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Hip-back symptom treatment involves more than THA or spine fusion alone
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Patients who present with leg and back pain can pose an interesting challenge to surgeons because the combined presentation makes it difficult to determine the predominant source of the patient’s pain. Sources who spoke with Orthopaedics Today Europe said clinicians need to perform a thorough examination of a patient who presents with hip pain or back pain, or both, to successfully identify the hip-back connection and treat it.
The hip-back syndrome can typically affect elderly patients who present with pain that can either be diagnosed as a hip condition or spine a condition, according to Adrian C. Gardner, BM, MRCS, FRCS (T&O), of the Royal Orthopaedic Hospital, in Birmingham, United Kingdom.
“Firstly, by definition, hip-spine pain usually refers to the group of more elderly (but not always) patients who present with symptoms of back and leg pain of various types where the spine and/or the hip may be the culprit. By usual consensus, low back pain extends distally to the inferior part of the buttock, thus buttock pain is included as back pain. Spinal pain is usually felt in the back and can radiate to the buttock. Radicular pain is felt in the leg as a result of nerve root irritation in the sclerotome of that nerve. Hence, irritation of the L5 nerve root will give pain in the posterior thigh, lateral calf and anterolateral foot (the sciatic pain), but the sensory loss is in the L5 dermatome and weakness in the L5 myotome only,” Gardner told Orthopaedics Today Europe.
A painful connection
Spine pain that worsens during movement will often be exacerbated in the back and/or the leg. It may be associated with nerve dysfunction, such as sensory change, pins and needles, numbness or weakness. If there is an element of spinal stenosis associated with the pathology, then pain often worsens with walking and is relieved by standing still, or more so, by sitting, according to Gardner.
However, hip pain caused by osteoarthritis (OA) traditionally will usually present with anterior groin pain, which worsens during movement of the hip joint in any plane, although early signs are a loss of internal rotation, he noted.
“Pain will be worse with movement and weight bearing. Pain can radiate down the anterior aspect of the thigh to the knee, and in rare occasions only presents as knee pain,” Gardner said.
Clinical examinations are helpful
A thorough clinical examination is the best way to determine the source of the pain in these cases, Panayiotis J. Papagelopoulos, MD, of Athens University Medical School in Athens, Greece, told Orthopaedics Today Europe.
The examination is the best way to identify a possible coexistence between spine and hip pain, he said.
“Identification of the coexistence of lumbar spinal stenosis and lower extremity arthritis is important for proper disease management and knowledge of risk associated with total hip arthroplasty. Careful diagnosis is necessary to determine if both diseases are present and which is the cause of the patient’s lower extremity pain. Complete diagnosis also has implications on disease management,” Papagelopoulos said.
It is important to get a history, through physical examination and selective diagnostic testing for the initial diagnostic process.
While the hip-spine syndrome typically manifests in an elderly patient, it can be evident in a younger patient, especially one with degenerative disc disease and accompanying hip joint problems, such as early OA, tendinopathies around the hip, labral tears, sacroiliac joint inflammation, femoroacetabular impingement and other problems, Papagelopoulos said.
Clues may show origins of syndrome
During a clinical examination, patients who rotate their hips will rarely have any pain or irritability if the problem is originating from the spine, Alister J. Hart, MA, MD, FRCSG(Orth), of the Royal National Orthopaedic Hospital, in Stanmore, United Kingdom, said.
Pain below the knee, pain in both legs, associated numbness, and pins and needles usually will lead a clinician to believe the problem the patient is having is being caused by the spine. Sitting usually alleviates such pain if it is due to spinal stenosis, Hart noted.
However, in Hart’s experience, hip pain typically does not mimic spine pain or spinal conditions.
“I almost never (never and always do not exist in medicine) do a radiograph of the lumbar spine, as the radiation dose is very high and an MRI is superior. I have a low threshold for ordering an MRI of the spine. The cost is high in treating a hip problem in the presence of an undiagnosed back problem. Diagnostic hip injection of local anesthetic by a radiologist is the best investigation to differentiate between back and hip pain. A CT-SPECT is a useful second line investigation,” he told Orthopaedics Today Europe.
Also, orthopaedists should beware that L1, L2, L3 and L4 nerve root compression can cause hip and thigh pain that is similar to some types of hip problems, he said.
Typical occurrence in the elderly
The connection between the hip and spine is controversial and typically manifests itself in elderly patients, Luigi Zagra, MD, of the Istituto Ortopedico Galeazzi IRCCS, in Milan, Italy, told Orthopaedics Today Europe.
Elderly patients tend to develop more spinal and hip problems as they age, which makes a thorough and careful clinical evaluation very important when determining a diagnosis, according to Zagra, who is an Orthopaedics Today Europe Editorial Board member.
It is not enough to simply ask a patient if they have pain and where the pain is coming from. If a patient says they have groin pain and the clinician only looks at a radiograph and orders a hip replacement, this is not enough of a thorough evaluation to decide about performing a procedure, he said.
“You need to look at your patient, put them in a bed for the evaluation. Evaluate the hip’s internal and external rotation in a neutral position, or a supine position. If you evaluate the hips, for example, internal and external rotation with a flexion of the hip, sometimes the lumbar spine can mimic a hip problem. This can be tricky if you evaluate the patient in a supine position, and evaluate a hip’s external and internal rotation with the hip at 90°, or the most possible degrees of flexion. Then, evaluate a reduction and external and internal rotation at the neutral position. If the pain disappears, be careful, because a spine problem can mimic a hip problem,” Zagra said.
Pain source factors into plan
Once the source of pain has been narrowed down and identified, an individualized treatment plan can be designed for each patient, said Papagelopoulos said, who supports the practice of offering conservative, or nonoperative care, first to a patient to see if he or she responds to it.
“Individuals with lumbar spinal stenosis may respond favorably to mobilization of regions remote to the lumbar spine, including the hip and knee joints. Pain management using radio frequency neuromodulation or epidural injections may also improve the pain and functional status of the patients. The difficulty is in knowing when two or more different sources of pain are present. Treatment should focus on all of the individual clinical entities before patient comfort and quality of life are restored to normal,” Papagelopoulos said.
Hip arthritis may mean surgery
Zagra said surgeons should also consider the prevalence of the symptoms that come from the hip before deciding on a treatment option. If it is clear the patient has hip arthritis, then surgery will likely be necessary.
“This way you can improve the walking probability of the patient and you improve the joint movement, reduce the stiffness of the joint, and this can be a relief to the spine, as well. However, if pain is mainly coming from the spine, try to treat conservatively. Sometimes for this patient, after conservative treatment on the lumbar side, they can have a worsening on the hip side, and at that time it would be a good indication for the hip replacement,” Zagra said.
A study by Peleg Ben-Galim, MD, and colleagues showed total hip replacement in patients with severe hip OA could improve low back pain and spine function, as well.
Conservative treatment may help
According to Zagra, it is important that surgeons not perform a hip replacement for a patient whose arthritis is only mild because the problem, then, is most likely coming from the spine. This is not an uncommon mistake for a surgeon to make.
Gardner agreed that conservative treatment has a place in both hip and spine treatment for this syndrome.
However, he added, if surgery is needed, there are procedures that can help each patient who has a proper diagnosis.
“Treatment is based on addressing the underlying pathology. For both the hip and spine there is a role for conservative treatment, including physiotherapy and hydrotherapy, repeat injections and pain management — all have been shown to have good results in the right patient. Surgically, inevitably in the hip, a hip replacement is performed of which there are many different types which address different specific aspects on a patient-specific basis. For the spine, decompression surgery is a good option to relieve nerve compression for leg pain. Back pain surgery is less reliable and opinions on the benefits are mixed. There may well be a place for fusion surgery in the presence of an extensive decompression or demonstrable instability in the spine,” Gardner said.
Regardless of the surgery selected, Gardner said hip surgeons need to have respect for spinopelvic anatomy and pelvic incidence, because in the presence of spinal deformity realignment surgery a hip replacement may be made unstable due to a change in pelvic retroversion. He also said a spine surgeon must be able to assess hip health, as well as a stiff spine, both of which can aggravate or worsen any unrecognized hip pathology. – by Robert Linnehan
- Reference:
- Ben-Galim P, et al. Spine (Phila Pa 1976). 2007;doi:10.1097/BRS.0b013e318145a3c5.
- For more information:
- Adrian C. Gardner, BM, MRCS, FRCS (T&O), can be reached at Royal Orthopaedic Hospital, The Woodlands, Bristol Road South, Birmingham, West Midlands B31 2AP, United Kingdom; email: adrian.gardner@nhs.net.
- Alister J. Hart, MA, MD, FRCSG(Orth), can be reached at Institute of Orthopaedics and Musculoskeletal Science, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore HA7 4LP, United Kingdom; email: a.hart@ucl.ac.uk.
- Panayiotis J. Papagelopoulos, MD, can be reached at Athens University Medical School and Attikon University General Hospital, 1, Rimini Str, P.C. 124 62, Chaidari, Athens, Greece; email: pjportho@otenet.gr.
- Luigi Zagra, MD, can be reached at Istituto Ortopedico Galeazzi IRCCS via R. Galeazzi 4, 20161, Milan, Italy; email: luigi.zagra@fastwebnet.it.
Disclosures: Gardner, Hart, Papagelopoulos and Zagra report no relevant financial disclosures.
What methods are best to identify the underlying pain generator in patients with hip-spine syndrome?
Intra-articular injections helpful
There is no doubt there are a few patients who present to the outpatient clinic with pain in the groin, buttock and lower back with some radiation down the leg and it can be fairly difficult to delineate whether the pain is arising from the hip or the spine. In my practice, I rely heavily on an intra-articular injection of local anesthetic under fluoroscopic control to elucidate whether the pain is intra- or extra-articular in origin. A positive response to the injection gives a clear indication the pain is intra-articular in origin and allows the surgeon and the patient to proceed with any further intervention on the hip, if necessary.
In a retrospective study of 67 patients who underwent a diagnostic hip injection at our institution, 55 patients responded positively, and, of them, 50 patients went on to have arthroscopic intervention. Arthroscopy confirmed intra-articular pathology in all 50 of these patients indicating the intra-articular injection of local anesthetic is an effective technique for distinguishing intra-articular hip pathology.
Another retrospective study carried out by Kivlan and colleagues on 72 patients who underwent hip arthroscopy indicated relief of pain was greater among patients diagnosed with chondral damage when they had an injection than it was for those without the injection, regardless of severity. Another interesting finding was the presence and severity of femoroacetabular impingement and labral pathology did not affect how much relief occurred due to the injection. They therefore concluded the interpretation and diagnostic value of an anesthetic injection in those patients with primary intra-articular pathology of the hip does not need to be altered by the presence of coexisting extra-articular hip pathology.
- References:
- Kivlan BR, et al. Arthroscopy. 2011;doi:10.1016/j.arthro.2010.12.009.
- Mathews J, et al. Arthroscopy. 2014;doi:10.1016/j.arthro.2013.11.023.
Vikas Khanduja, MA, MSc, FRCS, FRCS (Orth), is a consultant orthopaedic surgeon and Addenbrooke’s Associate Lecturer at Cambridge University Hospitals in the United Kingdom.
Disclosure: Khanduja reports no relevant financial disclosures.
‘Old-school’ is the best
Hip-spine syndrome was originally described by Offierski and MacNab more than 4 decades ago, and although it is frequently cited, clinically it is still frequently overlooked.
The first prospective clinical report on the influence of total hip replacement surgery upon low back pain (LBP), spinal function and symptomatology was published in 2007. Several points of interest were noted during the follow-up and interviews of patients in the study:
- Patients often have co-existing back and hip pain. All patients in the study group who were scheduled for hip replacement surgery due to hip osteoarthritis (OA) also were found to have at least moderate LBP and spinal disability prior to hip surgery;
- The patients’ perception of LBP averaged 5.04/10, a figure not much lower than the disabling, severe hip pain (7.08/10) for which they sought surgical treatment;
- Following hip arthroplasty, their LBP VAS and Oswestry spinal disability scores significantly improved; and
- The patients often could not differentiate or isolate the back pain from the hip pain.
Since discrepancy exists between the clinical signs and symptoms and the radiographic imaging both in hip OA and degenerative disc disease, it is wise to stick to basic clinical principles.
The most efficient methods to identify the underlying pain generator in patients with hip/spine syndrome are “old school” clinical methods, ensuring a thorough history and clinical examination.
Important giveaways start when the patient walks into your office. Classic “moment relieving” gait will typically indicate the hip as the pain generator while a “list” type of back inclination or a forward leaning sagittal tilt may indicate spinal stenosis.
Spine surgeons should always examine hip pain upon range of motion and rotation for patients with back pain while hip surgeons may want to note radiculopathy, straight leg raise and neurological exam for “hip” patients.
Peleg Ben-Galim, MD, is director of spine surgery in the Department of Orthopedic Surgery at Kaplan Medical Center, in Rehovot, Israel.
Disclosure: Ben-Galim reports no relevant financial disclosures.