Meralgia paresthetica (PM), also known as Bernhardt-Roth neuralgia or lateral cutaneous nerve neuropathy (LCNF), comes from the Greek term meros algos, meaning hip pain. PM is caused by damage to the LCNB. The most common cause of damage to this nerve is compression at the level of the inguinal ligament.
Epidemiology/Etiology
Although spontaneous cases of PM can occur in any age group, it most often occurs between the ages of 30 and 40 years. The incidence in children may be higher than previously thought. One third of children treated for osteoid osteoma developed MP (Anloague, 1975). There is no consensus yet on the predominance of gender or race. But one study that looked at 150 cases of PM found that the disease was more common in men (Harney, 2007).
As already mentioned, LCNB mononeuropathy is usually caused by compression of this nerve as it passes through the inguinal ligament. Pinching may have an idiopathic or iatrogenic cause.
Idiopathic (or spontaneous) causes
- Mechanical factors: obesity, as well as other conditions accompanied by an increase in intra-abdominal volume, such as tight clothing, pregnancy and ascites, in which this nerve can be kinked or compressed by the convex abdominal cavity as it exits the pelvic cavity.
- Metabolic factors: diabetes mellitus, alcoholism and lead poisoning.
Iatrogenic causes
- Iatrogenic causes may be associated with hip replacement or spinal surgery. During spine surgery, the front of the thigh may be compressed by the surgical equipment used during the operation.
Causes of meralgia paresthetica
The main cause of the disease is considered to be the anatomical distinctive features of the human body.
And also the main cause of the disease is excess weight, it is dangerous, namely in the area of the hips and abdomen. Deviation in men may be a consequence of wearing a tight belt. It puts pressure on the abdomen, thereby causing compression of the nerve. The main cause of pathology in women may be wearing tight corsets.
A hematoma or tumor in the abdominal area is considered a dangerous reason for the aggravation of the deviation.
Temporary Roth Disease is also possible; it occurs in women during pregnancy. Occurs due to the fact that the inguinal ligaments of a pregnant woman are stretched, and this causes compression of the nerve.
Diabetes, malaria, typhoid fever, etc. are considered infrequent causes of pathology.
Clinical picture
Patients may have symptoms such as pain, burning, numbness, coldness, or itching in the anterolateral thigh. As mentioned earlier, the LCNB provides sensory innervation to the skin of the anterolateral and lateral aspects of the thigh. Therefore, a patient with PM will experience symptoms in this part of the hip (both superficial and deep).
A person may have mild pain that resolves spontaneously or more severe pain that limits function. Patients may report pain with prolonged standing or walking. The pain may be relieved by sitting because this position reduces the tension on the LCL or inguinal ligament. This decrease in tension may be associated with a decrease in symptoms. Each patient will have a specific clinical presentation and distribution of symptoms.
Manifestations of meralgia paresthetica
The disease is characterized by slow onset and unilateral neuropathy. Discomfort begins in different areas of the thigh - colic, burning sensation, loss of sensitivity. In the future, the disorder does not disappear, but continues to be a travel companion; after a couple of months, pain occurs. Sometimes there is a complete loss of sensitivity in the area of neuropathy. Although movement disorders are not noticed.
Roth's disease is characterized by feeling unwell after exercise or standing for a long time. This happens due to the tension of the affected channel. When a person takes a lying or sitting position, the feeling of pain leaves him.
Due to the long-term illness, the skin loses its elasticity and becomes thinner, which is due to a disorder in the nutrition of the skin. In some cases, trophic ulcers may occur, and in severe cases, lameness will appear.
Grade
Sequential study of medical history
- PM is characterized by the presence and history of various symptoms mentioned in the “Clinical presentation” section.
Physical examination
- Palpation of the lateral part of the inguinal ligament (where the nerve crosses the inguinal ligament) is usually painful. Some patients also experience hair loss in the LCNB area because they constantly rub the area.
Additional tests
- To rule out red flags, an x-ray of the pelvic bones is performed (to rule out tumors). When a metabolic cause is suspected, blood tests and thyroid function tests are performed.
Bernard-Rott syndrome
Bernard-Roth neuralgia
Synonyms for Roth-Bernardt syndrome, or Neuritis of the lateral cutaneous tibial nerve.
This is a tunnel syndrome with compression of a large nerve trunk in the groin area.
Clinical manifestations:
Pain in the groin area, which radiates to the thigh along the front surface. Most often the pain is burning in nature.
Numbness in this area and crawling in the groin and thigh area.
Symptoms worsen when sitting.
Sometimes hair may fall out in the affected area.
Historical reference:
Authors: Roth Vladimir Karlovich - Russian neurologist, 1848-1916. Moscow.
Bernhardt Martin - German neurologist, Berlin, 1844-1915.
The syndrome was first described in 1895 by Roth and Bernhard independently of each other.
Causes:
Anatomically, the congenital narrowness of the space between the ilium and the inguinal ligament. Next, mechanical factors matter:
-wearing tightly fitting clothing (jeans)
-carrying a mobile phone in your trouser pocket
Treatment:
The most effective method in our Clinic in Kaluga is recognized to be a drug blockade under ultrasound navigation with the administration of steroids. It is carried out 3 times within 3 weeks.
At the same time, we prescribe massage and manual therapy to eliminate mechanical compression of the nerve.
Treatment results:
The effect is good; in our clinical practice, 100% of patients who sought help got rid of the disease
Bernard-Roth neuralgia
Synonyms for Roth-Bernardt syndrome, or Neuritis of the lateral cutaneous tibial nerve.
This is a tunnel syndrome with compression of a large nerve trunk in the groin area.
Clinical manifestations:
Pain in the groin area, which radiates to the thigh along the front surface. Most often the pain is burning in nature.
Numbness in this area and crawling in the groin and thigh area.
Symptoms worsen when sitting.
Sometimes hair may fall out in the affected area.
Historical reference:
Authors: Roth Vladimir Karlovich - Russian neurologist, 1848-1916. Moscow.
Bernhardt Martin - German neurologist, Berlin, 1844-1915.
The syndrome was first described in 1895 by Roth and Bernhard independently of each other.
Causes:
Anatomically, the congenital narrowness of the space between the ilium and the inguinal ligament. Next, mechanical factors matter:
-wearing tightly fitting clothing (jeans)
-carrying a mobile phone in your trouser pocket
Treatment:
The most effective method in our Clinic in Kaluga is recognized to be a drug blockade under ultrasound navigation with the administration of steroids. It is carried out 3 times within 3 weeks.
At the same time, we prescribe massage and manual therapy to eliminate mechanical compression of the nerve.
Treatment results:
The effect is good; in our clinical practice, 100% of patients who sought help got rid of the disease
Treatment
The goal of PM treatment is to relieve compression from the LCNB. The first step will be conservative treatment. If this does not help, the next step is drug treatment. Surgical treatment is indicated when all of the above methods do not eliminate symptoms.
Conservative treatment
- Conservative treatment involves eliminating factors that irritate LCNB. For example, this includes weight loss, patient education and counseling (encouraging wearing loose clothing and avoiding tight belts). Pain can be reduced by applying cold packs to the painful area.
Medication support
- Nerve block: localized infiltration of LCNB. These are injections of a corticosteroid and an analgesic, or more commonly a corticosteroid and a local anesthetic, which reduce pain and improve mobility in most patients with PM.
- Non-steroidal anti-inflammatory drugs can also be used.
- In patients with PM who have not responded to conservative treatment, pulsed radiofrequency neuromodulation of the LCNB can be considered. This is a treatment method that reduces pain by generating radio waves that produce heat. These radio waves are delivered through needles inserted into the skin above the spine. The use of visualization allows you to determine the location of needle insertion.
Surgery
Surgery should be resorted to only when all conservative treatment methods have failed. Conservative treatment of PM is effective in more than 90% of patients, but patients with severe and persistent pain despite adequate conservative treatment should consider surgical treatment.
Two surgical methods have been developed for the treatment of PM:
- Decompression (also known as neurolysis): a procedure in which the LCNB is released from surrounding tissue.
- Neuroctomy: Excision of a small portion of the nerve as it passes through the inguinal ligament.
A neurectomy eliminates positive symptoms but leaves an area of numbness in the anterolateral thigh that usually decreases in size over time. The effectiveness of neuroectomy is higher than that of neurolysis.
Physical therapy
Kinesio taping
Small pilot studies suggest that kinesio taping should be part of therapy in patients with PM. Kinesio taping will reduce the symptoms experienced by the patient. The exact physiological mechanisms are still unknown. This method is supposed to increase lymphatic and vascular flow, reduce pain, improve normal muscle function, increase proprioception and help correct possible joint deformities. Despite its purported benefits, the available evidence is insufficient to support the use of kinesio taping for PM. Randomized, placebo-controlled trials are needed.
Acupuncture
The benefits of acupuncture as a treatment for PM have been demonstrated in clinical trials. Available literature suggests that acupuncture may be effective in the treatment of PM. However, the exact physiological mechanisms behind this are still under study. Further research is needed (Harney, 2007; Cheatham, 2013).
Transcutaneous electrical nerve stimulation
Transcutaneous electrical nerve stimulation (TENS) is effective in the treatment of PM. TENS is thought to activate central mechanisms to provide analgesia. Low-frequency TENS activates μ-opioid receptors in the spinal cord and brainstem, while high-frequency TENS exerts its effects through δ-opioid receptors (Tharion, 1997; Jason, 2016).
Neurostimulation methods
Neurostimulation techniques, including transcranial magnetic stimulation and cortical electrical stimulation, spinal cord stimulation, and deep brain stimulation, have also been found effective in treating neuropathic pain in PM (Jason, 2016).
Exercises
Exercise for 30 minutes a day (at least three to four days a week) can help manage chronic pain by increasing muscle strength, endurance, and muscle flexibility (Delgado, 2015).
Possible examples of training are (Harney, 2007):
- Aerobic exercises (walking, exercise bike, swimming, aerobics).
- Flexibility exercises. This includes exercises with increasing resistance, the use of weights and isometric exercises.
- Strengthening exercises. Exercise programs can increase inspiratory muscle strength and modulate autonomic function in patients with diabetic neuropathy.
- Balance exercises. Programs that include multisensory balance training can induce adaptive responses in the neuromuscular system that will improve postural control, balance, and functional abilities in women. BOSU training can help improve static balance and functional ability in women.
Low frequency laser therapy
Available research suggests that NCRT has a positive effect on pain control in PM, but further research with high scientific rigor is needed to identify treatment protocols that optimize the effect of NCRT for neuropathic pain (Khalil, 2008).
Weight loss in obese patients
The goal of physical therapists is to promote successful weight management and overall health by appropriately increasing patients' physical activity levels. They are assessed to determine the patient's current activity level and any barriers to increasing activity. Physical therapists then propose a treatment plan designed to address these barriers and promote optimal activity for the patient (Anloague, 2009).
Manual therapy
There are several case studies of the use of manual therapy for PM. Techniques used in these studies included active release techniques, pelvic mobilization/manipulation techniques, myofascial therapy for the rectus femoris and iliopsoas muscles, transverse friction massage of the inguinal ligament, stretching exercises for the hip and pelvic muscles, and core stabilization exercises. Evidence suggests that these interventions may be effective and safe for alleviating PM symptoms. Further high-quality studies are needed to evaluate these treatment options. The Terret study reported a case in which manual therapy on the hip and pelvis resulted in PM (Cheatham, 2013).
Examination of meralgia paresthetica
The examination of meralgia paresthetica consists of the following steps:
- examination of the patient and the totality of information received from the patient
- ultrasonography
- Magnetic resonance imaging
- CT scan
- diagnostic method, which is also based on ionizing x-ray radiation
- studies of the functional state of muscles and peripheral nerves