MERALGIA PARESTHETICA

CASE PRESENTATION
Mr. A., a 57 year old Hispanic man, complains of episodic numbness of both lateral thighs for the last 3 years. The symptom
is exacerbated by walking and eases after 20-30 minutes by resting or sitting down. He denies tingling, pain, and weakness in
his legs. He denies urinary incontinence or retention. There has been no change in his bowel habits. He has gained 50 pounds
over the last 3 years.
Mr. A.’s past medical history is significant for type 2 diabetes diagnosed 10 years ago. He has not had microvascular
complications of his diabetes. He also has hypertension, morbid obesity, OSA, and osteoarthritis of the knees. He is on
CPAP at night. His medications include metformin 1000mg bid, valsartan/HCTZ 160/25 qd, furosemide 20mg qd, and
tramadol 50mg BID prn.
Family history is remarkable for diabetes in both parents.
He is a veteran and is on disability. No history of smoking, alcohol use, or use of illicit drugs.
Examination discloses a morbidly obese man (BMI = 58) with BP 120/70. Subcutaneous tissue is quite prominent. Motor
strength is 5/5 in his lower extremities and reflexes are 2+ at the knees bilaterally. Pinprick and tactile sensation is slightly
decreased over the lateral aspects of both thighs.
A diagnosis of meralgia paresthetica is considered.

DISCUSSION
What is meralgia paresthetica?
Meralgia paresthetica (MP) is a clinical syndrome characterized by numbness, paresthesias, and pain in the anterolateral
thigh. It results from either an entrapment neuropathy or a neuroma of the lateral femoral cutaneous nerve (LFCN). The term
“meralgia paresthetica” comes from the Greek words meros (“thigh”) and algos (“pain”). Perhaps the most famous case is
that of Sigmund Freud, who described symptoms in himself as well as in one of his sons.
The LFCN is an entirely sensory nerve that is derived from one of several different combinations of the lumbar nerve roots
L1, L2, and L3. The nerve emerges from the lateral aspect of the psoas muscle and travels in a retroperitoneal route, beneath
the iliac fascia, across the anterior surface of the iliacus muscle, and toward the anterior superior iliac spine. Distally, it enters
the anterior region of the thigh by passing under, through, or above the inguinal ligament. During surgery in this region, the
nerve commonly becomes trapped, stretched, or injured.

What causes MP?

The etiology of this mononeuropathy is often multifactorial. It can
be caused by mechanical factors, metabolic diseases, and iatrogenic
factors. The nerve can be injured anywhere along its course: in a
retroperitoneal location, at the inguinal ligament, or at the point
where it penetrates the fascia lata in the thigh.
Mechanical causes, such as wearing seat belts, girdles, and tight
trousers, can result in direct pressure on the LFCN. Obesity,
pregnancy, and conditions associated with increased abdominal
pressure can also predispose to injury. Pelvic disease, including
pelvic tumors, can present as MP. In rare instances, a bone tumor in
the iliac crest can present as MP.
Metabolic disorders, such as diabetes mellitus, alcoholism, and lead
poisoning, can cause an isolated neuropathy of the LFCN.
The iatrogenic form occurs as a well-known complication of many
surgical procedures. For example, injury can occur during spine
procedures, iliac crest bone harvestings, hip replacements, and
aorto-bifemoral bypasses.
What is the clinical presentation of MP?
Patients typically describe numbness, tingling, pain, burning, and
decreased sensitivity to pain, touch, and temperature in the distribution of the LFCN. Hypersensitivity to touch and
dysesthesias may also be reported. Palpating the area in question usually aggravates symptoms.
Many patients have tenderness over the lateral inguinal ligament at the point where the nerve crosses the ligament. The
condition is exacerbated by hip extension during walking or getting into and out of an automobile. An area of hair loss may
be present on the thigh secondary to repetitive rubbing of the region by the patient.
The symptoms are usually unilateral, however, 20% of patients present with bilateral complaints.
What are the findings on the physical examination?
Pinprick and light touch tend to be abnormal in a 10" x 6" oval-shaped area on the anterolateral thigh, as illustrated below.
The distribution of the LFCN is not strictly lateral. Sensory abnormalities can also be seen over
the anterior thigh. The lower extremity neurologic examination is otherwise normal. In particular,
straight leg raise is negative and deep tendon reflexes and distal motor strength are preserved.
There is no evidence of hip, back, or sacroiliac joint abnormality.
The pelvic compression test is a simple, noninvasive test that has been recently described for MP.
It is based on the premise that, as the LFCN is compressed by the inguinal ligament, relaxing the
ligament should relieve pressure and lead to temporary alleviation of symptoms. To do the test,
the patient is asked to take a lateral position on the examination table with non-affected side
down. The patient should focus on the symptoms. Placing a hand on the symptomatic area to
enhance the dysesthesia can help. The examiner then applies a lateral compressive force on the
pelvis for 45 seconds and the patient is asked to report any changes in the nature and severity of the symptoms. A positive
test result is an improvement in symptoms.
What is the role of electrodiagnostic and imaging studies in the diagnosis of MP?
Sensory nerve conduction abnormalities have been described in MP. However, findings are extremely variable and it is often
difficult to perform a nerve conduction study in overweight individuals. If a nerve conduction study is performed, it is
essential to study the contralateral side for comparison. Electromyography (EMG) has no role in the diagnosis as there are no
motor manifestations. Though of limited utility for MP, EMG and nerve conduction studies can be used to evaluate for
lumbar radiculopathy or plexopathy, entities that are in the differential.
CAT scan of the abdomen and pelvis is sometimes useful in cases where a compressive cause like tumor is suspected.
What is the treatment of MP?
Initial treatment is directed at easing compression on the nerve. A history of recent weight gain, tightness when wearing
trousers, or recent trauma should be sought. The patient should avoid wearing tight clothing. Application of protective
padding over the involved region should be considered.
NSAIDs can be useful to alleviate pain. It can be worthwhile trying tricyclic antidepressants or anticonvulsants to treat
neuropathic pain. Topical agents, such as capsaicin cream and lidocaine patches, can be tried to decrease cutaneous
hypersensitivity.
More than 90 percent of patients respond to these conservative and symptomatic treatments.
MP in pregnancy usually resolves after delivery.
Injection of lidocaine and corticosteroid in the area of the inguinal ligament can be beneficial to decrease local inflammation
and swelling.
If complaints become intractable and disabling, surgery is an option. Decompression of the nerve by sectioning the inferior
slip of the attachment of the inguinal ligament to the anterior superior iliac spine can provide long lasting relief for some
patients. This procedure has the advantage of preserving sensory function, but it is not uniformly successful. Sectioning of
the LFCN as it exits the pelvis is the most definitive procedure, but has the disadvantage of permanent anesthesia.

THE CASE IN CONTEXT

Our patient is morbidly obese and diabetic and has episodic numbness involving lateral aspects of the thighs in the LFCN
territory. He most likely has MP. Obesity, weight gain, and diabetes play important roles as mechanical and metabolic
factors behind his nerve injury. As noted, having bilateral involvement is not unusual. Our patient does not have pain and his
symptoms are not disabling. He is advised to lose weight, avoid tight clothing, and use NSAIDs as needed. The importance
of diabetic control is emphasized.

REFERENCES
1. Grossman M, Ducey S, Nadle S, Levy T. Meralgia paresthetica: diagnosis and treatment. J Am Acad Orthop Surg
2001; 9: 336-344.
2. Nouraei R, Anand B. A novel approach to the diagnosis and management of meralgia paresthetica. Neurosurgery
2007; 60:696–700.
3. Parisi T, Mandrekar J. Meralgia paresthetica: relation to obesity, advanced age, and diabetes mellitus. Neurology
2011; 77: 1538-1542.
4. UpToDate 2011.