Hospital Medicine

Meralgia paresthetica

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Meralgia Paresthetica

I. What every physician needs to know.

Meralgia paresthetica is a neurologic disorder characterized by paresthesias and numbness in the anterolateral thigh, typically caused by pressure on the lateral femoral cutaneous nerve (LFCN) from external (tight clothing) or internal (obesity, pregnancy, pelvic tumors) sources. The term comes from the Greek meros (thigh) and algos (pain).

II. Diagnostic Confirmation: Are you sure your patient has Meralgia Paresthetica?

A. History Part I: Pattern Recognition:

Paresthesias, often described as a "burning" or "tingling" in the upper and lateral thigh.

Frequently associated with allodynia.

No other associated neurologic symptoms (i.e. no hypo/hyperreflexia or weakness).

Typically unilateral (~20% of cases bilateral).

Typically worsened by prolonged standing and improved by sitting.

B. History Part 2: Prevalence:

Incidence: 0.43/10,000 person years. Possibly a higher incidence in men.

More common in obese or pregnant patients, diabetics, and those with carpal tunnel syndrome.

Other risk factors include tight clothing (belts, pants, corsets), limb length discrepancy, and alcohol abuse.

C. History Part 3: Competing diagnoses that can mimic Meralgia Paresthetica.

Lumbar disc herniation (often associated with other neurologic symptoms).

Metastatic disease in the iliac crest.

D. Physical Examination Findings.

Aggravating factors: Tapping on the inguinal ligament, Posterior extension of the thigh.

Tenderness over the lateral inguinal ligament.

Hair loss over the anterior thigh (due to patients repeatedly rubbing this area).

E. What diagnostic tests should be performed?

If the patient has a characteristic history and exam, no further studies are needed.

If there is uncertainty about the diagnosis, electrophysiologic testing can be done. Sensory nerve conduction velocity (SNCV) testing has the best evidence in meralgia paresthetica. If electrophysiologic testing is performed, it should be done bilaterally (for comparison, as responses can be quite variable, particularly in obese patients).

A diagnostic/therapeutic block of the LFCN (typically done where the nerve enters the thigh, adjacent to the anterior superior iliac spine) may also be performed. Rarely, patients may undergo biopsy of the LFCN. A common finding is decreased nerve fiber density, particularly of large myelinated fibers.

1. What laboratory studies (if any) should be ordered to help establish the diagnosis? How should the results be interpreted?

No laboratory studies are required for diagnosis. Screening tests for diabetes and lead poisoning may be considered since these conditions are associated with increased risk of meralgia paresthetica.

2. What imaging studies (if any) should be ordered to help establish the diagnosis? How should the results be interpreted?

If there is doubt about the diagnosis, ultrasound of the LFCN may be considered. In one study, a cross-sectional area of >5 millimeters2 (mm2) was associated with a sensitivity and specificity of 96% for meralgia paresthetica.

If there are any "red flag" symptoms that suggest a mimicking diagnosis, imaging studies can be done, including pelvic x-rays (to identify bony tumors) and spine x-ray, computed tomography (CT) or magnetic resonance imaging (MRI) [disc herniations].

F. Over-utilized or “wasted” diagnostic tests associated with this diagnosis.

While some providers utilize somatosensory-evoked potentials (SSEP) recorded on the scalp following lateral femoral cutaneous nerve stimulation, there is conflicting evidence on whether this test is of any value.

III. Default Management.

Most patients (>80%) will have improvement in symptoms over 4-6 months with conservative management.

Reassure patient that the symptoms are not related to a more serious problem (such as a back or spinal cord lesion).

Counsel on avoidance of aggravating factors (such as tight clothing) and on weight loss.

A. Immediate management.

For confirmation of the diagnosis as well as treatment, a local anesthetic block can be performed.

B. Physical Examination Tips to Guide Management.

None

C. Laboratory Tests to Monitor Response To, and Adjustments in, Management.

None

D. Long-term management.

If symptoms persist or are significantly bothersome, anticonvulsants (such as carbamazepine, phenytoin, or gabapentin) can tried as treatment for neuropathic pain.

There are also reports of successful use of capsaicin cream and the lidocaine patch.

Surgery (including neurolysis or transection of the LFCN) is generally reserved for disease refractory to other treatments. While studies evaluating neurolysis and resection have been small, the evidence to date suggests that neurolysis typically provides at least some relief, although it may be temporary. Conversely, patients undergoing neurectomy of the LFCN often have significant lasting improvement in symptoms, but have associated complete numbness of the anterior thigh.

E. Common Pitfalls and Side-Effects of Management.

Surgical treatment should be done only in those resistant to conservative management. A side effect of many surgeries is permanent loss of sensation in the anterolateral thigh.

IV. Management with Co-Morbidities.

A. Renal Insufficiency.

No change in standard management.

B. Liver Insufficiency.

No change in standard management.

C. Systolic and Diastolic Heart Failure.

No change in standard management.

D. Coronary Artery Disease or Peripheral Vascular Disease.

No change in standard management.

E. Diabetes or other Endocrine issues.

No change in standard management.

F. Malignancy.

No change in standard management.

G. Immunosuppression (HIV, chronic steroids, etc).

No change in standard management.

H. Primary Lung Disease (COPD, Asthma, ILD).

No change in standard management.

I. Gastrointestinal or Nutrition Issues.

No change in standard management.

J. Hematologic or Coagulation Issues.

No change in standard management.

K. Dementia or Psychiatric Illness/Treatment.

No change in standard management.

V. Transitions of Care.

A. Sign-out considerations While Hospitalized.

Condition typically does not result in hospitalization.

B. Anticipated Length of Stay.

Condition typically does not result in hospitalization.

C. When is the Patient Ready for Discharge.

Condition typically does not result in hospitalization.

D. Arranging for Clinic Follow-up.

1. When should clinic follow up be arranged and with whom.

Follow-up with primary care physician to consider other treatment options if no improvement in symptoms in 1 month.

2. What tests should be conducted prior to discharge to enable best clinic first visit.

None

3. What tests should be ordered as an outpatient prior to, or on the day of, the clinic visit.

None

E. Placement Considerations.

None

F. Prognosis and Patient Counseling.

Eighty to 90% of patients improve within 6 months with conservative treatment.

Avoid tight clothing (including belts), alcohol use (associated with increased risk of meralgia paresthetica), and prolonged standing.

Weight loss can improve symptoms.

VI. Patient Safety and Quality Measures.

A. Core Indicator Standards and Documentation.

None

B. Appropriate Prophylaxis and Other Measures to Prevent Readmission.

None

VII. What's the evidence?

Harney, D, Patijn, J. "Meralgia paresthetica: diagnosis and management strategies". Pain Med. vol. 8. 2007. pp. 669-677.

Patijn, J. "Meralgia paresthetica". Pain Prac. vol. 11. 2011. pp. 1-7.

Yang, SM, Kim, DH. "L1 Radiculopathy mimicking meralgia paresthetica: a case report". Muscle Nerve. vol. 41. 2010. pp. 566-8.

Moucharafieh, R, Wehbe, J, Maalouf, G. "Meralgia paresthetica: a result of tight new trendy low cut trousers ("taille basse")". Int J Surg. vol. 6. 2008. pp. 164-8.

Berini, SE. "Chronic meralgia paresthetica and neurectomy: a clinical pathologic study". Neurology. vol. 82. 2014. pp. 1551-5.

(This article describes pathologic findings of involved nerves as well as surgical outcomes.)

Cheatam, SW. "Meralgia paresthetica: a review of the literature". IJSPT. vol. 8. 2013. pp. 883-93.

(Good review of the literature.)

Suh, DH. "Sonographic and electrophysiologic findings in patients with meralgia paresthetica". Clinical Neurophysiology. vol. 124. 2013. pp. 1460-4.

(Discussion of use of ultrasound to diagnose MP.)
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