica: 3-Tesla magnetic resonance neurography. Skeletal Radiol. 2013;42(6):803-808. doi:10.1007/s00256-012-1557-4
  17. Dureja GP, Gulaya V, Jayalakshmi TS, Mandal P. Management of meralgia paresthetica: a multimodality regimen. Anesth Analg. 1995;80:1060–1061.
  18. Skaggs CD, Winchester BA, Vianin M, et al. A manual therapy and exercise approach to meralgia paresthetica in pregnancy: a case report. J Chiropr Med. 2006;5(3):92-96.
  19. Houle S. Chiropractic management of chronic idiopathic meralgia paresthetica: a case study. J Chiropr Med. 2012;11(1):36-41.
  20. Kalichman L, Vered E, Volchek L. Relieving symptoms of meralgia paresthetica using Kinesio taping: a pilot study. Arch Phys Med Rehabil. 2010;91(7):1137-1139.
  21. Wang X-z, Zhu D-x. Treatment of 43 cases of lateral femoral cutaneous neuritis with pricking and cupping therapy. J of Acup and Tuina Sci. 2009;7(6):366-367.
  22. Tagliafi co A, Serafi ni G, Lacelli F, et al. Ultrasoundguided treatment of meralgia paresthetica (lateral femoral cutaneous neuropathy): technical description and results of treatment in 20 consecutive patients. J Ultrasound Med. 2011;30(10):1341-1346.
  23. Tumber PS, Bhatia A, Chan VW. Ultrasound-guided lateral femoral cutaneous nerve block for meralgia paresthetica. Anesth Analg. 2008;106:1021–1022.
  24. Patijn, Jacob, et al. "20. Meralgia paresthetica." Pain Practice 11.3 (2011): 302-308.
  25. Barna SA, Hu MM, Buxo C, Trella J, Cosgrove GR. Spinal cord stimulation for treatment of meralgia paresthetica. Pain Physician. 2005;8:315–318.
  26. de Ruiter GC, Wurzer JA, Kloet A. Decision making in the surgical treatment of meralgia paresthetica: neurolysis versus neurectomy. Acta Neurochir (Wien). 2012;154(10):1765-1772.
  27. Emamhadi M. Surgery for Meralgia Paresthetica: neurolysis versus nerve resection. Turk Neurosurg. 2012;22(6):758-762.
Created by:
John Kiel on 14 June 2019 08:39:20
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Last edited:
5 October 2022 13:09:19
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