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1117

CLINICAL NOTE

Posterior Femoral Cutaneous Nerve Mononeuropathy:


A Case Report
Henry C. Tong, MD, Andrew Haig, MD
ABSTRACT. Tong HC, Haig AJ. Posterior femoral cutane- not been demonstrated in a clinical case. We present a case of
ous nerve mononeuropathy: a case report. Arch Phys Med PFCN mononeuropathy detected by Dumitru’s technique.
Rehabil 2000;81:1117-8.
CASE REPORT
Isolated posterior femoral cutaneous nerve (PFCN) lesions
are rare, with only six cases reported in the modern literature A 25-year-old woman was hospitalized for treatment of
and one case documented with a nerve conduction study. A severe chronic headaches. She received two intramuscular
25-year-old woman had sensory loss in the posterolateral thigh injections in the right buttock for treatment of her headaches,
after two right gluteal intramuscular injections. Nerve conduc- but she did not know what medication was given. On discharge,
tion studies using Dumitru’s technique showed a 9µV response she noted numbness in the right posterolateral thigh, which
on the asymptomatic side, but no response on the symptomatic persisted more than 5 months, up to the time of referral for
side, and no abnormalities on needle examination of the back electrodiagnostic consultation. She denied having low back
and lower extremities. Although a single case does not prove pain, bowel and bladder changes, and any focal weakness. She
the validity of a technique, this case provides the rare opportu- did not report any other associated acute illness or trauma. Her
nity to demonstrate the utility of Dumitru’s technique. medical history was positive for cervical cancer, status posthys-
Key Words: Electromyography; Neural conduction; Femo- terectomy. She denied having had diabetes mellitus or thyroid
ral nerve; Rehabilitation. disease. There was no family history of nerve or muscle disease.
The patient had not experienced fevers, chills, weight change,
r 2000 by the American Congress of Rehabilitation Medi- nausea, or vomiting. Review of systems was otherwise nega-
cine and the American Academy of Physical Medicine and
Rehabilitation tive.
The patient was intelligent, cooperative, well developed, and
well nourished, with normal tone, muscle bulk, and passive
range of motion. She had normal strength in her legs. Sensation
T HE POSTERIOR femoral cutaneous nerve (PFCN) arises
from the ventral primary rami of S1, S2, and S3 of the
sacral plexus. It exits from the pelvis through the sciatic
was intact in the L1-S2 dermatomes bilaterally except for
decreased sensation in the right buttock and posterior thigh (fig
foramen below the piriformis muscle and posteromedial to the 1). Reflexes were symmetric and 2⫹ at the biceps, triceps, and
sciatic nerve. Superficially, it gives rise to the perineal and brachioradialis. They were symmetric and 2⫹ at the knees and
inferior clunial branches, which provide sensory innervation to ankles. Toes were downgoing bilaterally.
the inferior posterior buttock. The main nerve trunk then
continues distally in the midline along the posterior thigh METHODS
superficial to and between the long head of the biceps femoris Nerve conduction studies of the right sural sensory, peroneal
and semitendinosis musculature. Here it provides sensory motor, and tibial motor nerve branches were evaluated with
innervation to the posterior thigh.1 Distally, at the back of the standard techniques.7,8 A 50-mm disposable concentric needle
knee, it pierces the deep fascia and its terminal twigs communi- was used to examine the right leg muscles. The MiniPM
cate with the sural nerve. It generally supplies the skin over the technique was used to assess the paraspinal muscles.9 Briefly, at
popliteal fossa and usually a part of the upper posterior leg. four locations across from L3-S1, a 50-mm monopolar needle
Isolated PFCN lesions are rarely reported. A Medline search was inserted in three directions (medial, craniomedial, and
covering the period 1966 to 1998 found two cases caused by caudal-medial) from each of these locations.
injection,2,3 three by compression,4 and one of unknown Nerve conduction study of the PFCN was performed anti-
etiology.5 Two cases were documented clinically by electrophysi- dromically bilaterally using the technique proposed by Dumitru
ologic testing. Dumitru and Marquis5 reported one case with and Nelson.6 An active electrode is placed at the midline of the
somatosensory evoked potential (SSEP) findings. Subse- posterior thigh 6cm proximal to the popliteal crease and
quently, Iyer and Shields2 showed a single case with nerve stimulation is performed 12cm proximally. This technique has
conduction study findings. Dumitru and Nelson6 subsequently been shown to reliably detect the PFCN waveform and not a
described a new technique in 40 asymptomatic persons. The volume conducted sciatic mixed nerve waveform.6 We chose to
utility of that technique in detecting pathology in the PFCN has use a 2-cm circular ‘‘ground’’ electrode as an active electrode.

RESULTS
Nerve conduction studies of the sural, tibial motor, and
From the Department of Physical Medicine and Rehabilitation, University of peroneal motor branches showed normal distal latencies and
Michigan, Ann Arbor, MI.
Submitted April 30, 1999. Accepted in revised form October 22, 1999.
amplitudes. Needle examination of the medial gastrocnemus,
No commercial party having a direct financial interest in the results of the research anterior tibialis, vastus medialis, gluteus medius, external
supporting this article has or will confer a benefit upon the authors or upon any hamstring, and lumbar paraspinal muscles was within normal
organization with which the authors are associated. limits. MiniPM paraspinal evaluation had a total score of 0
Reprint requests to Henry Tong, MD, Department of PM&R, Spine Program, 325
East Eisenhower, 2nd floor, Ann Arbor, MI 48108.
(95% of asymptomatic subjects score 0 to 2).9 The left posterior
0003-9993/00/8108-5605$3.00/0 femoral cutaneous nerve sensory evoked response amplitude
doi:10.1053/apmr.2000.5564 was 9.2µV, with an onset latency of 2.7msec and a peak latency

Arch Phys Med Rehabil Vol 81, August 2000


1118 POSTERIOR FEMORAL CUTANEOUS NERVE, Tong

The previous case verified by SSEP was a 40-year-old patient


who had a nonspecific connective tissue disease with a positive
rheumatoid factor and antinuclear antibody. Her symptoms
began after a left putamen hemorrhage 4 years earlier. No cause
of her mononeuropathy was found. The three cases of compres-
sive neuropathy were diagnosed clinically; in two of the cases
the symptoms were provoked by sitting and alleviated by
standing or lying prone.4
Our case is probably related to a gluteal intramuscular
injection, which was also reported to be the cause in two of the
four reports we found.2,3 Isolated PFCN injury caused by
injections is rare since usually the sciatic nerve is involved. In
two reviews of 137 and 247 cases of nerve injuries resulting
from injections in the legs, isolated injuries of the sciatic nerve
accounted for about 95% of the injuries, while isolated PFCN
injuries accounted for about 1%.2,3 In our case, the loss of
sensation in the posterior thigh is consistent with a PFCN
Fig 1. Sensory loss on physical examination. Pinprick testing from lesion. There was also, however, sensory loss in the inferior
sensate toward insensate areas, and from insensate toward sensate medial buttock region that is consistent with an inferior medial
areas corresponded to within 1cm. clunial nerve lesion. This is explained by the fact that as the
PFCN leaves the sciatic foramen, it gives rise to inferior medial
of 3.7msec from a distance of 12cm (conduction velocity clunial branches that provide sensory innervation to the inferior
44m/sec). Exact location of the nerve’s course was confirmed posterior buttock. This means that the intramuscular injection
by decreased response on movement of either the stimulating or must have injured the PFCN as it left the sciatic foramen before
active electrode across the thigh. The right PFCN showed no it gave rise to the inferior cluneal branches. This is rare, since
response despite high amperage stimulation attempted at 5-mm the sciatic nerve is in close proximity to the PFCN at this level
intervals from medial to lateral across the posterior thigh and and is more commonly injured due to the large size of the
movement of the active electrode methodically across the distal nerve.2
thigh in similar 5-mm intervals. A diagnosis of an isolated right In the case report section of the six cases reported, one did
PFCN neuropathy was made, based on the clinical findings not mention the physical examination3 and two only mentioned
substantiated by the results of electrophysiologic testing. that there was numbness in the region of the PFCN.4,5 Two
cases had decreased sensation in the posterior thigh and lower
DISCUSSION buttock, which is similar to our patient.4 This suggests that in a
Standard electrodiagnostic techniques using nerve conduc- significant number of posterior femoral cutaneous neuropa-
tion studies and needle electromyography are often adequate for thies, the inferior clunial nerve is also affected.
identifying pathology involving most peripheral nerves.5 Until In none of the other cases was outcome discussed. Our case
recently, however, there was no described formal method to was never retested with nerve conduction studies. Before she
evaluate the PFCN.6 In this case, the method described by was lost to follow-up, however, she was seen in clinic 6 months
Dumitru and Nelson6 was used for several reasons. The method later and had continued numbness in her right posterior thigh.
is described in detail; it uses easily identifiable landmarks (ie,
the midline of the thigh and the midpopliteal region), and there References
are exact measurements for the location of the recording and 1. Hollinshead WH. Anatomy for surgeons: the back and limbs, Vol. 3.
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Shields,2 the PFCN was stimulated at the gluteal fold with 2. Iyer VG, Shields CB. Isolated injection injury to the posterior
recording electrodes placed over the upper angle of the femoral cutaneous nerve. Neurosurgery 1989;25:835-8.
popliteal fossa. This is not as rigorous a technique since the 3. Obach J, Aragones JM, Ruano D. The infrapiriformis foramen
syndrome resulting from intragluteal injection. J Neurol Sci 1983;58:
distance between the stimulating cathode and active electrode 135-42.
will vary, depending on the femur lengths being equal, the 4. Arnoldussen WJ, Korten JJ. Pressure neuropathy of the posterior
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the location of the popliteal fossa, and the ability to locate the 5. Dumitru D, Marquis S. Posterior femoral cutaneous nerve neuropa-
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described by Dumitru has been tested in 40 healthy subjects (20 1988;69:44-5.
men, 20 women) and a response was obtained in all 80 nerves 6. Dumitru D, Nelson MR. Posterior femoral cutaneous nerve conduc-
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Belfus; 1995.
This is the first case to be described that uses the surface 8. Kimura J. Electromyography in diseases of nerve and muscle:
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Arch Phys Med Rehabil Vol 81, August 2000