The sciatic and femoral nerves represent the two largest peripheral collections of lumbar and sacral nerve roots[
1]. There have been other cadaveric reports of variance in sciatic and femoral nerve as well as piriformis and iliopsoas complex muscle anatomy similar to what is described in this case[
2‐
9,
12,
15]. However, to the authors’ knowledge, these variants have yet to be reported in one single specimen, and thus the potential clinical significance of these sole variants may be enhanced when possessed together.
Straight leg raise and femoral nerve traction tests are commonly performed orthopedic maneuvers done to ascertain the presence of a lumbar disc herniation[
16,
17]. Femoral nerve traction testing has a reported sensitivity of 50% and specificity of 100% for the diagnosis of midlumbar nerve root impingement, and appears to be insensitive and only 50% specific for lower lumbar nerve root impingement[
18]. Straight leg raise testing has sensitivity and specificity characteristics of 16% and 31% respectively for midlumbar nerve root impingement. For the diagnosis of lower lumbar nerve root impingement, straight leg raise testing is 69% sensitive and 84% specific[
18]. Reproduction of radicular leg pain in both sciatic and femoral nerve distributions with nerve traction testing is a common sign of lumbar disc herniations[
16‐
18], and variations in both the course of the sciatic and femoral nerves as well as the surrounding musculature may affect the results of these nerve traction tests[
2,
4]. Recovery from radicular symptoms is often problematic and may be due to diagnostic problems in challenging cases. In a retrospective study conducted by Suri et al. in 2012, 81% of patients who sought conservative care for their leg pain associated with a lumbar disc herniation experienced resolution of symptoms in an average of 6 months. However, within 1 year post resolution, 25% had experienced a recurrence in their leg pain[
19]. Patients who are refractory to care may warrant a reexamination, keeping in mind the many variations in anatomy, dermatomal patterns, and false positive/negatives of certain orthopedic tests[
18,
20‐
22]. A study of the distribution of dermatomal pain patterns by Murphy et al. showed 64.1% of the 169 lumbar spine pain patients presented with non-dermatomal pain distributions[
23]. The sensitivity and specificity of lumbar spine dermatomal pain patterns associated with radiculopathies is too low to be useful in the identification of a specific nerve root level[
23]. This is likely due to the communications between posterior collateral sensory ganglia and preganglionic neurons of different nerve root levels, creating variations in cutaneous sensations[
22,
24]. Several authors have concluded that variant femoral or sciatic nerve anatomy may produce a clinical picture analogous to that of a lumbar or lumbosacral radiculopathy[
2,
4,
5,
7,
14]. Consideration of these anatomical variants, especially combined femoral and sciatic nerve variants, may prompt earlier or more focused diagnostic tests when a suspected lumbar spine disc herniation is refractory to care. One such test that may prove helpful to clinicians would be needle electromyography, as it can assist in the differentiation of radiculopathy and entrapment neuropathies[
11].
Variants in lumbar and lumbosacral plexus anatomy should be considered when a symptomatic lumbar disc herniation is refractory to care. Recognition of these anatomical variants may lead to earlier intervention of physiologic testing, better treatment outcomes and improved patient satisfaction. Future studies examining the prevalence of these combined variants in the general population would be of interest to clinicians.