What are the management options for meralgia paresthetica?

Management of Meralgia Paresthetica

The treatment of meralgia paresthetica should follow a stepwise approach, beginning with conservative measures, progressing to pharmacological interventions, and finally considering interventional procedures for refractory cases. 1

Conservative Measures (First-line, 0-3 months)

• Remove mechanical compression factors:

  • Eliminate tight clothing, belts, or tool belts
  • Modify activities that exacerbate symptoms
  • Weight reduction for patients with obesity 1

• Topical treatments:

  • Lidocaine patches (4% OTC or 5% prescription)
  • Lidocaine cream/ointment
  • Consider topical amitriptyline 1

• Physical modalities:

  • Apply superficial heat or cold to affected area
  • Limit cold application to 10 minutes at a time to prevent tissue damage 1

Pharmacological Interventions (First-line, concurrent with conservative measures)

• Neuropathic pain medications:
  • Gabapentin (starting at 300mg at bedtime, up to 2400mg daily in divided doses)
  • Pregabalin (75-300mg every 12 hours) 1
  • Oral amitriptyline

Interventional Procedures (Second-line, 3-6 months if no improvement)

• Local anesthetic with corticosteroid injection:

  • Injection around the lateral femoral cutaneous nerve
  • Serves both diagnostic and therapeutic purposes 1

• Pulsed radiofrequency:

  • Consider if injections provide only temporary relief 1

Surgical Options (Third-line, 6+ months with persistent symptoms)

• Surgical decompression (neurolysis):

  • First-line surgical approach
  • Preserves nerve function while relieving compression 1, 2

• Nerve transection (neurectomy):

  • Reserve option when neurolysis fails
  • Results in permanent sensory loss in the distribution of the nerve 1

• Advanced options:

  • Peripheral nerve stimulation in specialized centers for intractable cases 1, 3

Treatment Algorithm

1. Initial phase (0-3 months):

   • Eliminate mechanical factors
   • Apply topical lidocaine
   • Start oral neuropathic pain medications

2. Intermediate phase (3-6 months):

   • Local anesthetic with corticosteroid injection
   • Consider pulsed radiofrequency if injections provide only temporary relief

3. Advanced phase (6+ months):

   • Consider surgical options (neurolysis preferred over neurectomy)
   • Evaluate for peripheral nerve stimulation in specialized centers 1

Special Considerations

• Surgical decompression/neurolysis has shown significant pain reduction (mean NRS pain value reduction of 6.6 points) with high patient satisfaction (86% reporting complete satisfaction) 2

• Conservative management alone can yield long-lasting improvement in approximately 36% of patients, while the remaining may require surgical intervention 4

• Iatrogenic meralgia paresthetica can occur after orthopedic procedures such as anterior iliac-crest bone-graft harvesting and anterior pelvic procedures, or from prone positioning during spine surgery 5

• The diagnosis should be confirmed before invasive treatment, typically through relief of symptoms after injection of a local anesthetic agent 5