3010jumonline.qxp:Layout 1 9/21/11 10:54 AM Page 1341 ORIGINAL RESEARCH Ultrasound-Guided Treatment of Meralgia Paresthetica (Lateral Femoral Cutaneous Neuropathy) Technical Description and Results of Treatment in 20 Consecutive Patients Alberto Tagliafico, MD, Giovanni Serafini, MD, Francesca Lacelli, MD, Nadia Perrone, MD, Valtero Valsania, MD, Carlo Martinoli, MD Article includes CME test Objectives—The purposes of this study were to describe a technique for treatment of meralgia paresthetica (lateral femoral cutaneous neuropathy) using ultrasound guidance and to report the results of treatment. Methods—Twenty consecutive patients (7 male and 13 female; age range, 23–66 years; mean, 39 years) with meralgia paresthetica confirmed by electromyography were treated with perineural injection of 1 mL of methylprednisolone acetate (40 mg/mL) and 8 mL of mepivacaine, 2%, under direct ultrasound guidance. Main outcome measures included the technical success of the procedure, visual analog scale score for the lateral femoral cutaneous nerve (pain, burning sensation, and paresthesia), and visual analog scale global quality of life score. Results—Technical success (successful nerve block at the distribution of the lateral femoral cutaneous nerve) was achieved in all patients. Five patients felt slight sharp pain during needle insertion. The symptoms in 16 patients (80%) diminished progressively after the first week. The 4 remaining patients (20%) required a further perineural injection. The symptoms disappeared in all patients 2 months after injection (mean visual analog scale score ± SD for lateral femoral cutaneous neuropathy at baseline, 8.1 ± 2.1; at 2 months, 2.1 ± 0.5; t = 6.2; P < .001). The mean visual analog scale quality of life scored decreased from 6.9 ± 3.2 to 2.3 ± 2.5 (t = 5.3; P < .002). Received March 31, 2011, from the Department of Radiology, National Institute for Cancer Research, Genoa, Italy (A.T.); Departments of Radiology (G.S., F.L., N.P.) and Neurology (V.V.), Santa Corona Hospital, Pietra Ligure, Italy; and Department of Radiology, Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy (C.M.). Revision requested April 15, 2011. Revised manuscript accepted for publication May 2, 2011. Preliminary data from this article were presented as a scientific communication at the 96th Scientific Assembly and Annual Meeting of the Radiological Society of North America; November 30, 2010; Chicago, Illinois. Address correspondence to Alberto Tagliafico, MD, Institute of Anatomy, Department of Experimental Medicine, University of Genoa, Largo Rosanna Benzi 8, 16132 Genoa, Italy. E-mail: [email protected] Conclusions—Treatment of meralgia paresthetica with ultrasound-guided perineural injections resulted in substantial symptom relief in most patients 2 months after injection. Randomized placebo-controlled trials of this treatment should be considered in the future. Key Words—injection; lateral femoral cutaneous nerve; meralgia paresthetica; ultrasound L ateral femoral cutaneous nerve compression and entrapment are rare and occur more commonly in obese patients and in pregnancy because of abdominal bulging over the inguinal ligament, with subsequent compression of the nerve at the lateral end of the inguinal ligament. Symptoms may be worsened by walking or prolonged standing and typically disappear with weight loss, abdominal muscles exercises, or delivery. Lateral femoral neuropathy causes the syndrome of meralgia paresthetica, which is characterized by numbness, hypersensitivity, and paresthesia in the anterolateral region of the thigh which, is the area of distribution of ©2011 by the American Institute of Ultrasound in Medicine | J Ultrasound Med 2011; 30:1341–1346 | 0278-4297 | www.aium.org 3010jumonline.qxp:Layout 1 9/21/11 10:54 AM Page 1342 Tagliafico et al—Ultrasound-Guided Treatment of Meralgia Paresthetica this nerve.1 Local anesthetics are usually used to block the lateral femoral cutaneous nerve before surgical procedures and to confirm lateral femoral cutaneous neuropathy. Moreover, local anesthetics may also be used to treat lateral femoral cutaneous neuropathy.2–4 Blockade of the lateral femoral cutaneous nerve has been classically described using anatomic landmarks, but the anatomic variability of the nerve may be responsible for failure rates as high as 60%.5 Ultrasound guidance has been shown to be particularly suitable for injection of tiny and superficial structures such as the lateral femoral cutaneous nerve, overcoming the anatomic variability in most patients.6–10 It has recently been suggested that ultrasound guidance can facilitate blockade of the nerve for diagnostic and therapeutic purposes and may be particularly beneficial in patients with challenging surface anatomic landmarks and when lowvolume injections are desired.10 However, that suggestion arose from a retrospective evaluation of 10 patients treated without a standardized protocol.10 Moreover, in a very preliminary study, it was reported that treatment of lateral femoral cutaneous neuropathy under ultrasound guidance was effective in reducing patient discomfort.11,12 No defined “evidence-based” treatment exists for this condition. Its has been suggested that injection of the lateral femoral cutaneous nerve may be attempted to treat patients with meralgia paresthetica who do not respond to oral medications or conservative measures.11 Given the limited experience existing in the literature and in clinical practice regarding ultrasound-guided treatment of this condition, the purposes of our study were to describe a technique for treatment of meralgia paresthetica under ultrasound guidance and to report the outcomes obtained with this technique. Materials and Methods Between June 2009 and January 2011, 20 consecutive patients (7 male and 13 female; age range, 23–66 years; mean, 39 years; body mass index range, 20.14–31.12 kg/m2; mean, 25.22 kg/m2) with a diagnosis of meralgia paresthetica (bilateral in 1 patient) were included in this prospective study. Patients were referred to the sonography unit for treatment with ultrasound-guided percutaneous perineural injection of methylprednisolone acetate and a local anesthetic. The diagnosis of meralgia paresthetica was established from the following indicators: clinical history, physical examination, electromyographic findings (lateral cutaneous nerve amplitude potential <10 μV, latency >3.5 milliseconds, and normal thigh muscle 1342 needle examination findings), symptoms lasting for at least 6 weeks, no evidence of other specific diseases of the musculoskeletal system after physical examination (eg, normal strength and no thigh muscle atrophy), and exclusion of other causes of pain or sensory disturbances.13,14 The diagnosis was made by a neurologist and a neurosurgeon with 15 and 11 years of experience, respectively. The patients were given detailed information on the procedure, and informed written consent was obtained from all of them. The study was approved by the Institutional Review Board. Technique The procedure in all cases was performed by 3 sonographers with expertise in interventional musculoskeletal procedures (G.S., F.L., and A.T.) using a commercially available ultrasound scanner equipped with a 7- to 17MHz transducer. The anterior superior iliac spine was palpated and visualized with the ultrasound probe as a hyperechoic structure with posterior acoustic shadowing. The technical approach described was adapted from previous studies.13 The perineural injection technique involved the following steps: Location of the Anterior Superior Iliac Spine With the patient in the supine position, the transducer was placed over the pathologic superior iliac region at the level of the anterior superior iliac spine. The lateral end of the probe was placed on the anterior superior iliac spine, and the medial end extended medially in an anatomic transverse plane. With the probe in this position, the medial end of the probe was angled slightly in a caudal direction so the transducer was parallel with the inguinal ligament. The transducer was gently moved in a mediocaudal direction while the operator searched for the echo signature of the lateral femoral cutaneous nerve. Using this approach, the nerve appeared in cross section as an oval structure on short-axis images and tubular on longitudinal images (Figure 1). Several sweeps were occasionally necessary to visualize the lateral femoral cutaneous nerve because of the anatomic variability of the nerve. Once the nerve was visualized in a transverse plane, the nerve was traced proximally and distally to confirm its appropriate course toward the lateral thigh. The nerve was visualized in a longitudinal plane for confirmation as well. Location of the Puncture Site Axial sonographic sections were obtained on the anterior superior iliac spine, and once situated with the nerve in the J Ultrasound Med 2011; 30:1341–1346 3010jumonline.qxp:Layout 1 9/21/11 10:54 AM Page 1343 Tagliafico et al—Ultrasound-Guided Treatment of Meralgia Paresthetica center of the probe, we moved the transducer medially to allow easier needle access. The needle was inserted by a lateral or coaxial approach. The approach was tailored depending on the position of the lateral femoral cutaneous nerve relative to the anterior superior iliac spine. Figure 1. A, Short-axis sonogram over the anterior superior iliac spine (ASIS) showing the inguinal ligament (arrowheads) and the normal lateral femoral cutaneous nerve (arrow). B, Confirmatory long-axis sonogram over the lateral femoral cutaneous nerve at the level of the anterior superior iliac spine showing the nerve as a tiny structure (arrows). C, Anatomic position of the nerve. Perineural Injection A Under rigorous aseptic conditions, the transducer was inserted into a sterile bag, and sterile gel was applied to the area of interest. The needle was advanced under direct ultrasound visualization in a longitudinal view, whereas the lateral femoral cutaneous nerve was visualized in a shortaxis view. Injection of the drug mixture resulted in perineural spreading that resembled a donut (Figure 2). We then performed percutaneous perineural injection of 1 mL of methylprednisolone acetate (40 mg/mL) and 8 mL of mepivacaine, 2%, using a 22-gauge spinal needle under direct ultrasound guidance. Needle insertion was performed by a freehand technique With this method, one hand held the transducer, and the free hand inserted the needle. This technique allowed changes in the needle direction during puncture. Moreover, the needle had to be inserted at an angle that normally is not supported by commercially available devices. All of the patients were followed weekly for the first 3 months by their referring physicians (neurologists and neurosurgeons). Main Outcome Measures Two parameters were measured before the first treatment and during follow-up. First, lateral femoral cutaneous neuropathy symptoms (pain, burning sensation, and paresthesia) were evaluated by a 10-point visual analog scale ranging from 0 (no symptoms) to 10 (intolerable symptoms). Second, the influence of lateral femoral cutaneous neuropathy on the global quality of life was evaluated by a 10-point visual analog scale ranging from 0 (no influence on quality of life) to 10 (very low quality of life). This method showed good validity and excellent reliability.14 A repeated (dependent) measures t test was used to evaluate the differences before and after the treatment. P < .05 was considered statistically significant. Moreover, the technical success of the procedure was assessed at the time of injection. The procedure was considered successful when an effective block in the distribution of the lateral femoral cutaneous nerve was obtained. The average time of time of the procedure was recorded with a stopwatch. Local and general complications related to the local anesthetic and corticosteroid were recorded. J Ultrasound Med 2011; 30:1341–1346 B C 1343 3010jumonline.qxp:Layout 1 9/21/11 10:54 AM Page 1344 Tagliafico et al—Ultrasound-Guided Treatment of Meralgia Paresthetica Results All patients had satisfactory ultrasound-guided perineural injections. The average time for the procedure was 12 minutes (range, 5–14 minutes), mainly depending on the time Figure 2. Ultrasound-guided injection around the lateral femoral cutaneous nerve. A, The needle (arrows) reaches the nerve (arrowhead). B, The therapeutic solution is injected in the perineural tissues (star) and spaces the nerve out from the adjacent structures. C, Illustration of the procedure. A needed to find the lateral femoral cutaneous nerve. Five patients felt slight sharp pain in the anterolateral thigh during needle insertion; the pain disappeared immediately after needle repositioning. After injection, no local or general complications were observed. The symptoms diminished progressively after the first week in 16 patients (80%). The 4 remaining patients (20%) required a further injection because the pain had not remitted. The symptoms disappeared in all patients 2 months after perineural injection (mean visual analog scale score ± SD related to lateral femoral cutaneous neuropathy at baseline: 8.1 ± 2.1; at 2 months: 2.1 ± 0.5; t = 6.2; P < .001). The mean visual analog scale quality of life decreased from 6.9 ± 3.2 to 2.3 ± 2.5 (t = 5.3; P < .002). Discussion B C 1344 The lateral femoral cutaneous nerve is purely sensory; it arises from the L2 and L3 spinal nerve roots, travels downward lateral to the psoas muscle, and then crosses the iliacus muscle. Near the anterior superior iliac spine, the nerve courses in contact with the lateral aspect of the inguinal ligament and innervates the lateral thigh. Finally, the nerve divides into anterior and posterior branches; however, these terminal branches are not visible on sonography. Anatomic studies showed that the distance from the lateral femoral cutaneous nerve to the anterior superior iliac spine at the inguinal ligament can range from 3 mm to 7.3 cm.6,8,15 In a study by Hospodar et al,6 the course of the nerve was variable but was most commonly found 10 to 15 mm from the anterior superior iliac spine, although it was found as far medially as 46 mm. Meralgia paresthetica is a lateral femoral cutaneous nerve entrapment syndrome causing burning, numbness, and paresthesias along the proximolateral aspect of the thigh. It is idiopathic most patients but can also be caused by trauma (avulsion fracture of the anterior superior iliac spine), pelvic and retroperitoneal tumors, stretching of the nerve due to prolonged leg and trunk hyperextension, leg length discrepancies, prolonged standing, external compression by belts, weight gain, and tight clothing.16 The initial treatment of meralgia paresthetica is conservative.17 Patients who do not respond to conservative measures may be considered for surgical decompression. An alternative to surgery may be administration of local lidocaine with steroids around the course of the lateral femoral cutaneous nerve.15 Ultrasound-guided injections allow real-time visualization of relevant anatomy and needle positioning. In this study, real-time visualization of the nerve resolved the problem of anatomic variability and J Ultrasound Med 2011; 30:1341–1346 3010jumonline.qxp:Layout 1 9/21/11 10:54 AM Page 1345 Tagliafico et al—Ultrasound-Guided Treatment of Meralgia Paresthetica probably increased the effectiveness of the procedure. However, we reported a sonographic Tinel sign in 5 patients. This phenomenon was probably due to the wavy course of the nerve. On the contrary, no patient reported paresthesia during injection, suggesting that the needle did not come in direct contact with the nerve for a time sufficient to cause sensory alterations. In this study, sonography identified the nerve in all cases, including 4 obese patients. This approach guaranteed successful treatment in every patient. This result was better in comparison to blind injection of the nerve, in which failure rates reached 60%.5 The success rate in this study was similar to the result obtained previously in a series of 10 patients who underwent sensory blockade of the lateral femoral cutaneous nerve.10 In this study, the patient population had a lower body mass index than previously reported.10 No notable postprocedural short- or long-term complications were observed. It has been reported that femoral and obturator nerve involvements are possible complications of lateral femoral cutaneous nerve injections.10 A possible explanation for this difference may have been that the injectate volume was less than the 10- to 15-mL range that has been considered as a cutoff to avoid complications. Moreover, the operator ability in performing this kind of procedure is important for minimizing complications. Several limitations of the study should be taken into account. First, we did not have a control group, and the follow-up duration was short. Another limitation was that the study evaluated only the effects of 1 or 2 injections. From this study, it is not possible to determine whether some patients might benefit from more than 2 injections. However, after 2 injections, all patients reported improvement of symptoms, and none of them required a third injection. Another possible limitation was the relatively low number of patients evaluated; however, to the best of our knowledge, this study included the largest number of patients treated under ultrasound guidance to date. Moreover, the results of this study were both clinically and statistically significant. Ultrasound guidance is thought to be superior to blind techniques. However, the efficacy of this procedure is yet to be proven; no randomized controlled or quasirandomized controlled trials are available.17 A strength of the study was that the accuracy of needle placement near the lateral femoral cutaneous nerve was proven, and the study design was prospective using a standardized protocol. The study provides another example of how a ultrasound-guided technique increases accuracy.18 We believe that an ultrasound-guided approach may enhance the therapeutic effect of the injected drugs. J Ultrasound Med 2011; 30:1341–1346 In conclusion, we believe that ultrasound-guided perineural injection of the lateral femoral cutaneous nerve is quick, simple, economical, and effective. This procedure may be an interesting option in the percutaneous treatment of meralgia paresthetica. Randomized placebo-controlled trials of this treatment should be considered in the future. References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. Martinoli C, Bianchi S. Hip. 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Grothaus MC, Holt M, Mekhail AO, Ebraheim NA, Yeasting RA. Lateral femoral cutaneous nerve: an anatomic study. Clin Orthop Relat Res 2005; 437:164–168. Aszmann OC, Dellon ES, Dellon AL. Anatomical course of the lateral femoral cutaneous nerve and its susceptibility to compression and injury. Plast Reconstr Surg 1997; 100:600–604. Hurdle MF, Weingarten TN, Crisostomo RA, Psimos C, Smith J. Ultrasound-guided blockade of the lateral femoral cutaneous nerve: technical description and review of 10 cases. Arch Phys Med Rehabil2007; 88:1362– 1364. Tagliafico A, Bodner G, Rosenberg I, et al. Peripheral nerves: ultrasoundguided interventional procedures. Semin Musculoskelet Radiol 2010; 14:559–566. Tagliafico A, Valsania V, Lacelli F, Perrone N, Succio G, Serafini G. USguided treatment of meralgia paresthetica (lateral femoral cutaneous nerve neuropathy): results of treatment in 9 patients. 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