What is the best treatment for meralgia paresthetica and what causes it?

Treatment and Etiology of Meralgia Paresthetica

What Causes Meralgia Paresthetica

Meralgia paresthetica results from entrapment or compression of the lateral femoral cutaneous nerve (LFCN), most commonly as it exits the pelvis near the inguinal ligament. 1, 2

• Mechanical compression is the most common spontaneous cause, occurring where the nerve passes under or through the inguinal ligament near the anterior superior iliac spine 2
• Iatrogenic injury accounts for a significant proportion of cases, particularly following anterior iliac crest bone graft harvesting, anterior pelvic procedures, hip arthroplasty, or prone positioning during spine surgery 3, 2
• Anatomic variability of the LFCN around the anterior superior iliac spine increases susceptibility to compression and injury 2
• Exacerbating factors include tight clothing, belts, obesity, pregnancy, and prolonged standing or walking 2, 4

The condition manifests as numbness, paresthesias, dysesthesias, and pain over the anterolateral thigh, worsening with hip extension, standing, and walking 4

Best Treatment Approach

First-Line Conservative Management (0-4 weeks)

Initial treatment should focus on removing compressive factors combined with neuropathic pain medications, specifically gabapentin or pregabalin. 5

• Remove mechanical compression: eliminate tight-fitted clothing, belts, and weight-bearing equipment 2, 4
• Weight loss if obesity is a contributing factor 4
• Gabapentin: start at 300 mg at bedtime, titrate up to 2400 mg daily divided into three doses 5
• Pregabalin: 75-300 mg every 12 hours as an alternative first-line neuropathic agent 5
• NSAIDs can be added for additional pain control 2

Conservative management alone provides long-lasting improvement in approximately 36% of patients 3

Second-Line Treatment (4-12 weeks)

If first-line therapy fails after 4 weeks, add corticosteroid injection and consider second-line neuropathic medications. 5, 2

• Local corticosteroid injection at the site of nerve entrapment near the inguinal ligament provides diagnostic confirmation and therapeutic benefit 2
• Tricyclic antidepressants (amitriptyline) as second-line medication 5
• SNRIs (venlafaxine up to 75 mg daily) as an alternative second-line agent 5

Important caveat: Gabapentin frequently causes lower limb edema, which may counteract treatment benefits 5. Pregabalin and gabapentin both cause somnolence, while tricyclic antidepressants have anticholinergic effects 5

Third-Line Surgical Intervention (>12 weeks)

Surgical decompression (neurolysis) should be considered when conservative measures and injections fail after 3-4 months of appropriate treatment. 5, 6

The evidence strongly favors surgical decompression/neurolysis over neurectomy as the primary surgical approach. 6 A 2018 study demonstrated that decompression achieved a mean pain reduction of 6.6 points on the numeric rating scale, with 86% complete patient satisfaction and preservation of sensation in the LFCN distribution 6. This directly contradicts older literature favoring neurectomy.

• Surgical decompression/neurolysis is the procedure of choice, preserving nerve function while relieving compression 6
• Neurectomy (nerve transection) should be reserved only for cases where decompression fails, accepting permanent numbness as a trade-off 3, 2
• Peripheral nerve stimulation represents an emerging option for refractory cases before proceeding to neurectomy 4

Critical Decision Points

The key algorithmic decision is timing of surgical referral: if a patient has failed 3-4 months of combined conservative management (neuropathic medications + activity modification + corticosteroid injection), surgical decompression should be offered rather than prolonging ineffective medical management 5, 6

Common pitfall: The older literature (2000-2001) suggests neurectomy as equivalent or superior to neurolysis 3, 2, but the more recent 2018 study with systematic outcome analysis demonstrates superior results with decompression while preserving sensation 6. The 2025 guideline recommendations align with prioritizing decompression 5.

Diagnostic confirmation: Relief of symptoms after local anesthetic injection confirms the diagnosis and predicts response to definitive treatment 2. If no improvement occurs with injection, consider proximal LFCN compression or alternative diagnoses 2