Meralgia Paresthetica.

PURPOSE OF REVIEW: This review article summaries the epidemiology, etiology, clinical presentations, and latest treatment modalities of meralgia paresthetica, including the latest data about peripheral and spinal cord stimulation therapy. Meralgia paresthetica (MP) causes burning, stinging, or numbness in the anterolateral part of the thigh, usually due to compression of the lateral femoral cutaneous nerve (LFCN). RECENT FINDINGS: There are emerging data regarding the benefit of interventional pain procedures, including steroid injection and radiofrequency ablation, and other interventions including spinal cord and peripheral nerve stimulation reserved for refractory cases. The strength of evidence for treatment choices in meralgia paraesthetica is weak. Some observational studies are comparing local injection of corticosteroid versus surgical interventions. However, more extensive studies are needed regarding the long-term benefit of peripheral and spinal cord stimulation therapy.

Risk factors of meralgia paresthetica after prone position surgery: Possible influence of operating position, laminectomy level, and preoperative thoracic kyphosis.

Obesity and a prolonged surgical duration are reported risk factors for meralgia paresthetica (MP) after prone position surgery; however, this fails to explain why MP seldom occurs after prone position craniotomy. We reviewed the incidence of MP after spinal surgery and craniotomy in the prone position and investigated whether unidentified factors are involved in the mechanism of postoperative MP. Between January 2014 and March 2020, we performed 556 prone position surgeries. We excluded patients aged ≤16 years and those who were comatose or who required redo-surgery, and reviewed 446 eligible patients (124 who underwent craniotomies and 322 who underwent posterior spinal surgeries). Postoperative MP occurred in 46 (10.3%) patients with a higher incidence after spinal surgery than after craniotomy (13.7% vs. 1.6%, p < 0.001). Among the 322 patients who received posterior spinal surgery, thoracic and lumbar laminectomies were associated with a higher incidence of MP than cervical laminectomy. Analyses limited to those patients who received thoracic and lumbar laminectomies revealed that the preoperative thoracic kyphosis (TK) angle was significantly greater in patients with MP than in those without MP (average TK angle, 38.9° vs. 23.1°; p < 0.001), and that the preoperative lumbar lordosis angle did not significantly differ between the two groups. Apart from the known predisposing factors, we found that thoracolumbar-sacral laminectomy in patients with a greater TK angle is also a risk factor for MP after prone position surgery.

Carpal Tunnel Syndrome and Meralgia Paresthetica in Pregnancy.

IMPORTANCE: Carpal tunnel syndrome and meralgia paresthetica are 2 common neuropathies complicating pregnancy. Each of these causes significant discomfort but can be diagnosed and treated safely during pregnancy. OBJECTIVE: This article outlines the existing literature diagnosis, treatment, and prognosis of carpal tunnel syndrome and meralgia paresthetica, specifically looking at the implications during pregnancy. The aim is to provide a reference for physicians diagnosing and treating neuropathies in pregnant patients. EVIDENCE ACQUISITION: Existing literature on neuropathies during pregnancy, clinical presentation, and treatment options for both carpal tunnel syndrome and meralgia paresthetica was reviewed through a MEDLINE and PubMed search. Referenced articles were reviewed and used as primary source materials as appropriate. RESULTS: Carpal tunnel syndrome affects individuals of all ages and sexes but is more prevalent in women, particularly during pregnancy. Meralgia paresthetica can occur in various circumstances but is most commonly associated with prolonged second stage in lithotomy position. Multiple clinical signs and neurologic tests are useful to establish the diagnosis of either neuropathy. Effective treatment for carpal tunnel syndrome includes wrist splints, steroid and lidocaine injections, and release surgery. Optimal treatment of meralgia paresthetica remains controversial but includes nerve block injections and active release techniques. CONCLUSIONS AND RELEVANCE: Neuropathies are common in pregnancy and can result in significant impairment. Accurate diagnosis is possible during pregnancy and can usually be accomplished with bedside neurologic tests. Treatment options can be safely considered during pregnancy and can result in symptomatic improvement and reduction in chronic symptoms.

The Correlation of Meralgia Paresthetica and Spinal Surgery in Prone Position.

AIM: To investigate the incidence, risk factors, and recovery of patients with meralgia paresthetica (MP) following posterior spine surgery. MATERIAL AND METHODS: Patients who underwent posterior spine surgeries in prone position at the authors’ clinics were included in this study. Patients with preoperative MP were excluded. RESULTS: Among the 560 patients who underwent spine surgery in prone position, 117 (21%) had impaired sensation along the anterolateral aspect of the thigh. One hundred three of them were treated with conservative treatment, whereas 14 underwent surgery for MP. CONCLUSION: Conservative treatment is the first option for MP. Patients who do not recover with conservative treatment may undergo surgical treatment.

Association Between Surgical Level and Early Postoperative Thigh Symptoms Among Patients Undergoing Standalone Lateral Lumbar Interbody Fusion.

BACKGROUND: Lateral lumbar interbody fusion (LLIF) has often been associated with postoperative lumbar plexus symptoms, including pain, paresthesia, and motor deficits in the lower extremities, especially the anterior thigh regions. Previous studies have suggested that LLIF procedures at L4-L5 will be associated with a greater motor deficit rate than other levels. However, it is unclear which level has the greatest risk of pain and paresthesia. The purpose of the present retrospective observational study was to investigate the difference in the incidence of early postoperative thigh symptoms (pain and paresthesia) stratified by procedure level among patients who had undergone standalone LLIF. METHODS: We reviewed the data from consecutive patients who had undergone LLIF at a single academic institution. A total of 285 standalone LLIF cases without preoperative motor deficits were identified. The incidence of postoperative thigh pain and paresthesia at the 6-week postoperative follow-up examination was assessed at all levels from T12-L1 to L4-L5. RESULTS: A total of 81 patients (28.4%) had anterior thigh pain and 62 (21.8%) had anterior thigh paresthesia. The presence of ≥3 levels fused (odds ratio [OR], 2.96; P = 0.004) and surgery at L2-L3 (OR, 2.59; P = 0.001) were significant risk factors for postoperative anterior thigh paresthesia on univariate analysis but were not associated with anterior thigh pain. Multivariate analyses demonstrated that only surgery L2-L3 was an independent risk factor for anterior thigh paresthesia (OR, 2.09; P = 0.049). CONCLUSIONS: Our results have demonstrated that standalone LLIF at the L2-L3 was significantly associated with a greater incidence of postoperative anterior thigh paresthesia but that the incidence of postoperative thigh pain showed no significant association with any operative level.

Reducing Lateral Femoral Cutaneous Nerve Palsy in Obese Patients in the Beach Chair Position: Effect of a Standardized Positioning and Padding Protocol.

INTRODUCTION: To report on the effectiveness of a standardized patient positioning and padding protocol in reducing lateral femoral cutaneous nerve (LFCN) palsy in obese patients who have undergone shoulder surgery in the beach chair position. METHODS: We retrospectively reviewed the medical records of 400 consecutive patients with a body mass index (BMI) of ≥30 kg/m who underwent either open or arthroscopic shoulder surgery in the beach chair position by a single surgeon. Before June 2013, all patients were placed in standard beach chair positioning with no extra padding. After June 2013, patients had foam padding placed over their thighs underneath a wide safety strap and underneath the abdominal pannus. Flexion at the waist was minimized, and reverse Trendelenburg was used to position the shoulder appropriately. Patient demographic and surgical data, including age, sex, weight, BMI, presence of diabetes, procedure duration, American Society of Anesthesiologists (ASA) grade, and anesthesia type (general, regional, regional/general) were recorded. Symptoms of LFCN palsy were specifically elicited postoperatively in a prospective fashion and identified clinically by focal pain, numbness, and/or tingling over the anterolateral thigh. RESULTS: The median age was 58.0 years, and the study consisted of 142 male (36%) and 258 female (64%) subjects. Five cases (3.6%) of LFCN palsy occurred with conventional beach chair positioning, and a single case (0.4%) occurred with the standardized positioning and padding technique (P = 0.02). Median age, sex, presence of diabetes, median BMI, surgery type, and surgical time were not significantly different between the patients who did and did not develop LFCN palsy. All cases resolved completely within 6 months. DISCUSSION: The occurrence of LFCN palsy following shoulder surgery in the beach chair position remains uncommon, even among obese patients. Use of a standardized positioning and padding protocol for obese patients in the beach chair position reduced the prevalence of LFCN palsy. LEVEL OF EVIDENCE: Level III (prognostic).

Post-operative neuropathy after total hip arthroplasty.

Nerve palsy is a well-described complication following total hip arthroplasty, but is highly distressing and disabling. A nerve palsy may cause difficulty with the post-operative rehabilitation, and overall mobility of the patient. Nerve palsy may result from compression and tension to the affected nerve(s) during the course of the operation via surgical manipulation and retractor placement, tension from limb lengthening or compression from post-operative hematoma. In the literature, hip dysplasia, lengthening of the leg, the use of an uncemented femoral component, and female gender are associated with a greater risk of nerve palsy. We examined our experience at a high-volume, tertiary care referral centre, and found an overall incidence of 0.3% out of 39 056 primary hip arthroplasties. Risk factors found to be associated with the incidence of nerve palsy at our institution included the presence of spinal stenosis or lumbar disc disease, age younger than 50, and smoking. If a nerve palsy is diagnosed, imaging is mandatory and surgical evacuation or compressive haematomas may be beneficial. As palsies are slow to recover, supportive care such as bracing, therapy, and reassurance are the mainstays of treatment. Cite this article: Bone Joint J 2017;99-B(1 Supple A):46-9.

Long-term prognosis of nerve palsy after total hip arthroplasty: results of two-year-follow-ups and long-term results after a mean time of 8 years.

INTRODUCTION: Nerve damage is a rare but serious complication after THA. There exist only little data about the outcome of these patients particularly regarding the long-term results later than 2 years postoperatively. Aim of this study is to answer the following questions: Is the recovery to be expected for light nerve lesions different from the severe ones? Is there a possibility of nerve recovery more than 2 years after THA? Is the potential of nerve recovery depending on the affected nerve? MATERIALS AND METHODS: This study investigates 2,255 primary THA as well as revision surgeries performed from 1988 to 2003 relating to iatrogenic nerve lesion. We classified the nerve lesion according to the core muscle strength in severe (M0-M2) and light (M3-M4) nerve damage and differentiated between femoral, sciatic and superior gluteal nerve, according to the electromyography. RESULTS: We found 34 cases of iatrogenic nerve damage representing an incidence of 1.5 %. 17 of 34 (50 %) patients showed a complete recovery after 2 years. Out of the remaining 17 patients, six out of seven patients with a final examination after a median time of 93 months achieved further improvement. The different nerves showed no significant different potential of recovery. CONCLUSIONS: In contrast to the literature, an improvement beyond the limit of 2 years is probable and independent of the nerve affected.

Femoral neuropathy following total hip arthroplasty: review and management guidelines.

Femoral neuropathy following primary or revision total hip arthroplasty (THA) is a rare but acknowledged complication. Treatment of femoral neuropathy has long been debated and there is a paucity of accepted principles on which to base management. Currently, no definitive management protocol exists in the literature. A literature search was performed by a review of PubMed, Google Scholar and OVID articles published from 1972-2011. The literature reports an incidence rate of femoral neuropathy following THA ranging from 0.1 to 2.4 percent. Determining the precise aetiology, establishing a diagnosis and subsequent treatment of femoral nerve injury remains a difficult task, with conservative management remaining the treatment benchmark. In this review, we aim to summarise the aetiologies and risk factors associated with femoral neuropathy following THA and provide management guidelines.

Iatrogenic femoral nerve injury: a systematic review.

PURPOSE: Iatrogenic femoral nerve injury is a recognized complication of abdominal and pelvic surgery. It causes distress and disability and may lead to permanent motor and/or sensory sequelae. The aim of this systematic review was to explore the contemporary spectrum of this injury reported in the literature. METHODS: A systematic review of iatrogenic femoral nerve injuries reported between 2000 and October 2010 was undertaken using the electronic databases Medline, PubMed, Cochrane Library, and Google Scholar. The context, frequency, mechanism of injury, and outcome were recorded. Relevant clinical and anatomical literature was reviewed to provide an overview of the surgical anatomy. RESULTS: Iatrogenic femoral nerve injury is not rare, occurring as a complication of common abdominal, pelvic, and orthopedic operations and after femoral nerve blocks and femoral artery puncture. Mechanisms of injury are diverse and include direct trauma and ischemia from retraction or stretching of the nerve. Variant anatomy is very rarely the source of the problem. Although the prognosis in most cases is good some affected patients require nerve repair or grafting and some are left with permanent residual neurologic deficits. CONCLUSIONS: A wider awareness of this complication, particularly the context in which it may occur, together with an appropriate understanding of the anatomy of the femoral nerve may help to reduce the frequency of this distressing and disabling iatrogenic complication.

Acute femoral neuropathy following renal transplantation: a retrospective, multicenter study in China.

BACKGROUND: We investigated the relationship between the mode and duration of iliac artery anastomosis and acute femoral neuropathy (AFN). METHODS: A retrospective analysis was performed for 83 AFN cases from 6 transplantation centers in China. The incidence and nature of dysfunction of AFN were classified based upon the duration of iliac arterial anastomosis. No prisoners were used, and no organs from prisoners were used to obtain the data. RESULTS: The incidence of AFN was 3.6% (53/1,449) in internal iliac anastomosis (group 1), 3.1% (11/346) in external iliac anastomosis (group 2) (P > .05 vs. group 1), and was 54.2% (19/35) in internal iliac ligation with external iliac anastomosis (group 3 P < .01 vs. groups 1 and 2). In group 1, the duration of the arterial anastomosis was 20 minutes in 52 cases (98.1%). In group 2, the duration of arterial anastomosis was 20 minutes in 10 cases (91%). In group 3, the duration of the arterial anastomosis was >20 minutes in all cases; 20 cases showed injury to the iliolumbar or deep iliac circumflex artery. CONCLUSION: The incidence of AFN was associated with the selection of iliac arteries, the duration of the arterial anastomosis, and an injury to the iliolumbar or deep iliac circumflex artery.

Incidence of lateral femoral cutaneous nerve neuropraxia after anterior approach hip arthroplasty.

BACKGROUND: Although injury to the lateral femoral cutaneous nerve (LFCN) is a known complication of anterior approaches to the hip and pelvis, no study has quantified its' incidence in anterior arthroplasty procedures. QUESTIONS/PURPOSES: We therefore defined the incidence, functional impact, and natural history of LFCN neuropraxia after an anterior approach for both hip resurfacing (HR) and primary total hip arthroplasty (THA). METHODS: We followed 132 patients who underwent an anterior hip approach (55 THA; 77 HR). We administered self-reported questionnaires for sensory deficits of LFCN, neuropathic pain score (DN4), visual analog scale, as well as SF-12, UCLA, and WOMAC scores at one year postoperatively. A subset of 60 patients (30 THA; 30 HR) was evaluated at two time intervals. RESULTS: One hundred seven patients (81%) reported LFCN neuropraxia with a mean severity score of 2.32/10 and a mean DN4 score of 2.42/10. Hip resurfacing had a higher incidence of neuropraxia as compared with THA: 91% versus 67%, respectively. No functional limitations were reported on SF-12, WOMAC, or UCLA scores. Of the subset of 60 patients followed over an average of 12 months, 53 (88%) reported neuropraxia at the first followup interval with only three (6%) having complete resolution at second followup. Improvement in DN4 scores was observed over time: 3.6 versus 2.5, respectively. CONCLUSIONS: Although LFCN neuropraxia was a frequent complication after anterior approach THA, it did not lead to functional limitations in our patients. A decrease in symptoms occurred over time but only a small number of patients reported complete resolution. LEVEL OF EVIDENCE: Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Neurologic injuries after total hip arthroplasty.

Neurologic injuries are a potentially devastating complication of total hip arthroplasty (THA). Review of the literature reveals that these injuries are uncommon. The reported incidence ranges from 0.08% to 7.6%. The incidence in primary THA ranges from 0.09% to 3.7% and in revision THA from 0% to 7.6%. Reported etiologies include intraoperative direct nerve injury, significant leg lengthening, improper retractor placement, cement extravasation, cement-related thermal damage, patient positioning, manipulation, and postoperative hematoma. Risk factors include developmental dysplasia of the hip, the female sex, posttraumatic arthritis, and revision surgery. However, no single risk factor has been consistently reported to be significant, and many patients with no known risk factors incur neurologic injuries.

Neuropatía femoral en cirugía urológica / Femoral neuropathy in urological surgery

Se presentan cuatro casos de neuropatía femoral secundarios a cirugía urológica, el primero tras lumbotomía derecha hace más de 20 años y los otros tres en los últimos cuatro años, con incisión iliaca. Se comentan los mecanismos de producción de la lesión, evolución, tratamiento y prevención de esta infrecuente complicación neurológica y se revisa la literatura sobre dicha patología en la actividad urológica

We present four cases of femoral neuropathy due to urological surgery, first case happened after right lumbotomy twenty years ago and the other three cases in the last four years after iliac incision. We review lesion production mecanism, evolution, treatment and prevention of this rare neurological complication. We do a literature review about this pathology related with urological activity

Incidence rates and determinants in meralgia paresthetica in general practice.

OBJECTIVE: To determine incidence rates for meralgia paresthetica (MP) in the primary care setting and establish determinants for MP in a case-control study in general practices. METHODS: Using a cohort (in total 173,375 patient years) of registered persons in primary care from a computerized registration network for general practitioners (GPs) in the Rotterdam area from 1990 to 1998, persons with the diagnosis MP were included. In a nested case-control study we studied the relationship between comorbidity (e. g. carpal tunnel syndrome, pregnancy, osteoarthritis of the hip, overweight, symptoms of the pubic bone, thrombosis of the leg, diabetes mellitus and the use of corticosteroids) and the occurrence of MP. RESULTS: The incidence rate of MP is 4.3 per 10,000 person years. MP is more often present in patients suffering from carpal tunnel syndrome OR 7.7 (95 % CI 1.9-31.1) and is related to pregnancy OR 12.0 (95 % CI 1.2-118.0). CONCLUSIONS: This is the first report on incidence rates of MP and on suspected determinants studied in a case-control setting in general practice. Carpal tunnel syndrome and pregnancy are significantly related to MP. Calculating the Population Attributable Risk in this study leaves 79% of all MP unexplained. Our results suggest that MP is caused by a combined susceptibility for entrapment and a trigger causing entrapment. More research on determinants is needed. Because MP occurs in every GP practice at least once a year more studies are needed on prognosis and treatment.