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CLINICAL STUDIES

A NOVEL APPROACH TO THE DIAGNOSIS AND MANAGEMENT OF MERALGIA PARESTHETICA


S.A. Reza Nouraei, M.B.B.Chir.
West London Neuroscience Centre, Charing Cross Hospital, London, United Kingdom

Bobby Anand, M.R.C.S.


West London Neuroscience Centre, Charing Cross Hospital, London, United Kingdom

George Spink, M.R.C.S.


West London Neuroscience Centre, Charing Cross Hospital, London, United Kingdom

Kevin S. ONeill, F.R.C.S.(S.N.)


West London Neuroscience Centre, Charing Cross Hospital, London, United Kingdom Reprint requests: Kevin S. ONeill, F.R.C.S.(S.N.), West London Neuroscience Centre, Charing Cross Hospital, London W6 8RF, United Kingdom. Email: koneill@hhnt.org Received, June 7, 2006. Accepted, December 5, 2006.

OBJECTIVE: To review the results of conservative and surgical treatment of meralgia paresthetica (MP), with particular reference to the use of a simple clinical test for diagnosing this condition and the outcome of primary nerve decompression surgery. METHODS: Records of all patients with a diagnosis of MP were reviewed. Information was obtained about clinical presentation and risk factors, diagnostic evaluation, management, and outcome. Actuarial analysis was used to determine the intervention-free interval after surgical decompression. RESULTS: Between 2000 and 2005, MP was diagnosed in 45 patients. There were 27 men and 18 women, and the average age at presentation and duration of symptoms were 47 and 1.9 years, respectively. The pelvic compression test had a sensitivity of 95% and a specicity of 93.3% for this condition. Twenty-ve patients were managed conservatively and 20 required operative intervention, which was bilateral in two patients. The average follow-up period was 25 months, and the actuarial 2- and 5-year intervention-free rates were 91 and 78%, respectively, with no specic risk factors for revision surgery. CONCLUSION: The pelvic compression test is a sensitive and specic test for MP, helping to distinguish it from lumbosacral radicular pain. Most patients with this condition can be managed successfully with conservative measures, and those requiring surgery can be treated effectively with nerve decompression.
KEY WORDS: Meralgia paresthetica, Nerve decompression, Peripheral neuropathy, Thigh pain
Neurosurgery 60:696700, 2007
DOI: 10.1227/01.NEU.0000255392.69914.F7

www.neurosurgery-online.com

eralgia paresthetica (MP) is a monon e u ro p a t h y re s u l t i n g f ro m t h e compression of the lateral femoral cutaneous nerve (LFCN) as it crosses between the anterior superior iliac spine (ASIS) and the inguinal ligament to enter the thigh (2). The nerve receives sensory input from the skin of the anterolateral thigh. Affected patients consequently experience a very prominent painful dysesthesia and, less commonly, vasomotor disturbance in the cutaneous distribution of the nerve (5). This condition can be confused with, and in a small group of patients it can coexist with, lumbosacral radicular pain. This can lead to diagnostic difculties in discerning the exact nature and cause of a patients symptoms which, in the context of concurrent spinal stenosis, can lead to unnecessary spinal surgery being performed (10). Conversely, MP can arise de novo as a transient compression neuropathy result-

ing from patient positioning for spinal surgery (6). The apparent persistence of lower limb symptoms in the early postoperative period after spinal surgery can be misconstrued by the patient and the physician as a suboptimal surgical outcome. As soon as it is suspected, MP can be diagnosed or excluded by electrophysiological studies of the LFCN (7). However, to our knowledge, there are no satisfactory, easy-to-apply clinical tests at present to help distinguish it from lumbosacral radicular pain to help direct the diagnostic effort. Many patients can be managed conservatively with measures including avoidance of tightly tting garments, analgesia, and physical therapy (12). However, patients whose symptoms persist despite maximal medical therapy require operative intervention. At present, there is controversy regarding the optimal treatment of this condition; two main operative approaches, primary nerve decom-

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pression or resection, have been advocated by different authors (11). In this study, we reviewed our experience with the management of MP, with particular reference to the description and evaluation of a simple clinical test for diagnosing it in the clinic, and the long-term results of an operative approach aimed at preserving thigh sensation.

PATIENTS AND METHODS


Details of all patients treated for MP by the senior author (KSO) were obtained from a prospectively collected database. Information about patient demographics, clinical presentation, diagnostic workup, conservative treatment, operative management, and postoperative complications were obtained. Information about symptom resolution, recurrence of symptoms, and any secondary surgical procedures were obtained from follow-up records. Data were presented either as means with standard deviation or as percentages when appropriate. The symptom-free interval and time to reintervention were illustrated using the Kaplan-Meier method, and the impact of different preoperative variables on success or other outcomes of the operation was calculated with a multivariate Cox proportional hazards ratio model.

Pelvic Compression Test


The pelvic compression test is a simple and noninvasive test for MP that, to our knowledge, has not been described previously for this condition. It is based on the premise that as the LFCN is compressed by the inguinal ligament, relaxing the ligament should relieve pressure on the nerve and lead to a temporary alleviation of symptoms. This can be achieved by laying the patient on the examination couch in the lateral position on their nonsymptomatic side. The patient is asked to focus on their symptoms and to place the ipsilateral hand on the symptomatic area, which can enhance dysesthesia. The examiner then applies a lateral compressive force on the pelvis as shown in Figure 1. This pressure is maintained for 45 seconds and the patient is asked to report any changes in the nature and severity of the symptoms. Positive test results are considered as an improvement in patient symptoms. The sensitivity and specicity of this test for MP was evaluated in a population of patients with electrophysiologically proven MP and in a second group of patients with lumbosacral pain radiating to the lower limb.

FIGURE 1. Illustrations demonstrating the pelvic compression test. A, the patient is positioned on his or her side on an examination couch. B, downward pressure is applied and maintained for approximately 45 seconds. After 30 seconds, the patient is asked whether or not the symptoms have eased. A positive response constitutes a positive test result.

proximally with tenotomy scissors (Fig. 2). A 2.7-mm, 0-degree pediatric airway endoscope normally used for pediatric sinus surgery (Karl Storz, Tuttlingen, Germany) is sometimes used to demonstrate the nerve within the tunnel and ensure that the tunnel is fully decompressed. The nerve is then mobilized and the fascial ridge between the ASIS and sartorius origin, over which the nerve bridges, is divided, decompressing the nerve posterolaterally. A probe is then introduced parallel to the nerve distally to identify any constricting distal aponeuroticofascial tunnels. As soon as the nerve is fully decompressed, a limited neurolysis is performed, releasing any perifascicular constrictions. The incision is then closed in the usual manner.

RESULTS
Clinical Data
During the study period, MP was diagnosed in 45 patients. The diagnosis was initially clinical; those patients who did not respond to conservative treatment went on to undergo electrophysiological studies. There were 27 men and 18 women, and the average age at presentation was 47 11 years (mean standard deviation; range, 3070 yr). Twenty-four patients had a signicant history of lower back pain, 10 of whom had undergone a previous spinal surgical procedure. Nine patients had a lower abdominal procedure including appendicectomy or previous acetabular surgery, and 10 patients had a body mass

Surgical Technique of LFCN Decompression


A 2- to 3-cm incision is placed inferomedial to the ASIS inferior and along the line of the inguinal ligament. The investing layer of fascia overlying the sartorius muscle is cleared and carefully divided longitudinally (Fig. 2A). The subfascial plane is explored carefully to identify the nerve (Fig. 2B). The nerve is followed proximally to the inguinal ligament, and a blunt probe is used to demonstrate the tunnel between ASIS, the inguinal ligament, and the origin of sartorius. Using an artery clip, the inferior leaf of the inguinal ligament is lifted and, with the nerve protected with a dissector, divided and splayed. This decompresses the nerve anteromedially. This can be extended

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TABLE 1. Frequency of presenting symptomsa Conservative management Age (yr SD) Male sex (%) Duration of symptoms Chronic back pain (%) Sciatica Previous spinal surgery Clinical obesity Symptoms Burning pain Hypersensitivity Paresthesia Aggravated by walking Affecting sleep 47 11 64 1.9 1.4 56 44 16 28 84 96 100 32 40 Surgical management 47 12 50 2.2 1.8 48 29 30 16 100 65 (P 0.02) 95 21 77 (P 0.02)

a SD, standard deviation. All P values were greater than 0.05, except for those provided in the table.

FIGURE 2. A, intraoperative photograph demonstrating that a constricting aponeuroticofascial tunnel has been identied and elevated with a dissector. B, intraoperative photograph showing a constricting tunnel under the inguinal ligament being divided with tenotomy scissors.

index of more than 30. The average duration of symptoms was 1.9 2 years, and there were 24 and 18 right- and left-sided lesions, respectively, and three patients with bilateral MP. All patients reported burning pain with varying degrees of numbness; 33 patients reported hypersensitivity in the distribution of the LFCN. Seven patients reported that their symptoms were affected by walking, but no other clear exacerbating or relieving factors were identied in the remaining patients. Symptoms affected sleep in 76% of all patients. The frequency of symptoms between patients who were managed conservatively and those who eventually required operation was compared with the 2 test and binary logistic regression There were no major differences between the two groups; however, patients who were managed conservatively had a greater incidence of hypersensitivity as a predominant symptom. Conversely, patients who required operative therapy were more likely to have symptoms that significantly disturbed their sleep (Table 1). Figure 3 provides an overview of the management of patients, showing that, of the 45 patients who had MP at presentation, 22 responded to conservative measures. The remaining 23 underwent electrophysiological confirmation of their diagnosis before further treatment. This consisted of therapeutic injection of local anesthetic and steroids (bupivacaine and triamcinolone acetate) in seven patients who had signicant comorbidity and 16 patients who underwent primary surgery. Therapeutic steroid and local anesthetic injection failed to

FIGURE 3. Flowchart demonstrating the management of MP in this series.

resolve symptoms in four patients, who then went on to undergo nerve decompressive surgery.

Pelvic Compression Test


The pelvic compression test was performed in all patients who had abnormal nerve conduction studies and underwent surgery for MP as well as in 15 patients with sciatic pain in whom the

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FIGURE 4. Line graph demonstrating the intervention-free interval after surgical decompression for MP (actuarial analysis).

diagnosis of MP was excluded electrophysiologically. The test results were positive in 19 out of 20 patients with MP and negative in 14 out of 15 patients with sciatic-type lower limb pain (P 0.0001, 2 test). This gave the test a sensitivity and specicity of 95 and 93.3%, respectively. In calculating sensitivity and specicity, we used only the population of patients who underwent surgical nerve decompression because these patients all had electrophysiological conrmation of their diagnosis.

Surgical Treatment and Outcome


Of the patients treated operatively, all underwent LFCN decompression surgery as described above in the Patients and Methods section. The average follow-up period was 25 months (range, 763 mo). There were two bilateral procedures, and three revisions were required. Of these, two patients underwent a revision decompression, resulting in symptom resolution in both patients; one patient required an LCFN transection, which again resolved his symptoms. All patients were discharged home the day after the procedure, and no immediate postoperative complications were noted. We found no evidence of wound infection or seroma formation in the early postoperative follow-up period. The actuarial likelihood of a patient remaining free of revision surgery at 2 and 5 years was 91 and 79%, respectively (Fig. 4). A multivariate Cox proportional hazards ratio model could not identify any independent risk factors for surgical reintervention. Variables used to construct the Cox regression model were age and sex of the patient, presence of back pain or previous spinal or groin surgery, side of the lesion, and the duration of symptoms.

DISCUSSION
MP is a compressive mononeuropathy of the lateral femoral cutaneous nerve of the thigh with a reported population incidence of 1 in 10,000 (8). It affects both sexes equally and typically presents with a burning pain and abnormal sensation over the distribution of the nerve in the anterolateral compartment of the thigh (Fig. 1). In this study, we reviewed our experience with the

diagnosis and management of this condition. It can frequently coexist with low back pain and radicular symptoms and can, therefore, present signicant diagnostic and therapeutic challenges (4). Our study demonstrates that the pelvic compression test is a useful and simple clinical test that can be used for screening purposes and, as we have demonstrated, can be of particular benet in those patients in whom MP and low back pain coexist. The test is also useful in directing the initial diagnostic effort and in the postoperative evaluation of patients who have undergone spinal surgery. Given that patient positioning is a recognized risk factor for MP in a proportion of patients undergoing spinal surgery (6), it is very important that this diagnosis be considered when evaluating residual lower limb pain in patients who have undergone spinal surgery. It is also useful for patient selection purposes when nerve decompression surgery is considered. The test temporarily relieves compression at the level of the inguinal ligament, which surgery aims to achieve permanently. Therefore, it provides useful information about whether or not nerve decompression is likely to be benecial. More than half of our patients were managed successfully with conservative measures, including weight loss, avoidance of tightly fitting garments, and physiotherapy; a small group derived lasting relief after local anesthetic and steroid injection. Patients who did not respond to these measures underwent nerve decompression surgery. There is a divergence of opinion in the literature about the optimal surgical management of this condition. Some authors advocate primary nerve decompression as the optimal primary treatment for this condition, whereas others advocate primary nerve resection as the initial therapy (11). We have found LFCN decompression to be a viable and successful rst-line treatment, with a 2-year success rate of more than 90%, while allowing thigh sensation to be preserved. It can be carried out successfully through a small groin incision; however, operative success depends both on careful patient selection and adequate surgical decompression of the nerve. Regarding patient selection, positive pelvic compression test results indicate that the nerve is likely to be compressed around its exit point into the thigh, and surgical decompression should, therefore, be of some benet. In our practice, suspected nerve entrapment is electrophysiologically conrmed in all patients. Regarding surgical management, we nd that the lateral femoral cutaneous nerve consistently courses within an aponeuroticofascial tunnel around its exit point into the thigh, an observation that is in keeping with anatomic studies of the course of the LFCN around its exit point (1, 2). We pay particular attention to decompressing the nerve throughout the full length of this tunnel, as well as under the inguinal ligament, assisted by endoscopic vision when necessary. Using this approach, only three revisions needed to be performed, and only one nerve needed to be transected. In those patients who required revision surgery, symptom relief was invariably attained after the second procedure. This compares favorably with the published literature, in which operative success rates have been reported to range from 77 to 93% (3, 9, 1113). In conclusion, we recommend the use of the pelvic compression test as a simple and noninvasive method of clinical screen-

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ing for meralgia paresthetica, and submit that surgical decompression of the nerve can be a highly successful first-line method of treatment in carefully selected patients.

REFERENCES
1. de Ridder VA, de Lange S, Popta JV: Anatomical variations of the lateral femoral cutaneous nerve and the consequences for surgery. J Orthop Trauma 13:207211, 1999. 2. Dias Filho LC, Valenca MM, Guimaraes Filho FA, Medeiros RC, Silva RA, Morais MG, Valente FP, Franca SM: Lateral femoral cutaneous neuralgia: An anatomical insight. Clin Anat 16:309316, 2003. 3. Ducic I, Dellon AL, Taylor NS: Decompression of the lateral femoral cutaneous nerve in the treatment of meralgia paresthetica. J Reconstr Microsurg 22:113118, 2006. 4. Erbay H: Meralgia paresthetica in differential diagnosis of low-back pain. Clin J Pain 18:132135, 2002. 5. Grossman MG, Ducey SA, Nadler SS, Levy AS: Meralgia paresthetica: Diagnosis and treatment. J Am Acad Orthop Surg 9:336344, 2001. 6. Gupta A, Muzumdar D, Ramani PS: Meralgia paraesthetica following lumbar spine surgery: A study in 110 consecutive surgically treated cases. Neurol India 52:6466, 2004. 7. Lagueny A, Deliac MM, Deliac P, Durandeau A: Diagnostic and prognostic value of electrophysiologic tests in meralgia paresthetica. Muscle Nerve 14:5156, 1991. 8. Latinovic R, Gulliford MC, Hughes RA: Incidence of common compressive neuropathies in primary care. J Neurol Neurosurg Psychiatry 77:263265, 2006. 9. Nahabedian MY, Dellon AL: Meralgia paresthetica: Etiology, diagnosis, and outcome of surgical decompression. Ann Plast Surg 35:590594, 1995. 10. Seror P, Seror R: Meralgia paresthetica: Clinical and electrophysiological diagnosis in 120 cases. Muscle Nerve 33:650654, 2006. 11. van Eerten PV, Polder TW, Broere CA: Operative treatment of meralgia paresthetica: Transection versus neurolysis. Neurosurgery 37:6365, 1995. 12. Williams PH, Trzil KP: Management of meralgia paresthetica. J Neurosurg 74:7680, 1991. 13. Yang SH, Wu CC, Chen PQ: Postoperative meralgia paresthetica after posterior spine surgery: Incidence, risk factors, and clinical outcomes. Spine 30:E547E550, 2005.

COMMENTS

eading this study dedicated to the diagnosis and treatment of meralgia paraesthesica (MP), we appreciated that, for the rst time, a clinical test was introduced and applied to screen the patients indicated for surgical decompression. We remember the description of this peculiar clinical picture by Sigmund Freud at the beginning of the century (1). The father of psychoanalysis experienced pain within the anterolateral surface of the thigh owing to femorocutaneous nerve entrapment, but he could not demonstrate that his symptomatology was not a sort of psychogenic disease! The pelvic compression test (PCT) proposed by the authors allows for the true prediction of the outcome of nerve decompression as obtained by the section of the inguinal ligament. If the causes of nerve compression are different (i.e., ganglion cysts, posttraumatic brosis, etc.), the test will also be negative in the presence of electromyographic signs of nerve damage leading to more accurate diagnostic examinations and neuroimaging investigations. We will certainly perform this test in the next patient we observe with pain in anterolateral surface of the thigh! Angelo Franzini Giovanni Broggi Milan, Italy
1. Schiller F: Sigmund Freuds meralgia paresthetica. Neurology 35:557358, 1985.

he authors describe a new clinical test, PCT, for the diagnosis of MP. They report a sensitivity and specificity of 95 and 93%, respectively for the PCT in establishing the diagnosis of MP. One of the authors major points is that the PCT is particularly valuable in helping to distinguish MP from lumbar radiculopathy or other lumbar spinal disorders. It seems to me that in its classic form, the symptoms of MP are fairly stereotypical and the diagnosis should be fairly straightforward for the astute clinician. Frankly, upper lumbar radiculopathy is relatively uncommon, and the characteristics of radicular pain, its frequent association with lower back pain, and the presence of other neurological findings should help distinguish this condition from MP in most cases. Traditionally, the diagnosis of MP has been conrmed through electrophysiological testing. Side-to-side amplitude difference of the sensory nerve action potential of the lateral femoral cutaneous nerve has been shown to be a more sensitive predictor of MP than the absolute amplitude of the sensory nerve action potential. In fact, a side-to-side amplitude ratio greater than 2.3 combined with a sensory nerve action potential amplitude of less than 3 microvolts has been shown to provide a specicity in excess of 98% (1). The authors series does reinforce the concept that most patients with MP can be successfully managed with conservative therapy. However, patients who fail nonoperative measures should be considered for surgical treatment. The major issue is whether or not to perform decompression with neurolysis or peripheral neurectomy. Indeed, there are proponents of both approaches. The authors results of decompression and neurolysis are certainly impressive, and there are certainly other reports of excellent results with simple decompression (2). In contrast, there are authors who have reported superior results with nerve transaction (3). Most surgeons who advocate decompression cite the possibility of painful neuroma formation. However, in my experience, formation of a painful neuroma is relatively rare in a pure sensory nerve that is surgically transected cleanly. The authors seem to not place much emphasis on the use of diagnostic nerve blocks. However, it has been my experience that, if properly performed, repetitive diagnostic local anesthetic blockade of the lateral femoral cutaneous nerve does carry some degree of prognostic value for surgical treatment, whether it be decompression or transection. Richard K. Osenbach Durham, North Carolina

1. Seror P, Seror R: Meralgia paresthetica: Clinical and electrophysiological diagnosis in 120 cases. Muscle Nerve 33:650654, 2006. 2. Siu TL, Chandran KN: Neurolysis for meralgia paresthetica: An operative series of 45 cases. Surg Neurol 63:1923, 2005. 3. van Eerten PV, Polder TW, Broere CA: Operative treatment of meralgia paresthetica: Transection versus neurolysis. Neurosurgery 37:6365, 1995.

ouraei et al. have presented a large series of patients with MP. This is a large series that portrays the clinical presentation and surgical management well. The use of the PCT, which is well described, seems to be a useful adjunct to diagnosis. The large clinical experience and observations provided are a valuable addition to our literature. Edward C. Benzel Cleveland, Ohio

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