From the Guidelines
The treatment of obturator nerve entrapment should start with a multimodal approach, focusing on conservative management, including physical therapy and pharmacological treatment with medications such as gabapentin or pregabalin, as recommended by the most recent guidelines 1.
Initial Treatment
The initial treatment of obturator nerve entrapment typically involves physical therapy, focusing on stretching and strengthening exercises for the hip adductors and surrounding muscles, along with activity modification to avoid aggravating movements.
- Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen 400-800mg three times daily or naproxen 500mg twice daily for 1-2 weeks can help reduce inflammation and pain.
- For more significant pain, a short course of muscle relaxants like cyclobenzaprine 5-10mg at bedtime may be beneficial.
Pharmacological Treatment
For neuropathic pain associated with obturator nerve entrapment, the guidelines recommend initiating therapy with one or more of the following:
- A secondary-amine TCA (nortriptyline, desipramine) or an SSNRI (duloxetine, venlafaxine) 1.
- A calcium channel a-d ligand, either gabapentin or pregabalin, which have shown efficacy in several neuropathic pain conditions 1.
- For patients with localized peripheral neuropathic pain, topical lidocaine used alone or in combination with one of the other first-line therapies may be considered 1.
Further Treatment
If conservative measures fail, diagnostic and therapeutic obturator nerve blocks using 5-10ml of 0.25% bupivacaine with or without corticosteroids (such as 40mg methylprednisolone) can provide relief and confirm the diagnosis.
- For persistent cases, pulsed radiofrequency ablation may be considered.
- Surgical decompression is reserved for refractory cases with clear anatomical compression identified on imaging. This stepwise approach is recommended because the obturator nerve's deep location in the pelvis makes entrapment challenging to diagnose and treat, and most cases respond well to conservative management targeting the inflammatory process and muscle tension contributing to nerve compression.
From the Research
Treatment Options for Obturator Entrapment
- Dorsal root ganglion stimulation (DRGS) has been shown to be effective in treating severe intractable pain related to obturator nerve entrapment neuropathy, with one study reporting 90% pain relief in a patient who had not responded to conservative management or spinal cord stimulation 2.
- Surgical management of obturator nerve lesions, including decompression or primary repair, has been reported to result in improved symptoms, such as pain relief, numbness resolution, or improved adductor muscle strength, in patients with obturator neuropathy 3.
- Laparoscopic treatment, including obturator nerve neurolysis and section of the internal obturator muscle and the obturator membrane, has been described as a minimally invasive approach for treating obturator neuralgia resulting from compression of the obturator nerve in the obturator canal 4.
- Mesh repair and laparoscopic operation have been associated with improved treatment outcomes, including reduced perioperative morbidity and mortality rates, in patients with obturator hernias, which can be a cause of obturator nerve entrapment 5.
Anatomical Considerations
- Anatomical studies have identified potential compression areas of the obturator nerve, including the external obturator muscle and the fascia between the adductor brevis and longus muscles, which can inform surgical approaches to treating obturator nerve entrapment 6.
- The anterior branch of the obturator nerve has been found to be highly adherent to the fascia in some cases, and the medial femoral circumflex artery has been found to be in close connection with the posterior branch of the nerve, highlighting the complexity of the anatomy involved in obturator nerve entrapment 6.