The guidelines provided by the New York State Workers Compensation Board are intended to assist healthcare professionals in evaluating Meralgia Paresthetica. These directives aim to support physicians and healthcare practitioners in determining the appropriate treatment for this condition.
Healthcare professionals specializing in Meralgia Paresthetica can rely on the guidance provided by the Workers Compensation Board to make well-informed decisions about the most suitable level of care for their patients.
It is crucial to stress that these guidelines are not intended to replace clinical judgment or professional expertise. The ultimate decision regarding care should involve collaboration between the patient and their healthcare provider.
Meralgia Paresthetica
Meralgia paresthetica refers to a peripheral entrapment neuropathy affecting the lateral femoral cutaneous nerve, a sensory nerve that serves the upper lateral regions of the thigh. While nerve entrapment can occur at any point along the nerve, the condition typically arises due to localized pressure near the inguinal ligament. In occupational scenarios, it is often linked to pressure exerted by tight, heavy tool belts, or military armor.
Onset can be either relatively sudden, such as after a single night’s sleep, or gradual. Other contributing factors include trauma, scarring resulting from previous trauma or surgery, and impacts from systemic rheumatological disorders. Symptoms manifest as tingling and numbness within the nerve’s distribution. Pain may be absent, mild, or, in rare cases, intense. Notably, there is no associated muscle weakness.
Diagnostic Studies
Magnetic Resonance Neurography:
Suggested for the diagnosis of meralgia paresthetica.
Indications: In the majority of cases, clinical diagnosis and empirical treatment are adequate, rendering testing unnecessary. However, testing is recommended before surgery to affirm the diagnosis and precisely identify the entrapment location for the operative approach.
Rationale: Diagnosis is commonly based on clinical evaluation, and imaging is usually not required. However, in situations where there is uncertainty about the accuracy of the diagnosis or when contemplating surgery, a nerve conduction study is advised to validate the diagnosis and pinpoint the entrapment location.
Nerve Conduction Study:
Advised to confirm the diagnosis of meralgia paresthetica and localize the entrapment.
Indications: In most instances, clinical diagnosis and empirical treatment yield positive outcomes, eliminating the need for testing. Nevertheless, testing is recommended before surgery to affirm the diagnosis and precisely identify the entrapment location for the operative approach.
Frequency/Dose/Duration: Once. It is generally not recommended until symptoms persist for at least three weeks to allow sufficient time for electrical findings to develop.
Rationale: Diagnosis is typically clinical, and imaging is usually unnecessary. However, in cases where there is uncertainty about the accuracy of the diagnosis or when contemplating surgery, a nerve conduction study is recommended to confirm the diagnosis and pinpoint the entrapment location.
Medications
For the majority of patients, the initial recommendations for managing pain include ibuprofen, naproxen, or other traditional NSAIDs. Acetaminophen (or its analogue paracetamol) may serve as a reasonable substitute for NSAIDs in patients ineligible for them, although existing evidence suggests that acetaminophen is slightly less effective. Research indicates that NSAIDs are equally effective in relieving pain as opioids (including tramadol) and result in fewer impairments.
Non-Steroidal Anti-inflammatory Drugs (NSAIDs):
Recommended: for treating meralgia paresthetica.
Indications: NSAIDs are recommended for treatment, and over-the-counter (OTC) options may be suitable and should be attempted initially.
Frequency/Duration: As-needed use may be reasonable for many patients.
Indications for Discontinuation: Resolution of meralgia paresthetica, lack of efficacy, or the emergence of adverse effects necessitating discontinuation.
NSAIDs for Patients at High Risk of Gastrointestinal Bleeding:
Recommended: simultaneous use of cytoprotective drugs, such as misoprostol, sucralfate, histamine Type 2 receptor blockers, and proton pump inhibitors for patients at a high risk of gastrointestinal bleeding.
Indications: Consideration for patients with a high-risk factor profile who also need NSAIDs, particularly if longer-term treatment is anticipated. At-risk patients include those with a history of prior gastrointestinal bleeding, the elderly, diabetics, and cigarette smokers.
Frequency/Dose/Duration: Proton pump inhibitors, misoprostol, sucralfate, H2 blockers are recommended, with dosage and frequency per manufacturer. There is generally no substantial belief in differences in efficacy for preventing gastrointestinal bleeding.
NSAIDs for Patients at Risk for Cardiovascular Adverse Effects
Patients with documented cardiovascular disease or multiple risk factors for cardiovascular problems should participate in a thorough discussion regarding the potential advantages and disadvantages of NSAID therapy for pain control.
It is advised: Acetaminophen or aspirin is proposed as the initial line of treatment, as they seem to be the safest in terms of cardiovascular adverse effects.
It is recommended: If deemed necessary, non-selective NSAIDs are preferred over COX-2 specific drugs. For individuals using low-dose aspirin for primary or secondary prevention of cardiovascular disease, to minimize the potential counteraction of aspirin’s beneficial effects by NSAIDs, the NSAID should be taken at least 30 minutes after or eight hours before the daily aspirin.
Acetaminophen for Meralgia Paresthetica Treatment:
It is recommended: for managing meralgia paresthetica, especially in individuals with contraindications for NSAIDs.
Indications: All patients experiencing meralgia paresthetica pain, spanning acute, subacute, chronic, and post-operative cases.
Dose/Frequency: As per the manufacturer’s guidelines; may be used on an as-needed basis. There is evidence of hepatic toxicity when exceeding four gm/day.
Indications for Discontinuation: Resolution of pain, adverse effects, or intolerance.
Topical Lidocaine:
It is not recommended: for the treatment of meralgia paresthetica.
Hot and Cold Therapies
Cryotherapy:
Recommended for individuals with meralgia paresthetica.
Indications: Applicable to all individuals with meralgia paresthetica.
Frequency/Duration: Approximately three to five self-applications per day as needed.
Indications for Discontinuation: Cessation, adverse effects, non-compliance.
Heat Therapy:
Recommended for individuals with meralgia paresthetica.
Indications: Applicable to all individuals with meralgia paresthetica.
Frequency/Duration: Approximately three to five self-applications per day as needed.
Indications for Discontinuation: Cessation, adverse effects, non-compliance.
Injection Therapy
Glucocorticosteroid Injections:
Recommended for treating meralgia paresthetica if conservative treatments prove ineffective.
Indications: Meralgia paresthetica that is sufficiently severe and unresponsive to other conservative, non-invasive treatments.
Frequency/Dose/Duration: One injection. A second injection is not warranted if sufficient recovery occurs from the first.
Evidence for the Use of Glucocorticosteroid Injections for Treating Meralgia Paresthetica
Surgery
Surgical Release:
Recommended for treating specific individuals with meralgia paresthetica.
Indications: Individuals with persistent symptoms unresponsive to the aforementioned treatments and whose symptoms are severe enough to warrant invasive treatment. Diagnosis and entrapment site confirmation should be done by either a nerve conduction study or MR neurography.
Rationale: For individuals where there is uncertainty about the accuracy of the diagnosis or when contemplating surgery, a nerve conduction study or MR neurography is recommended to confirm the diagnosis and pinpoint the entrapment site.
Surgical release is rarely necessary, but it is recommended for individuals with continued symptoms unresponsive to the above treatments and severe enough to warrant invasive intervention.
Other
Spinal Cord Stimulator:
Not Recommended for treating individuals with meralgia paresthetica.
