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Findings
There is an enlarged, T2 hyperintense structure coursing about the right anterior superior iliac spine and deep to the inguinal ligament. This T2 hyperintense structure is seen to extend into the proximal aspect of the right thigh. The left side is a nice internal control where this structure is much less conspicuous as it is normal on the left side.
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Diagnosis: Meralgia Paresthetica
Meralgia paresthetica is a pain syndrome related to an entrapment of the lateral femoral cutaneous nerve (LFCN) as it traverses just deep to the inguinal ligament at the level of the anterior superior iliac spine (ASIS). The entrapment may rarely occur related to the sartorius origin about the ASIS. The LFCN is a sensory nerve that is derived from variant contributions of L1L3. It extends from the lateral psoas to then travel along the anterior aspect of the iliacus towards the ASIS where it then typically goes under the inguinal ligament into the anterolateral thigh. Known variation is particularly present of the nerve about the level of the ASIS.
Why the symptoms are precipitated is not known with some cases being iatrogenic and some thought perhaps related to obesity, tight fitting clothing, prolonged prone position, and other processes associated with increased abdominal pressure.
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Diagnosis Continued
Nonoperative measures with correcting the inciting event or at times antiinflammatory injection can be utilized. If recalcitrant, surgical intervention with neurolysis, transposition, or transection of the nerve have all been described.
This case I think highlights the attention to detail that is needed in helping provide accurate diagnosis in this case and many nerve related cases. There is an interplay between good clinical acumen, radiologists’ commitment to detailed plotting and technique, and then insight into the expected and unexpected findings in these cases. I am lucky to be surrounded by numerous radiologists that perform these cases exquisitely well and would especially like to thank Dr. Darryl Sneag. Dr. Sneag’s commitment to developing hardware, MRI technique, and our understanding of pathology to nerves on MRI has been unprecedented for the radiology community.
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References
Grossman, Mark G. MD; Ducey, Stephen A. MD; Nadler, Scott S. DO; Levy, Andrew S. MD. Meralgia Paresthetica: Diagnosis and Treatment. Journal of the American Academy of Orthopaedic Surgeons 9(5):p 336-344, September 2001.
Gomez YC, Remotti E, Momah DU, Zhang E, Swanson DD, Kim R, Urits I, Kaye AD, Robinson CL. Meralgia Paresthetica Review: Update on Presentation, Pathophysiology, and Treatment. Health Psychol Res. 2023 Mar 15;11:71454. doi: 10.52965/001c.71454. PMID: 36937080; PMCID: PMC10019995.
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