Meralgia Paresthetica Surgery

Meralgia Paresthetica Surgery

Options include:

NeurolysisNeurectomyTransposition.

Selective L2 nerve stimulation

In Neurectomy there are risks of denervation pain, and leaves an anesthetic area (usually a minor nuisance). May be best reserved for treatment failures.

There was insufficient evidence to recommended neurolysis or neurectomy treatment over the other. This highlights the importance of keeping a registry in order to compare outcomes between the two methods of treatment 1).

Approach

The operation is best performed under general anesthesia. A 4–6 cm oblique incision is centered 2 cm distal to the point of tenderness. Since the course of the nerve is variable, the operation is exploratory in nature, and generous exposure is required. If the nerve can’t be located, it is usually because the exposure is too superficial. If the nerve still cannot be found, a small abdominal muscle incision can be made and the nerve may be located in the retroperitoneal area. CAUTION: cases have occurred where the femoral nerve has erroneously been divided.

If neurectomy instead of neurolysis is elected, electrical stimulation should be performed prior to sectioning to rule out a motor component (which would disqualify the nerve as the LFCN). If the nerve is to be divided, it should be placed on stretch and then cut to allow the proximal end to retract back into the pelvis. Any segment of apparent pathology should be resected for microscopic analysis. Neurectomy results in anesthesia in the distribution of the LFCN that is rarely distressing and gradually reduces in size. A supra-inguinal ligament approach has also been described 2).

The considerable anatomic variability of this nerve may complicate surgical localization and thus prolong operative time. Ellis et al., report the use of preoperative high-resolution ultrasonography to map the LFCN in a patient with bilateral meralgia paresthetica. This simple, noninvasive imaging technique was seen to be effective at providing precise localization of the entrapped and, in this case, bilateral anatomically variant nerves. Preoperative high-resolution ultrasound mapping of the LCFN can be used to facilitate precise operative localization in the treatment of bilateral meralgia paresthetica. This is especially useful in the setting of suspected unusual nerve anatomy 3).


Malessy et al., presented a new technique using dynamic decompression and discussed the outcomes.

A retrospective cohort study was performed in a consecutive series of 19 cases. The goal of decompression was pain relief and recovery of sensation. The plane ventral to the LFCN was decompressed by cutting the fascia lata and the inferior aspect of the inguinal ligament. The plane dorsal to the LFCN was decompressed by cutting the fascia of the sartorius muscle. Subsequently, the thigh was brought in full range of flexion and extension/abduction. The authors identified and additionally cut fibers that tightened and caused compression at various locations of the LFCN during movement in all patients, referring to this technique as dynamic decompression. Postoperatively, an independent neurologist scored pain and sensation on a 4-point scale: completely resolved, improved, not changed, or worsened. Patients scored their remaining pain or sensory deficit as a percentage of the preoperative level. Statistical assessment was done using ANOVA to assess the association between outcome and duration of preoperative symptoms, BMI, and length of follow-up.

In 17 of the 19 cases (89%), the pain and/or paresthesia completely resolved. Patients in the remaining 2 cases (11%) experienced 70% and 80% reduction in pain. Sensation completely recovered in 13 of the 19 cases (69%). In 5 of the 19 cases (26%) sensation improved, but an area of hypesthesia remained. Four of these 5 patients indicated a sensory improvement of more than 75%, and the remaining patient had 50% improvement. Sensation remained unchanged in 1 case (5%) with persisting hypesthesia and mild hyperesthesia. There was no significant impact of preoperative symptom duration, BMI, and length of follow-up on postoperative outcome.

Dynamic decompression of the LFCN is an effective technique for the treatment of iMP. Most patients become completely pain free and sensation recovers considerably 4).

Transposition

Nineteen patients with meralgia paresthetica were treated in the Department of Neurological Surgery at University of Wisconsin between 2011 and 2016; 4 patients underwent simple decompression, 5 deep decompression, and 10 medial transposition. Data were collected prospectively and analyzed retrospectively. No randomization was performed. The groups were compared in terms of pain scores (based on a numeric rating scale) and reoperation rates.RESULTSThe numeric rating scale scores dropped significantly in the deep-decompression (p = 0.148) and transposition (p < 0.0001) groups at both the 3- and 12-month follow-up. The reoperation rates were significantly lower in the deep-decompression and transposition groups (p = 0.0454) than in the medial transposition group.CONCLUSIONSBoth deep decompression and transposition of the LFCN provide better results than simple decompression. Medial transposition confers the advantage of mobilizing the nerve away from the anterior superior iliac spine, giving it a straighter and more relaxed course in a softer muscle bed 5).

Neuromodulation

Philip et al., described the first reported use of pulsed radiofrequency neuromodulation to relieve the intractable pain associated with meralgia paresthetica.

A 33-year-old morbidly obese female with a history of lower back pain and previous spinal fusion presented with sensory dysesthesias and paresthesias in the right anterolateral thigh, consistent with meralgia paresthetica. Temporary relief occurred with multiple lateral femoral cutaneous nerve and fascia lata blocks at 2 different institutions. The patient expressed dissatisfaction with her previous treatments and requested “any” therapeutic intervention that might lead to long-lasting pain relief. At this time, we located the anterior superior iliac spine and reproduced concordant dysesthesia. Pulsed radiofrequency was then undertaken at 42 degrees C for 120 seconds followed by dexamethasone and bupivicaine. The patient reported exceptional and prolonged pain relief at 6-month follow-up.

Since this case report is not a prospective, randomized, controlled or blinded study, no conclusions may be drawn from the results attained on behalf of this single individual. Additional, larger group analyses studying this technique while eliminating bias from patient variables would be essential prior to assuming any validity to using pulsed radiofrequency techniques of neuromodulation for managing peripheral neuropathic pain processes.

The patient had experienced long-standing pain that was recalcitrant to conservative/pharmacologic therapy and multiple nerve blocks with local steroid instillations. A single treatment with pulsed radiofrequency resulted in complete and sustained cessation of pain. No side effects were evident. Pulsed radiofrequency of the LFCN may offer an effective, low risk treatment in patients with meralgia paresthetica who are refractory to conservative medical management or are unwilling or unfit to undergo surgery 6).

Case series

Patients whose symptoms did not improve after medical and conservative treatment for at least 3 months were included in this study. These patients underwent neurolysis and decompression surgery and had a mean postoperative follow-up of 38 months. Their pain levels were assessed by the VAS scoring system.

In 8 (61.5%) patients, the symptoms completely resolved within the first 3 months. In 5 (38.5%) patients, the complaints persisted partially and the recovery was observed after 12 months. In patients having a metabolic etiology, the duration of recovery was up to 12 months.

The long term results of surgery are good though only partial improvements in reported pain were seen in the early postoperative period, especially in patients with a metabolic etiology 7).


A total of 16 surgical decompressions could be identified. Retrospective analysis of prospectively collected patient data was performed, as well as systematic evaluation of the postoperative course, with regular follow-up examinations based on a standardized protocol. Pain was analyzed using an NRS (numeric rating scale). Several postsurgical parameters, including temperature hypersensitivity and numbness in the LFCN region, were compared with the presurgical data.Sixty-nine percent of patients had histories of trauma or surgery, which were designated as the onset of pain. Of these patients, 78% had hip prostheses, 2 had previous falls. Postoperatively, a significant reduction of 6.6 points in the mean NRS pain value was observed. All other evaluated parameters also improved postoperatively. Patient satisfaction was high, with 86% reporting complete satisfaction, and 14% reporting partial satisfaction.Previous studies favor either avulsion/neurectomy as the preferred procedure for MP treatment, or provide no recommendation. Our findings instead confirm the decompression/neurolysis approach as the primary surgical procedure of choice for the treatment of MP, if conservative treatment fails 8).


Six patients with intractable meralgia paresthetica with severe pain over antero-lateral thigh along the distribution of lateral cutaneous nerve of thigh which was further confirmed by nerve conduction study. These patients did not respond to the oral anti-neuropathic medications. The two successive diagnostic lateral femoral cutaneous nerve block not only had confirmed the diagnosis but also provided pain relief for a few days. Then the ultrasound-guided lateral femoral cutaneous nerve neurolysis was done using 50% alcohol. In all the patients, there were more than 50% decrease in pain intensity and improvement in quality of life after the procedure, and the relief and improvement were maintained for up to 12 weeks. This case series shows ultrasound-guided lateral femoral cutaneous nerve neurolysis is a safe and effective treatment for intractable meralgia paresthetica and also provides prolonged pain relief and is a good option in avoiding the surgery. Summary points The literature on neurolysis is rare, with only few case reports. This is the first case series on this topic, and it will greatly improve the evidence that ultrasound-guided neurolysis can also be used for intractable meralgia paresthetica patients who do not respond to conservative measures before proceeding to surgery 9).

References

1)

Payne R, Seaman S, Sieg E, Langan S, Harbaugh K, Rizk E. Evaluating the evidence: is neurolysis or neurectomy a better treatment for meralgia paresthetica? Acta Neurochir (Wien). 2017 May;159(5):931-936. doi: 10.1007/s00701-017-3136-x. Epub 2017 Mar 10. Review. PubMed PMID: 28283866.
2)

Aldrich EF, Van den Heever C. Suprainguinal Liga- ment Approach for Surgical Treatment of Meralgia Paresthetica. Technical Note. J Neurosurg. 1989; 70:492–494
3)

Ellis J, Schneider JR, Cloney M, Winfree CJ. Lateral Femoral Cutaneous Nerve Decompression Guided by Preoperative Ultrasound Mapping. Cureus. 2018 Nov 28;10(11):e3652. doi: 10.7759/cureus.3652. PubMed PMID: 30723651; PubMed Central PMCID: PMC6351113.
4)

Malessy MJA, Eekhof J, Pondaag W. Dynamic decompression of the lateral femoral cutaneous nerve to treat meralgia paresthetica: technique and results. J Neurosurg. 2018 Dec 1:1-9. doi: 10.3171/2018.9.JNS182004. [Epub ahead of print] PubMed PMID: 30544337.
5)

Hanna A. Transposition of the lateral femoral cutaneous nerve. J Neurosurg. 2018 Apr 1:1-6. doi: 10.3171/2017.8.JNS171120. [Epub ahead of print] PubMed PMID: 29652230.
6)

Philip CN, Candido KD, Joseph NJ, Crystal GJ. Successful treatment of meralgia paresthetica with pulsed radiofrequency of the lateral femoral cutaneous nerve. Pain Physician. 2009 Sep-Oct;12(5):881-5. PubMed PMID: 19787014.
7)

Ataizi ZS, Ertilav K, Ercan S. Surgical options for meralgia paresthetica: long-term outcomes in 13 cases. Br J Neurosurg. 2018 Nov 19:1-4. doi: 10.1080/02688697.2018.1538480. [Epub ahead of print] PubMed PMID: 30451004.
8)

Schwaiger K, Panzenbeck P, Purschke M, Russe E, Kaplan R, Heinrich K, Mandal P, Wechselberger G. Surgical decompression of the lateral femoral cutaneous nerve (LFCN) for Meralgia paresthetica treatment: Experimental or state of the art? A single-center outcome analysis. Medicine (Baltimore). 2018 Aug;97(33):e11914. doi: 10.1097/MD.0000000000011914. PubMed PMID: 30113491; PubMed Central PMCID: PMC6113044.
9)

Ahmed A, Arora D, Kochhar AK. Ultrasound-guided alcohol neurolysis of lateral femoral cutaneous nerve for intractable meralgia paresthetica: a case series. Br J Pain. 2016 Nov;10(4):232-237. Epub 2016 Sep 16. PubMed PMID: 27867513; PubMed Central PMCID: PMC5102099.

Neurologic Injury after Lateral Lumbar Interbody Fusion

Since the first description of LLIF in 2006, the indications for LLIF have expanded and the rate of LLIF procedures performed in the USA has increased. LLIF has several theoretical advantages compared to other approaches including the preservation of the anterior and posterior annular/ligamentous structures, insertion of wide cages resting on the dense apophyseal ring bilaterally, and augmentation of disc height with indirect decompression of neural elements. Favorable long-term outcomes and a reduced risk of visceral/vascular injuries, incidental dural tears, and perioperative infections have been reported. However, approach-related complications such as motor and sensory deficits remain a concern. In well-indicated patients, LLIF can be a safe procedure used for a variety of indications 1).

Hijji et al. published a systematic review analyzing the complication profile of LLIF. Their study included a total of 63 articles and 6819 patients. The most commonly reported complications were transient neurologic injury (36.07%). The clinical significance of those transient findings, however, is unclear since the rate of persistent neurologic complications was much lower (3.98%) 2)

The risk of lumbar plexus injury is particularly concerning at the L4-5 disc space. Although LLIF is associated with an increased prevalence of anterior thigh/groin pain as well as motor and sensory deficits immediately after surgery, our results support that pain and neurologic deficits decrease over time. The level treated appears to be a risk factor for lumbosacral plexus injury 3).

Interestingly, the use of rhBMP-2 was associated with higher rates of persistent motor deficits, which might be explained by a direct deleterious effect of this agent on the lumbosacral plexus 4).

In a retrospective chart review of 118 patients, Cahill et al. determined the incidence of femoral nerve injury, which is considered one of the worst neurological complications after LLIF. The authors reported an approximate 5% femoral nerve injury rate of all the LLIF procedures performed at L4-5. There were no femoral nerve injuries at any other levels 5).

During a 6-year time period of performing LLIF Aichmair et al., noted a learning curve with a decreasing proportional trend for anterior thigh pain, sensory as well as motor deficits 6)

Le et al. also observed a learning curve with a significant reduction in the incidence of postoperative thigh numbness during a 3-year period (from 26.1 to 10.7%) 7).

Levi AD from the University of Miami Hospital, adopted an exclusive mini-open muscle-splitting approach in LLIF with first-look inspection of the lumbosacral plexus nerve elements taht may improve motor and sensory outcomes in general and the incidence of postoperative groin/thighsensory dysfunction and psoas-pattern weakness in particular 8).

References

1)

Salzmann SN, Shue J, Hughes AP. Lateral Lumbar Interbody Fusion-Outcomes and Complications. Curr Rev Musculoskelet Med. 2017 Dec;10(4):539-546. doi: 10.1007/s12178-017-9444-1. Review. PubMed PMID: 29038952; PubMed Central PMCID: PMC5685966.
2)

Hijji FY, Narain AS, Bohl DD, Ahn J, Long WW, DiBattista JV, Kudaravalli KT, Singh K. Lateral lumbar interbody fusion: a systematic review of complication rates. Spine J. 2017 Oct;17(10):1412-1419. doi: 10.1016/j.spinee.2017.04.022. Epub 2017 Apr 26. Review. PubMed PMID: 28456671.
3)

Lykissas MG, Aichmair A, Hughes AP, Sama AA, Lebl DR, Taher F, Du JY, Cammisa FP, Girardi FP. Nerve injury after lateral lumbar interbody fusion: a review of 919 treated levels with identification of risk factors. Spine J. 2014 May 1;14(5):749-58. doi: 10.1016/j.spinee.2013.06.066. Epub 2013 Sep 5. PubMed PMID: 24012428.
4)

Lykissas MG, Aichmair A, Hughes AP, Sama AA, Lebl DR, Taher F, Du JY, Cammisa FP, Girardi FP. Nerve injury after lateral lumbar interbody fusion: a review of 919 treated levels with identification of risk factors. Spine J. 2014 May 1;14(5):749-58. doi: 10.1016/j.spinee.2013.06.066. Epub 2013 Sep 5. PubMed PMID: 24012428.
5)

Cahill KS, Martinez JL, Wang MY, Vanni S, Levi AD. Motor nerve injuries following the minimally invasive lateral transpsoas approach. J Neurosurg Spine. 2012 Sep;17(3):227-31. doi: 10.3171/2012.5.SPINE1288. Epub 2012 Jun 29. PubMed PMID: 22746272.
6)

Aichmair A, Lykissas MG, Girardi FP, Sama AA, Lebl DR, Taher F, Cammisa FP, Hughes AP. An institutional six-year trend analysis of the neurological outcome after lateral lumbar interbody fusion: a 6-year trend analysis of a single institution. Spine (Phila Pa 1976). 2013 Nov 1;38(23):E1483-90. doi: 10.1097/BRS.0b013e3182a3d1b4. PubMed PMID: 23873231.
7)

Le TV, Burkett CJ, Deukmedjian AR, Uribe JS. Postoperative lumbar plexus injury after lumbar retroperitoneal transpsoas minimally invasive lateral interbody fusion. Spine (Phila Pa 1976). 2013 Jan 1;38(1):E13-20. doi: 10.1097/BRS.0b013e318278417c. PubMed PMID: 23073358.
8)

Sellin JN, Brusko GD, Levi AD. Lateral Lumbar Interbody Fusion Revisited: Complication Avoidance and Outcomes with the Mini-Open Approach. World Neurosurg. 2019 Jan;121:e647-e653. doi: 10.1016/j.wneu.2018.09.180. Epub 2018 Oct 3. PubMed PMID: 30292030.

UpToDate: Intraneural ganglion cyst

An intraneural ganglion cyst (INGC) is a non-neoplastic mucinous cyst within the epineurium of a nerve and commences from an adjoining joint 1) 2)3) 4) 5) 6) 7).

These cysts are filled with a mucinous material which is walled off by a fibrous layer 8) 9) 10)

An intraneural ganglion cyst is an uncommon occurrence of the peripheral nerves.

Types

The most common type is the peroneal intraneural ganglion cyst. Other reported sites of involvement are the radial, ulnar, median, sciatic, tibial, and posterior interosseus nerves. The first case of intraneural ganglion cyst of the tibial nerve was described in 1967.

Etiology

According to the most widely accepted theory (articular/synovial theory), the cysts are formed from a capsular defect of an adjacent joint, so that synovial fluid spreads along the epineurium of a nerve branch 11).

Clinical features

As these cysts expand within the epineurium, they displace and compress the adjacent nerve fascicles leading to pain, paresthesia, tingling and muscle paralysis in the distribution of the involved nerve 12) 13).

Diagnosis

MRI is the method of choice for diagnosing intraneural ganglion cysts. However, ultrasound is also important 14).

Differential diagnosis

The differential considerations for cystic intraneural lesions include cystic nerve sheath tumors, atypical Baker’s cyst, and extraneural ganglion.

Cystic nerve sheath tumors such as schwannomas and extraneural ganglion can be differentiated from cystic intraneural lesions by MRI. A Baker’s cyst classically is more mass-like, with a characteristic location extending from the tibiofemoral joint to within the confines of the medial head of the gastrocnemius and the muscles of the joint capsule 15).

Treatment

Surgery is the only curative treatment with treatment success being dependent on ligature of the nerve endings supplying the articular branch 16).

Case series

Fricke et al. from Kiel, examined between 2011 and 2018 the patients using lower limb MRI. MRI scans were also performed for the follow-up examinations.

The patients had many symptoms. They were able to accurately detect the intraneural ganglion cysts on MRI and provide the treating surgeons with the basis for the operation to be performed.

The success of surgical therapy depends on the resection of the nerve endings supplying the joint as the only way to treat the origin of the disease and prevent recurrence. Based on there case studies, they can support the commonly favored articular/synovial theory. 17).

References

1) , 8)

Patel P, Schucany WG. A rare case of intraneural ganglion cyst involving the tibial nerve. Proc (Bayl Univ Med Cent) 2012;25:132–135.

2) , 9)

Uetani M, Hashmi R, Hayashi K, Nagatani Y, Narabayashi Y, Imamura K. Peripheral nerve intraneural ganglion cyst: MR findings in three cases. J Comput Assist Tomogr. 1998;22:629–632.

3) , 10)

Harbaugh KS, Tiel RL, Kline DG. Ganglion cyst involvement of peripheral nerves. J Neurosurg. 1997;87:403–408.

4)

Spinner RJ, Desy NM, Rock MG, Amrami KK. Peroneal intraneural ganglia. Part I. Techniques for successful diagnosis and treatment. Neurosurg Focus. 2007;22:E16.

5)

Jacobs RR, Maxwell JA, Kepes J. Ganglia of the nerve. Presentation of two unusual cases, a review of the literature, and a discussion of pathogenesis. Clin Orthop Relat Res. 1975:135–144.

6)

Adn M, Hamlat A, Morandi X, Guegan Y. Intraneural ganglion cyst of the tibial nerve. Acta Neurochir (Wien) 2006;148:885–889; discussion 889-890.

7)

Johnston JA, Lyne DE. Intraneural ganglion cyst of the peroneal nerve in a four-year-old girl: a case report. J Pediatr Orthop. 2007;27:944–946.

11) , 14) , 16) , 17)

Fricke T, Schmitt AD, Jansen O. Intraneural ganglion cysts of the lower limb. Rofo. 2018 Nov 19. doi: 10.1055/a-0777-2525. [Epub ahead of print] English, German. PubMed PMID: 30453381.

12)

Tehli O, Celikmez RC, Birgili B, Solmaz I, Celik E. Pure peroneal intraneural ganglion cyst ascending along the sciatic nerve. Turk Neurosurg. 2011;21:254–258.

13)

Liang T, Panu A, Crowther S, Low G, Lambert R. Ultrasound-guided aspiration and injection of an intraneural ganglion cyst of the common peroneal nerve. HSS J. 2013;9:270–274.

15)

Patel P, Schucany WG. A rare case of intraneural ganglion cyst involving the tibial nerve. Proc (Bayl Univ Med Cent). 2012 Apr;25(2):132-5. PubMed PMID: 22481843; PubMed Central PMCID: PMC3310510.
intraneural_ganglion_cyst.txt · Last modified: 2018/11/20 20:09 by administrador

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