Journal of Orthopaedic Science xxx (xxxx) xxx

Contents lists available at ScienceDirect

Journal of Orthopaedic Sciencejournal homepage: http://www.elsevier.com/locate/josCase Report

Simultaneous herpes zoster rash in the femoral and medial buttock
region that illustrates the innervation zone of the dorsal ramus of thelumbar spinal nerve root: A case report
Hiroshi Nomura a, *, Hiroshi Iwasaki b, Shigeharu Nomura a, Yasuhisa Tanaka cabc

Nomura Orthopaedic Clinic, Address: 4-8-1 Ayaragihon-machi, Shimonoseki, Yamaguchi 751-0849 JapanDepartment of Orthopedic Surgery, Wakayama Medical University, Address: 811-1 Kimiidera, Wakayama, Wakayama 641-8509 Japan
Department of Orthopedic Surgery, Tohoku Central Hospital, Yamagata, Japan, Address: 3-2-5 Wagou-machi, Yamagata, Yamagata 990-8510 Japana r t i c l e i n f oArticle history:
Received 24 January 2022
Received in revised form
30 March 2022
Accepted 15 May 2022
Available online xxx
Keywords:
Herpes zoster
Superior cluneal nerves
Dorsal ramus of the lumbar nerve root

1. Introduction
Although low back pain (LBP) is one of the most common
symptoms in daily orthopedic practice, its etiology is complex, witha wide variety of underlying causes, including lumbar muscle/fascial injury, lumbar facet syndrome, discogenic back pain, spinal
instability, lumbar vertebral fracture, and neurogenic back pain
[1,2]. Among them, pathological conditions of the lumbar dorsal
ramus have recently been identiﬁed as a source of LBP. These
conditions include degenerative posterior impingement involving
supporting structures of the lumbar spine, soft-tissue dissection, orstripping during lumbar decompression surgery, resulting in lumbar dorsal ramus syndrome [2e4]. Similarly, entrapment neuropathy of the superior cluneal nerve (SCN) and middle cluneal nerve(MCN), which originate from the lateral branch of the lumbar dorsal
ramus, are also known causes of LBP [5,6]. Regarding the upper
posterior trunk, although the cause of pain in the neck or scapula
associated with cervical radiculopathy is unclear, cervical dorsal
ramus syndrome is suspected to be a source of neck and scapular* Corresponding author. 4-8-1 Ayaragihon-machi, Shimonoseki, Yamaguchi 7510849 Japan. Fax: þ81 83-252-3030
E-mail address: hiroshi20052002@yahoo.co.jp (H. Nomura).

pain [7e9]. Therefore, to treat LBP due to mechanical pressure on
the dorsal rami as well as neck/scapular pain, it is important tovisually understand the precise innervation zones of the dorsal
rami. Historically, dermatomes have been outlined using various
anatomical techniques, such as contiguous tracing distally from thespinal nerve under a microscope to determine their peripheral
distribution on the skin in cadavers, or ﬁnding the anesthetic area
after rhizotomy in monkeys or human patients [10]. Additionally, areport from 1900 analyzed herpetic skin eruptions to outline dermatomes [11].
Previously, we reported a case of herpes zoster lesions occurring
simultaneously in the upper extremity and interscapular region,
likely extending from the C8 ganglion. This illustrated the zone
innervated by the dorsal ramus of the cervical nerve root in AMEcase reports in 2021 [12]. In the current report, we present a similarcase of herpes zoster rash occurring simultaneously in the femoraland medial buttock regions that illustrates the innervation zone ofthe dorsal ramus of the L3 spinal nerve.

2. Report of the caseA healthy 83-year-old woman presented to our clinic with rightfemoral neuralgia without any episodes. She had no major medical
history, except for lumbar spinal stenosis with mild intermittent
claudication on the right calf and buttock, and no immunodeﬁciency was noted. At the initial visit, she had no skin lesions on her
right lower extremity. She had radiating pain in the medial anddistal part of the thigh and buttock pain on the right side. We
diagnosed her with femoral neuralgia associated with the lumbar
spinal stenosis, and she was treated using 10 mg/day oral mirogabalin besylate. One month later, she re-visited our clinic andcomplained of a blistering skin rash in the medial and distal parts ofthe femur and medial buttock on the right side, which she ﬁrst
noticed around 1 week after the ﬁrst visit; she was then treated by adermatologist who diagnosed the skin rash as herpes zoster andprescribed oral amprenavir for 7 days. The distribution of the herpes zoster rash appeared to extend from the medial area of thehttps://doi.org/10.1016/j.jos.2022.05.006
0949-2658/© 2022 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.

Please cite this article as: H. Nomura, H. Iwasaki, S. Nomura et al., Simultaneous herpes zoster rash in the femoral and medial buttock region thatillustrates the innervation zone of the dorsal ramus of the lumbar spinal nerve root: A case report, Journal of Orthopaedic Science, https://doi.org/10.1016/j.jos.2022.05.006

H. Nomura, H. Iwasaki, S. Nomura et al.

Journal of Orthopaedic Science xxx (xxxx) xxx

posterior superior iliac spine to the caudal lateral area in the backon the right side, and was mainly located in the medial and distal
part of the thigh on the right side, which corresponds to theinnervation area of the L3 spinal nerve (Fig. 1). She presented withmild postherpetic neuralgia of the right femur and continued
10 mg/day oral mirogabalin besylate for another month.
3. Discussion
The dorsal ramus is a branch of the lumbar spinal nerves.
Anatomically, the spinal nerve splits into the dorsal and ventral
rami almost immediately after exiting the intervertebral foramen.
Then, the dorsal ramus passes dorsally and caudally, and divides
into the medial and lateral branches, which contain sensory andmotor ﬁbers, to supply the muscles and skin of the posterior trunk[2,13]. Generally, the medial branch supplies the tissue from themidline to the facet joint line, and the lateral branch innervates thetissues lateral to the facet joint. Lateral branches of L1-3 (occasionally including L4, 5) lumbar dorsal rami and S1-3 form the SCNand MCN, respectively, and SCN and MCN innervate the upper
lateral and medial surfaces of the buttock [14]. In the present case,lateral branch of the L3 lumbar dorsal ramus innervated the medial
side of the upper surface of the buttock, which corresponds to theregion where the herpes zoster rash appeared in the buttock. Inaddition, the rash region in the medial and distal part of the femur
corresponds to the innervation area of the L3 nerve root, referred toa dermatome of international standards for neurological classiﬁcation of spinal cord injury by the American Spinal Injury Association (Fig. 2, left) [15], and the dorsal ramus of the L3 spinal nerve(Fig. 2, right) [13]; therefore, the herpes zoster rash in the current
case was proposed to be caused by varicella zoster virus (VZV)
traveling from the same L3 ganglion on the right side. As mentioned
in our previous case report, reactivated VZV in the spinal dorsal root
ganglia typically travels from the individual dorsal root ganglia
along the microtubules of the sensory axons to the skin, causing
neurological pain followed by eruption of the rash [16,17]. The
present case also showed the same phenomenon as our previous
report, which visualizes the innervation zone of the dorsal ramus,
despite the difference between the cervical and lumbar nerve roots.
Based on several medical cases reported previously, the herpes
zoster rash arising from the lumbar dorsal ganglion is not always
accompanied by a rash on the posterior trunk, as it may depend on
the severity of reactivation of VZV [18].
Regarding the history of the dermatomes, Herringham ﬁrst reported the sensory distribution of segmental nerve ﬁbers from thebrachial plexus in 1886 through dissection of neonatal and adultcadavers [19]. Next, in 1893, Sherrington created a dermatome withnormal sensation by severing the dorsal nerve roots in rhesus
monkeys [20]. Sherrington compared the data with human skin
innervation and found similarities in sensory distribution between
monkeys and humans. In 1900, Head and Campbell studied 394
cases of VZV eruption (shingles) and created a dermatome map
demonstrating the region of shingles caused by VZV infection indifferent samples of spinal ganglia [11]. However, most cases ofshingles were originated from the upper cervical (a total of 36 cases
originated from C3 and 4 dorsal root ganglion), thoracic (284 fromT1-12), and proximal femur (49 from L1, 2) dorsal root ganglions,and the shingles on the upper/lower extremities were relatively
few (10 from C5-8 and 8 from L3-5). Thus, the innervation zone ofthe dorsal ramus from the cervical/lumbar dorsal root ganglion waslikely insufﬁcient from their study. In 1948, Keegan and Garrett
mapped hypoalgesia produced by anesthesia or compression froma herniated disc of a single nerve root, and demonstrated that linear
dermatomes extend downward in each limb [21]. We suggest a
broad survey of herpes zoster rash cases as an alternative method ofFig. 1. An 83-year-old woman presented with a blistering skin rash in the medial anddistal part of the femur (above), as well as the area from medial part of the posterior
superior iliac spine to the caudal lateral part in the buttock (below) on the right side. A
white line outlines an edge of the iliac cleft.

creating a precise dermatome of the dorsal ramus. This system will
enable clinicians to distinguish the innervation areas of the lateraland dorsal branches of the dorsal rami and identify the overlapping
adjacent dermatomes by examining many patients with herpes
zoster whose symptoms are similar to those of the present patient.
Since neurological pain with herpes zoster precedes theappearance of a skin rash by several days to a week, it is difﬁcult todiagnose it correctly in the initial phase. In the present case, we ﬁrst
suspected femoral neuralgia because of the temporal worsening ofintermittent claudication with lumbar spinal stenosis, although thefemoral area of radiating pain caused by herpes zoster was different
from the area of the regular pain. In the initial phase of herpes
zoster, several diseases may be suspected as alternative diagnoses,
including lumbar disc herniation [22], lumbar spinal stenosis [18]or malignant lymphoma [23]. For example, Koda et al. reported apatient with herpes zoster sciatica who had been ﬁrst diagnosed
with lumbar spinal stenosis and was intended to undergo surgicaltreatment, until a skin rash was detected [18]. It is also important toobserve that herpes zoster virus reactivation can produce chronic
radicular pain without eruption of the rash, which is called zostersine herpete (ZSH). Patients with ZSH are reported to suffer more
serious pain compared with patients with herpes zoster [24,25].
Diagnosis of ZSH or herpes zoster in the initial phase requires2

H. Nomura, H. Iwasaki, S. Nomura et al.

Journal of Orthopaedic Science xxx (xxxx) xxx

References[1] Suzuki H, Kanchiku T, Imajo Y, Yoshida Y, Nishida N, Taguchi T. Diagnosis andcharacters of non-speciﬁc low back pain in Japan: the yamaguchi low backpain study. PLoS One 2016 Aug;11(8):e0160454.
[2] Zhou L, Schneck CD, Shao Z. The anatomy of dorsal ramus nerves and its
implications in lower back pain. Neurosci Med 2012 Jun;3:192e201.
[3] Bogduk N, Wilson AS, Tynan W. The human lumbar dorsal rami. J Anat 1982
Mar;134(2):383e97.
[4] Gilmore CA, Patel J, Esebua LG, Burchell M. A review of peripheral nerve
stimulation techniques targeting the medial branches of the lumbar dorsal
rami in the treatment of chronic low back pain. Pain Med 2020 Aug;21(Suppl
1):S41e6.
[5] Chiba Y, Isu T, Kim K, Iwamoto N, Morimoto D, Yamazaki K. Association between intermittent low-back pain and superior cluneal nerve entrapment
neuropathy. J Neurosurg Spine 2016 Feb;24(2):263e7.
[6] Maigne JY, Doursounian L. Entrapment neuropathy of the medial superior
cluneal nerve. Nineteen cases surgically treated, with a minimum of 2 years’
follow-up. Spine (Phila Pa 1976) 1997 May;22(10):1156e9.
[7] Eubanks JD. Cervical radiculopathy: nonoperative management of neck pain
and radicular symptoms. Am Fam Physician 2010 Jan;81(1):33e40.
[8] Mizutamari M, Sei A, Tokiyoshi A, Fujimoto T, Taniwaki T, Togami W. Corresponding scapular pain with the nerve root involved in cervical radiculopathy.
J Orthop Surg 2010 Dec;18(3):356e60.
[9] Tanaka Y, Kokubun S, Sato T, Ozawa H. Cervical roots as origin of pain in theneck or scapular regions. Spine (Phila Pa 1976) 2006 Aug;31(17):E568e73.
[10] Downs MB, Laporte C. Conﬂicting dermatome maps: educational and clinicalimplications. J Orthop Sports Phys Ther 2011 Jun;41(6):427e34.
[11] Head H, Campbell AW, Kennedy PG. The pathology of herpes zoster and its
bearing on sensory localisation. Rev Med Virol 1997 Sep;7(3):131e43.
[12] Nomura H, Nomura S. Simultaneous herpes zoster rash in the upper extremity
and interscapular region that resembles innervation zone of the dorsal ramusof the cervical nerve root: a case report. AME Case Rep 2021 Jul;5:25.
[13] Gray H. In: Clemente CD, editor. Anatomy of the human Body. 13th Americaned. Philadelphia: Lea & Febiger; 1985. p. 1193e8.
[14] Wang Y, Yang J, Yan Y, Zhang L, Guo C, Peng Z. Possible pathogenic mechanism of gluteal pain in lumbar disc hernia. BMC Muscoskel Disord 2018
Jul;19(1):214.
[15] Huang H, Young W, Skaper S, Chen L, Moviglia G, Saberi H. Clinical neurorestorative therapeutic guidelines for spinal cord injury (IANR/CANR version2019). J Orthop Translat 2019 Nov;20(5):14e24.
[16] Diwaker D, Wilson DW. Microtubule-dependent trafﬁcking of alphaherpesviruses in the nervous system: the ins and outs. Viruses 2019
Dec;11(12):1165.
[17] Reichelt M, Zerboni L, Arvin AM. Mechanisms of varicella-zoster virus neuropathogenesis in human dorsal root ganglia. J Virol 2008 Apr;82(8):3971e83.
[18] Koda M, Mannoji C, Oikawa M, Murakami M, Okamoto Y, Kon T. Herpes zoster
sciatica mimicking lumbar canal stenosis: a case report. BMC Res Notes 2015
Jul;8:320.
[19] Herringham WP. The minute anatomy of the brachial plexus. Proc Roy Soc
Lond 1887 Jan;41(246e250):423e41.
[20] Sherrington CS. Experiments in examination of the peripheral distribution ofthe ﬁbres of the posterior roots of some spinal nerves. Part II, vol. 190. Philosophical Transactions of the Royal Society of London. Series B, Containing
Papers of a Biological Character; 1898. p. 45e186.
[21] Keegan JJ, Garrett FD. The segmental distribution of the cutaneous nerves inthe limbs of man. Anat Rec 1948 Dec;102(4):409e37.
[22] Wei FL, Li T, Song Y, Bai LY, Yuan Y, Zhou C. Sciatic herpes zoster suspected oflumbar disc herniation: an infrequent case report and literature review. Front
Surg 2021 May;8:663740.
[23] Hughes RA, Britton T, Richards M. Effects of lymphoma on the peripheral
nervous system. J R Soc Med 1994 Sep;87(9):526e30.
[24] Gilden D, Cohrs RJ, Mahalingam R, Nagel MA. Neurological disease producedby varicella zoster virus reactivation without rash. Curr Top Microbiol
Immunol 2010 Feb;342:243e53.
[25] Zhou J, Li J, Ma L, Cao S. Zoster sine herpete: a review. Korean J Pain 2020
Jul;33(3):208e15.

Fig. 2. Dermatome of the lower extremity cited from international standards forneurological classiﬁcation of spinal cord injury by the American Spinal Injury Association (left) and dermatome of dorsal rami cited from Anatomy of the Human Body
originally written by Henry Gray (right).

detection of active VZV IgM antibody in the serum or cerebrospinal
ﬂuid (CSF), or anti-VZV IgG antibody in the CSF, or the detection ofVZV DNA in blood mononuclear cells or the CSF [24].
In conclusion, a case of herpes zoster with simultaneous skinrash in the femoral and medial buttock regions was reported. The
medial buttock region illustrated by the herpes zoster rash corresponded to the innervation zone of the dorsal ramus of the L3
lumbar spinal nerve root. We suggest that simultaneous herpes
zoster rash is useful for visualizing detailed innervation of thedorsal ramus from the lumbar spinal nerves.
Consent section
The patient and/or her family were informed that data andphotographs from the case would be submitted for publication andgave their consent.
Declaration of competing interest
The authors declare that they have no conﬂict of interest.

3