Diagnosis and treatment of meralgia paresthetica between 2005 and 2018: a national cohort study

Meralgia paresthetica (MP) is the compression syndrome of the lateral femoral cutaneous nerve (LFCN) resulting in numbness and/or painful dysesthesia of the anterolateral thigh [1‐4]. For a long time, it was considered a rare disease [5, 6], but, beginning in the 1990s, a substantial increase in its prevalence has been observed, most likely due to growing rates of obesity and diabetes mellitus (DM) [7‐9].

In the absence of high-quality clinical trial data on MP, guidelines are lacking. Care for MP is determined predominantly by surgeon preference and experience [10, 11]. Most therapists agree that the diagnosis of MP is based primarily on clinical examination and patient history. To rule out a lumbar radiculopathy as a differential diagnosis, a spinal MRI is recommended. Neurophysiologic work-up may include LFCN conduction studies or somatosensory evoked potentials [12‐14].

Treatment options include local injections, open neurolysis or neurectomy, and various neuro-modulative approaches [3, 15‐25]. If surgical therapy is necessary, a variety of techniques exist. Some groups prefer decompressive techniques with nerve preservation or even transposition while others recommend neurectomy of the LFCN [26‐28]. A recent meta-analysis found slightly superior pain relief and lower rates of revision procedures for neurectomy, compared to decompressive procedures [29].

Large-scale evidence on the choice of diagnostic and therapeutic modalities in MP is lacking. The assessment of current practice, potential variations, and time trends has never been performed. We designed a national study aiming to report current practice in the diagnostic and therapeutic management of patients hospitalized for MP in Germany and time trends between years 2005 and 2018.

A mean number of 729 (± 67.5) patients were hospitalized for MP in years 2005, 2007, 2009, 2011, 2013, 2016, 2017, and 2018 in Germany, and a total of 5828 MP patients were included into our final analysis.

This is the first comprehensive analysis of trends in diagnostics and treatment of MP on a national level. The main results are, that diagnostic procedures, both imaging and non-imaging, became more prevalent between 2005 and 2018, while rates of surgical treatment decreased over time, with neuropreservative surgical techniques being performed substantially more frequently than techniques of nerve transection.

The fact that, in Germany, health care professionals increasingly rely on imaging, evoked potentials, and neurography in the diagnosis of MP is especially interesting, since the diagnosis of MP is based first and foremost on clinical examination. Increasing rates of MRI may, in parts, be due to increased incentive to exclude lumbar radiculopathy, given that delayed or false diagnoses comprise about 30% of litigation claims in neurosurgery [30, 31]. Growing rates of MRI in MP diagnostics may also be due to the more widespread availability of MRI and improvements in nerve visualization. This trend could lead to even higher rates of MRI in MP management in the future [32‐36]. The fact that rates of other diagnostics, such as LFCN conduction studies [7, 37, 38] and somatosensory evoked potentials, have also increased over time, may reflect increasingly robust evidence on their merits in MP diagnostics [12, 13]. For example, a study from 2006 found that changes in ipsilateral somatosensory evoked potentials (SSEPs) after stimulation of the posterior tibial nerve showed good sensitivity and specificity (85.7% and 82.4%, respectively; accuracy, 83.3%) for MP without the need for bilateral comparisons [14].

Regarding trends in MP management, we found that rates of surgical procedures decreased. At the same time, rates of non-surgical treatments and additional procedures focussing on psychosomatic components increased. Decreasing rates of surgical therapy in MP may be explained by improved medical treatment, such as anti-neuropathic pain medication, which may allow patients and therapists to forgo surgery [39, 40]. Another reason may be that a certain proportion of MP surgery may increasingly take place in an ambulatory setup. For example, in other nerve compression syndromes, such as cubital tunnel syndrome, a trend toward outpatient surgical management has been reported [41, 42]. To date, no data on shifts in the management of MP from in-hospital to outpatient environments exist. Therefore, it is unclear how many additional patients are operated on in the outpatient setting. However, even if we cannot assess potential changes in total numbers, we do not expect the proportions of types of surgery to change.

Throughout the entire study period, surgical management of MP in Germany was conducted using neuropreservative techniques, such as decompression of the LFCN, rather than neurectomy procedures. In the ongoing discussion on which surgical strategy to choose, the most comprehensive meta-analysis had to rely on observational studies in the absence of randomized controlled data [29]. Similar to our findings, it reports that neurolysis was more common than neurectomy. Regarding outcomes, complete pain relief was achieved more often after neurectomy (85%) than decompression surgery (63%). These results are supported by two Cochrane meta-analyses, who report slightly higher rates of postoperative benefit after neurectomy (94%) than after decompression surgery (88%) [19, 20]. Surgeons preferring neurectomy over neurolysis frequently point to histopathological findings in the compressed nerve. These findings suggest focal demyelination, thickened perineurium, subperineurial edema, Renaut bodies, and regenerating clusters [43, 44]. One may argue that such morphological changes are irreversible and neurectomy may therefore represent a more effective surgical strategy in MP than neurolysis [44]. Findings in animal models suggest a relationship between the duration of symptoms and reversibility of ischemic damage to the nerve induced by compression, yet clinical data on the reversibility of histopathological changes in nerve compression syndromes in humans is missing [45, 46]. In a recent observational study, hypesthesia in the innervation area of the LFCN after neurectomy was described as not “bothersome,” as measured on a bothersomeness scale ranging from 0 to 6 [26]. However, a systematic analysis of the effect of anterolateral thigh hypesthesia based on the validated quality-of-life measures is still lacking. A recent description of a more extensive and dynamic decompression technique revealed excellent results in terms of improvement of pain and/or paresthesia (89%), complete restoration of sensory function (69%), and some sensory improvements (26%) [27]. Transposition is a technical variation, which was shown to improve outcomes of neurolysis of the LFCN [28].

Increases in rates of complementary treatment modalities for chronic pain, such as treatment of psychosomatic components, as observed in our analysis in Germany, may reflect changes in chronic pain management toward more holistic approaches. Nevertheless, reports for their particular benefits in MP are lacking [47‐49].

A major strength of our study is that it allows for a comprehensive nationwide assessment across all disciplines involved in in-hospital MP care. However, our study has certain limitations. The fact that only data from Germany were included may limit the generalizability of our findings to healthcare systems in other countries. Also, the data set used was depersonalized, and therefore, distinct per-person analyses were not possible. Also, we cannot exclude the possibility of multiple inclusions per person. As mentioned above, patients treated in the outpatient sector were not included in our analysis, potentially introducing a certain degree of selection bias. However, surgical MP treatment in Germany is only rarely conducted in ambulatory facilities, and outpatient data on MP are not collected in a centralized system, unlike in-hospital data, which are more reliable in the assessment of treatment trends [42].

Between 2005 and 2018, MP care in Germany underwent significant changes. Rates of imaging, evoked potentials, neurography, and non-surgical management increased, while rates of surgical management decreased. Nerve transections for surgical treatment of MP were substantially less frequent than decompressive techniques.