Meralgia Paresthetica: Neurolysis or Neurectomy?

Response to Reviewer 1 Comments 

“Thank you for the opportunity to review this paper. 

This is a very interesting and well written paper on a topic that is rarely discussed but often encountered in clinical practice. 

As the authors report, there is a low degree of suspicion for the disorder, and therefore many cases may have been missed. 

The background presentation is very thorough and explanatory. The methodology is sound and the results are clear. The discussion section clearly incorporates the findings of this study. 

Figures are very illustrative. 

Minor comments. 

1. Abstract is a little bit confusing regarding number of patients. 

            “Data of a consecutive series of 52 patients” 

            “Neurolysis was performed in 47 patients, neurectomy in 8 cases, of whom 3 had undergone a previous decompression.” 

47 p with neurolysis plus 8 equals 55. Then one has to subtract 3 to end up with a total number of 52. It wasn't clear from the first viewing. 

2. Abstract 

            “Three patients reported pain relief, but no benefit on paresthesias.” 

It is not clear whether these patients underwent neurolysis or neurectomy. 

3. Abstract 

 “Decompression has proven to be adequate in almost all patients” 

When reading the paper, it becomes clear that decompression and neurolysis are used interchangeably. I suggest the authors clarify the connection of the 2 terms 

4. Introduction 

 “The core of this clinical condition is aptly summarized by the etymology of the term itself: meralgia (μηρός= thigh and ἄλγος= pain) paresthetica (πara= similar and αἴσθησις= sensation).” 

 I suggest a note on the Greek origin of the words translated 

5. Introduction 

“MP is classified into spontaneous and iatrogenic forms depending on the cause of the nerve injury or compression.” 

MP apparently stands for Meralgia paresthetica, but is not previously mentioned 

6. Introduction 

A figure of the anatomical course of the LFCN is recommended 

7. Introduction 

A figure of The Pelvic Compression Test is recommended 

8. Materials and Methods 

(Figg. 1,2). Please correct to Fig1,2 

Thank you very much for taking the time to review this manuscript. Please find the detailed responses below and the corresponding revisions/corrections highlighted in yellow and marked in red in the re-submitted file.  

Point-by-point response to Comments 

Comments 1 and 2 :   

1. Abstract is a little bit confusing regarding number of patients.   “Data of a consecutive series of 52 patients” “Neurolysis was performed in 47 patients, neurectomy in 8 cases, of whom 3 had undergone a previous decompression.”   47 p with neurolysis plus 8 equals 55. Then one has to subtract 3 to end up with a total number of 52. It wasn't clear from the first viewing.  

2.  “Three patients reported pain relief, but no benefit on paresthesias.”  

It is not clear whether these patients underwent neurolysis or neurectomy. 

Response: Thank you for pointing this out. I agree with this comment. I have modified the abstract so that the numerical results are clearer and neater. You can find the changes marked in red, underlined in yellow. 

Comments 3: “Decompression has proven to be adequate in almost all patients” 

When reading the paper, it becomes clear that decompression and neurolysis are used interchangeably. I suggest the authors clarify the connection of the 2 terms 

Response: Thank you very much for the point:  it is true, in fact in the text they are used as synonyms even though there is a conceptual difference. I point this out at the end of the introduction. You can find the changes marked in red, underlined in yellow. 

Comment 4: “The core of this clinical condition is aptly summarized by the etymology of the term itself: meralgia (μηρός= thigh and ἄλγος= pain) paresthetica (πara= similar and αἴσθησις= sensation).”  I suggest a note on the Greek origin of the words translated. 

Response: Thank you. I revised the text to specify the greek origin of the words. You can find the changes marked in red, underlined in yellow. 

Comment 5: Introduction 

“MP is classified into spontaneous and iatrogenic forms depending on the cause of the nerve injury or compression.” 

MP apparently stands for Meralgia paresthetica, but is not previously mentioned 

Response: Thank you very much, I completely agree, it was an oversight. Added abbreviation to the first “Meralgia parestetica” encountered in the text, first line of the introduction. 

Response to Reviewer 2 Comments 

Thank you very much for taking the time to review this manuscript and especially for the formatting and grammar suggestions. You can find in the text the changes as you indicated. Please find the corresponding revisions highlighted in green and marked in red in the re-submitted file.  

A formatting suggestion:

Please combine one and two sentence paragraphs together. A paragraph should ideally be composed of a minimum of three sentences to avoid a choppy narrative. Thank you very much, I accordingly revised it.

Some edits:

The sentence on page 2, “Electromyographic findings may be not specific when nerve conduction from the contralateral LFCN cannot be measured” should be, “Electrodiagnostic findings may be not specific when nerve conduction from the contralateral LFCN cannot be measured.” Thank you very much, I accordingly revised it.

The paragraph on page 2, “Sometimes, simply waiting, symptoms are waxing and waning” is a bit odd and should be rewritten. This is too brief to be a stand alone paragraph (see above).

 Thank you very much. I changed the sentence in “Sometimes a conservative attitude or simply waiting can lead to spontaneous resolution of symptoms” and I related it to the previous paragraph.

The paragraph on page 2, “The lack of high-level evidence keeps the debate inflamed about which treatment algorithm is better; in case of surgical approach, whether it is best to opt for neurolysis or neurectomy is also controversial” is awkward and should be rewritten. Thank you very much. I changed the sentence in “There is no high-level evidence on which is the best treatment to offer to MP patients. This makes the debate on this issue still open. In particular, as far as surgical treatment is concerned, it is not yet proven whether it is better to perform neurolysis or neurectomy.”

The sentence on page 4, “Generally speaking, when in difficulty, one must always think to be placed far too medial” is awkward and should be rewritten. Thank you very much. I changed the sentence in “In fact, the surgical approach needs to be performed in the correct position and working direction. Generally, the difficulty in identifying LFCN immediately can be due to a too medial position of the surgical access”.

The sentence on page 5, “Then the superficial layers are closed as usually” should be, “Then the superficial layers are closed as usual”. Thank you very much, I accordingly revised it.

The sentence on page 6, “At light of these results…” should be, “In light of these results…”. Thank you very much, I accordingly revised it.

The sentence on page 6, “On the contrary, neurectomy is the only effective treatment in case of meralgic pain due to inadvertent section of peripheral branches of the LFCN, so as it sometimes happens after an anterior approach to the hip joint.” Is this true? Are there really no other effectve treatments (e.g. nerve repair, RPNI, neuromodulation, etc.)? Thank you for this comment. Thank you for your comment. When we say that neurectomy is the only effective treatment in these cases, we mean that it is the only definitive one. In fact, the incomplete section of the nerve causes a lancinating pain that is resolved only with neurectomy. The other methods do not maintain effectiveness over time. Anyway, to be clear, I have replaced "effective" with “definitive" in the text.

The sentence on page 7, “The true bias is the significant disparity between the number of patients receiving neurolysis and those with neurectomy.” I am not sure this is true. One could argue that the study is more biased for a number of methodological reasons, including retrospective nature, patient assessment by the treating physician, incomplete records, lack of control group, lack of randomization, lack of cohort homogeneity, etc. Thank you very much, I accordingly revised it.

The sentence on page 7, “Neurectomy is mandatory as a first line treatment in cases of iatrogenic MP when the nerve has been already severely damaged, while is the second-line option in case of failed neurolysis.” There is no evidence in this paper (or elsewhere) to support this treatment recommendation. There are a number of other treatment options available in this circumstance that can be utilized in the setting of a nerve injury. Thank you very much, I accordingly revised it.