Meralgia Paresthetica: Inside Dr. Tollestrup’s Operating Room

By October 6, 2020 Meralgia Paresthetica, videos

Meralgia Paresthetica is a common problem that can be a complicated pain issue to resolve.
In this video we go inside the operating room with Dr. Tim Tollestrup to see how many different nerve anatomy variations there are for Meralgia Paresthetica.

It takes a skilled, experienced surgeon with a deep understanding of peripheral nerve anatomy to handle decompression of the lateral femoral cutaneous nerve, especially given the various presentations.

Let’s go inside the O.R. with Dr. Tollestrup….

Technically meralgia paresthetica involves compression of the lateral femoral cutaneous nerve. In the classic anatomic configuration, the entire lateral femoral cutaneous nerve comes out of the pelvis just to the inside of your hip bone, the anterior superior iliac spine, and underneath the inguinal ligament, which is a tough band of fibrous tissue that goes from the front of your hip bone to the pubic bone in the middle.

Here we are in the operating room, and we just have some really interesting anatomy. This vessel goes around a fairly normal in both location and caliber, lateral femoral cutaneous nerve, right here. The ASIS is right here. Then there’s some unusual nerve anatomy. There’s another nerve that was just super compressed coming over, about a centimeter posterior to the ASIS. This patient has meralgia paresthetica, which is compression in the lateral femoral cutaneous nerve.

They have basically a split nerve or a double nerve coming through here. It’s very interesting, two complete fascial tunnels with two complete separate nerves. And the interesting thing is you can clearly see that this one is probably the one that’s more symptomatic. It’s very red and inflamed, and the other one looks more normal, just fatty infiltrated. But I’ve never seen it quite like that.

Wanted to show this interesting but not uncommon variable anatomy with the lateral femoral cutaneous nerve. You can see, however, that it’s quite a bit smaller in caliber than a normal nerve should be. So that prompts an exploration immediately. And in this case, we have another lateral femoral cutaneous nerve, very possibly just a division of this one in the pelvis somewhere, or this could be a branch off the femoral branch, the genital femoral nerve. You can just see that even though the textbook always shows one nerve, there’s often multiple variations.

In some cases, patients don’t have a lateral femoral cutaneous nerve in the true sense. When you look in the usual location, there’s no nerve at all. Oftentimes in these scenarios that genital branch, the genital femoral nerve, which in the classic sense is a very tiny nerve, will actually be carrying the entire lateral femoral cutaneous nerve bundle with it, and so it’s very big.

If you’re having surgery on the lateral femoral cutaneous nerve, whether you’re planning on decompressing it or disconnecting it, you really need to have a surgeon who’s familiar with this anatomy because it can be very confusing if you get in there, and there’s no nerve where you expect the nerve to be. You have to understand all of these anatomic variations and know where to look for these nerves.