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Dynamic Decompression of the Lateral Femoral Cutaneous Nerve to Treat Meralgia Paresthetica: Technique and Results

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Dynamic Decompression of the Lateral Femoral Cutaneous Nerve to Treat Meralgia Paresthetica: Technique and Results CLINICAL ARTICLE J Neurosurg 131:1552–1560, 2019 Dynamic decompression of the lateral femoral cutaneous nerve to treat meralgia paresthetica: technique and results Martijn J. A. Malessy, MD, PhD,1,2 Job Eekhof, MD, PhD,2 and Willem Pondaag, MD, PhD1,2 1Leiden University Medical Center, and 2Alrijne Medical Center, Leiden, The Netherlands OBJECTIVE The results of lateral femoral cutaneous nerve (LFCN) decompression to treat idiopathic meralgia pares- thetica (iMP) vary widely. Techniques to decompress the LFCN differ, which may affect outcome, but in MP it is unknown to what extent. The authors present a new technique using dynamic decompression and discuss the outcomes. METHODS 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 identi- fied 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 re- maining 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. RESULTS 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 un- changed in 1 case (5%) with persisting hypesthesia and mild hyperesthesia. There was no significant impact of preop- erative symptom duration, BMI, and length of follow-up on postoperative outcome. CONCLUSIONS Dynamic decompression of the LFCN is an effective technique for the treatment of iMP. Most patients become completely pain free and sensation recovers considerably. https://thejns.org/doi/abs/10.3171/2018.9.JNS182004 KEYWORDS lateral femoral cutaneous nerve; meralgia paresthetica; dynamic decompression; peripheral nerve; nerve surgery AIN, paresthesia, and abnormal skin sensation on Treatment for iMP either is conservative or consists of the lateral side of the thigh result from pathology of 1) local injection with a combination of steroids with an different origins in the course of spinal nerves L2 anesthetic; 2) pulsed radiofrequency (PRF); 3) spinal cord Pand L3 to the lateral femoral cutaneous nerve (LFCN). stimulation; or 4) surgery.34 The objective evidence base The clinical diagnosis of idiopathic meralgia paresthetica for treatment choices is weak.23 Two surgical techniques (iMP) is made when a herniated lumbar disc or a pelvic are currently in use, namely LFCN decompression and tumor is excluded and the symptoms are not caused by neurectomy. It is unknown whether one technique is supe- trauma or surgical intervention. In the 1960s, it became rior to the other.23,35 generally accepted that the cause of iMP is compression of Over time, different techniques of decompression have the LFCN in its location beneath the lateral portion of the been described, consisting of cutting 1) the inguinal liga- inguinal ligament at the site of the anterior superior iliac ment over the femoral nerve;32 2) the division of the up- spine (ASIS).21 per blade of the inguinal ligament and deep fascia of the ABBREVIATIONS ASIS = anterior superior iliac spine; iMP = idiopathic meralgia paresthetica; LFCN = lateral femoral cutaneous nerve; PRF = pulsed radiofrequency; RCT = randomized controlled trial. SUBMITTED July 11, 2018. ACCEPTED September 26, 2018. INCLUDE WHEN CITING Published online December 7, 2018; DOI: 10.3171/2018.9.JNS182004. 1552 J Neurosurg Volume 131 • November 2019 ©AANS 2019, except where prohibited by US copyright law Unauthenticated | Downloaded 10/07/21 09:54 AM UTC Malessy et al. thigh;26 3) a small portion of the fibrous origin of the inter- TABLE 1. Data for patients who underwent decompression of the nal abdominal oblique muscle;27 and 4) a slot in the crest LFCN 28 of the ilium posterior to the ASIS. Other techniques are Variable Mean SD Median Range medial transposition of the LFCN17 and minimally inva- sive neurolysis.8 Textbooks and handbooks usually pro- Age (yrs) 50 8 54 27–61 vide fairly superficial information regarding the technique Duration of symptoms (yrs)* 61 70 23 9–223 of decompression.6,7,16,20,22,24,25,30,37,42 Follow-up (mos) 27 18 25 5–58 Many articles have reported the results of LFCN de- BMI (kg/m2) 30.2 5.5 28.2 21.5–39.2 compression. In the latest Cochrane review on treatment for i M P, 23 only 9 articles were considered of high quality Seventeen patients (12 women and 5 men) underwent 19 procedures. Two 2,13,15,29,31,33,38,41,44 men underwent LFCN decompression bilaterally. and were included. For unclear reasons, 2 * Interval between onset of symptoms and operation. studies that actually met the criteria were not used.4,39 Un- fortunately, 62,13,15,31,33,41 of these 112,4,13, 15, 29, 31, 33, 38, 39, 41,44 pa- pers could not be used to determine the relationship of the has not been described before. Here, we describe our tech- decompression technique and its outcome for the following nique in detail and present the results. reasons. First, patients with idiopathic as well as symptom- atic MP were grouped.2,13 It is known that the etiology un- derlying MP symptoms affects the outcome of decompres- Methods sion.4 Second, revision decompression or neurectomy was Patient Population performed following failed decompression, but was scored We performed a retrospective cohort study in a con- as one treatment.33 Third, results of decompression or neu- 41 secutive case series of patients who underwent dynamic rectomy were pooled. Fourth, nerves originating from LFCN decompression to treat iMP in the period between the femoral nerve were decompressed,41 which makes it 43 June 2013 and December 2017. unlikely that these nerves were the LFCN. Fifth, patients The indication for surgery was the presence in the were children15 or concerned only those with symptomatic 31 LCFN area of 1) persistent, annoying pain and/or pares- M P. thesia; and 2) abnormal sensation of the skin (hypesthe- The 5 remaining papers comprise well-delineated sia, dysesthesia, hyperesthesia, allodynia, or hyperalgesia). groups. Pain relief was obtained in 30% to 82% of the Patients had been previously treated elsewhere, but their 4,29,38,39,44 patients. Unfortunately, only 3 of these 5 articles symptoms were refractory to conservative measures, local included details regarding the surgical technique per- injection containing steroids and anesthetic, or, occasion- formed and were thus eligible for relating technique to out- ally, PRF. come.4,38,39 Benezis et al. performed ventral decompression Patients were excluded if they had prior LFCN sur- of the LFCN by opening the fascia lata and by sectioning gery. All patients were tested for symptomatic MP based the inguinal ligament. Complete pain relief was obtained on neuropathy due to prolonged external compression, in 64% of the patients.4 Siu and Chandran and Son et al. traumatic lesion in the area of the ASIS, an L2 or L3 ra- additionally addressed 3 structures dorsal to the LFCN, diculopathy, a lumbar plexopathy, a femoral neuropathy, namely a posterior sling of fascia from the inguinal liga- a lower abdominal wall procedure, or an iliac bone graft ment, the tendinous arc from the iliac fascia, and the dis- harvest. All patients had ultrasound and/or MRI examina- tal deep fascia of the thigh. Complete relief was achieved tions to rule out a retroperitoneal or intrapelvic mass. Ad- in 73% and 82% of the patients, respectively.38,39 Recently, ditional exclusion criteria were age ≤ 18 years or inability the effect on outcome of implementing technical modifica- to communicate in Dutch. tions was published.17 The number of patients per group Seventeen patients (12 women) met these criteria (Table was small and follow-up incomplete, making a meaning- 1). In 2 patients, the LFCN was decompressed bilaterally ful interpretation impossible. However, the applied surgical in separate sessions after full recovery of the first opera- modifications17 mirror the trend in time.4,38,39 Initially, only tion, amounting to 19 cases. ventral decompression was performed, and later dorsal de- The mean age of the patients at surgery was 50 years compression was added. Better outcomes were obtained (SD 8, range 27–61, and median 54 years). The mean in- with more extensive decompression. terval between onset of symptoms and operation was 61 The large variation in the reported outcome of LFCN months (SD 70, range 9–223, and median 23 months). The decompression for iMP is striking.4,29,38,39,44 This might be mean follow-up was 27 months (SD 18, range 5–58, and explained not only by inclusion bias, but also by the applied median 25 months). The mean BMI was 30.2 kg/m2 (SD surgical technique. In any case, so far all decompressions 5.5, range 21.5–39.2, and median 28.2 kg/m2).
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