PubMed · 8290831
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A Dubuisson. 1993-11-01. [Meralgia paresthetica].. https://pubmed.ncbi.nlm.nih.gov/8290831/
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Peripheral nerve entrapment syndromes may be caused by inflammation, trauma, or congenital deficits. Some entrapment neuropathies are overdiagnosed, particularly carpal tunnel syndrome. Other nerve entrapment syndromes, such as the thoracic outlet syndrome, posterior interosseous nerve syndrome, and anterior interosseous nerve syndrome, are rare. In most cases of an entrapment neuropathy, the diagnosis and management are straightforward, but much remains to be learned about the natural history, course, and prevention of these clinical conditions.
In bilateral dissections of 68 cadavers, four examples were found unilaterally of variant slips of iliacus and psoas major muscles. In three of them the femoral nerve was pierced by the variant slip. One of these variants was a previously undocumented accessory slip of iliacus, originating from the iliolumbar ligament, passing inferiorly anterior to iliacus, and traversing the femoral nerve; its tendon split to be attached proximally to the lesser trochanter of the femur and distally to an unknown insertion. Such anomalies might cause tension on the femoral nerve resulting in referred pain to the hip and knee joints and to the lumbar dermatomes L2,3 and 4.
Laparoscopic techniques currently constitute an alternative proposed for the repair of hernias of the inguinofemoral region. Nerve injuries have led some teams to recommend technical principles based on the anatomical relations of these nerves with the subperitoneal fascia transversalis and inguinal fossae. An anatomical study consisting of dissection of nonembalmed cadavres, allowed, after evisceration, dissection of the lumbar plexus and its terminal branches, particularly those supplying the inguinofemoral region: iliohypogastric and ilio-inguinal nerves, the genitofemoral nerve, the femoral nerve and the lateral cutaneous nerve of the thigh. Via transperitoneal laparoscopy, the posterior surface of the anterior abdominal wall is centered on the deep inguinal ring, containing testicular vessels and the vas deferens. This deep inguinal ring receives the genitofemoral nerve. Medially, the anterior parietal peritoneum describes three folds formed by the outline of the epigastric artery, umbilical artery and urachus on the midline. The outline of Hesselbach's ligament separates the deep inguinal ring from Hesselbach's triangle, the zone of weakness of direct inguinal hernia. The iliac psoas muscle pass laterally underneath the inguinal ligament, while the external iliac vessels, subsequently becoming the femoral vessels, are located medially. Pectineal ligament lies on the posterior surface of the femoral ring between the umbilical artery and the epigastric artery. Installation of an abdominal wall prosthesis, either transperitoneally or retroperitoneally, must be centered on the deep inguinal ring, and its solid sutures are located medially to the pectineal ligament and anterior abdominal wall. On the other hand, the nerves at risk of being damaged are situated laterally: the ilio-inguinal and ilio-hypogastric nerves in the plane between external oblique and internal oblique above the anterior superior iliac spine, lateral cutaneous nerve of the thigh under the inguinal ligament close to the anterior superior iliac spine, genitofemoral nerve with the spermatic cord in the deep inguinal ring and femoral nerve underneath the inguinal ligament with the psoas muscle lateral to the external iliac artery. No stapling must be performed under the plane of the inguinal ligament to avoid damage to the femoral vessels and lateral to the deep inguinal ring to avoid nerve damage.