Case XVIII: Thigh Pain 2

Department of Neurosurgery, University of Wisconsin, Madison, WI, USA


18.1 Case Presentation

A 33-year-old female presents with a 2-month history of left anterior thigh pain. The pain is shooting, shock-like, and fluctuates between 6 and 10 on the VAS . She has baseline chronic low back pain. PMH significant for migraine headaches and bipolar disorder. FH positive for cancer colon in her father. Socially, she has smoked half pack of cigarettes per day for 16 years. On examination, left ilio-psoas 4, quadriceps 4+, the remaining muscle groups are 5/5. Sensation is intact to light touch. DTRs: Achilles 2+ bilaterally, patellar 3+ bilaterally with positive adductor and suprapatellar reflexes. No tenderness on palpation of the lumbar spine. There is negative straight leg raise test and positive femoral stretch test on the left.

18.2 Questions

  1. 1.

    What is the most likely diagnosis?


  2. 2.

    What studies do you need?


  3. 3.

    Any other workup?



  1. 1.

    Left L3 radiculopathy , versus femoral neuropathy.


  2. 2.

    MRI of the lumbar spine.


    Fig. 18.1

    Figure 18.1. There are 2 lesions, one to the right, intradural, the other to the left extraspinal. They are isointense on T1 (A) hyperintense on T2 (B) and contrast-enhancing (C and D). These are likely nerve sheath tumors .


  3. 3.

    Look for stigmata of neurofibromatosis: café-au-lait patches, subcutaneous tumors. MRI of the brain and total spine. May obtain an EMG /NCS of the left lower limb.


18.3 Question

  1. 4.

    No other stigmata of neurofibromatosis, MRI of the brain and total spine is negative. EMG was not obtained. What do you recommend?



  1. 4.

    Surgical resection of the symptomatic lesion (the left one) (Appendix 2); follow up with serial imaging of the right one. Surgery can be done through a posterior left paraspinal (Wiltse) approach [1], or a retroperitoneal approach (as an examinee, just pick one and describe it). Either way, set up for general anesthesia and intraoperative EMG monitoring.

    1. I.

      Posterior paraspinal approach:
Aug 29, 2017 | Posted by in ORTHOPEDIC | Comments Off on Case XVIII: Thigh Pain 2
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