Hip-spine syndrome can lead to failed hip replacement and lumbar spinal fusion complication

Ross Hauser, MD; Danielle R. Steilen-Matias, MMS, PA-C

Hip-spine syndrome leads to failed hip replacement and lumbar spinal fusion.

It is challenging enough to think about getting a major surgery such as a spinal fusion or a hip replacement. It is even more challenging to think that after you had a spinal fusion you really needed a hip replacement, or that you already had a hip replacement and now you are now being told that you need a spinal fusion. This is the situation many people face. In this article, we will discuss pain after spinal surgery that is now diagnosed as being hip-related and pain after spinal fusion that is now being diagnosed as spine-related.

I had lower back pain, I was diagnosed with lumbar spinal stenosis. I had fusion surgery. After the surgery, I had the same pain

These are the types of emails we receive.

It was my hip all along

I had lower back pain, I was diagnosed with lumbar spinal stenosis. I had fusion surgery. After the surgery, I had the same pain. Now my doctors think it was my hip all along.

It was my back all along

I had a hip replacement because my MRI showed osteoarthritis and I was in a lot of pain. After the surgery, I still had the same pain. Now my doctors think it was my back all along. Now I should get the spinal fusion.

How can this be?

Some of you may be thinking that this is far-fetched, how can this be? If you are among those thinking this, you are then not among the people who had a hip replacement because of back pain and a spinal fusion because of hip pain. You are not among the people who neither they nor their doctors realized they were getting surgery for the wrong thing. Below we will present the research and clinical findings.

Some people do very well with getting both these surgeries. These are not the people who are reaching out to us. We see the people with the problems we described above, and those we will describe below, and those who would rather not go through these major surgeries. But again, more people have successful surgeries than failed surgeries.


First, Danielle R. Steilen-Matias, MMS, PA-C explains the common problems we see in our patients.

Learning points summary:

In this next section, we will explore research leading up to clinical observations in helping patients with hip and low back pain problems.


What are we seeing in this image? The complexity of the hip, pelvic, and low back instability.

To some surgeons, the back is the back and the hip is the hip. If the MRI shows disc degeneration, then there is justification for spinal surgery. If the MRI shows hip degeneration, then there is justification for hip replacement. This x-ray below belongs to Ross Hauser, MD. It is not one of his patients, it is actually HIS x-ray. Dr, Hauser’s years of ironman competitions and other “hardcore” competitions certainly took a toll. Look at what is going on here and the extent of pelvic, hip, and spine problems.

Dr. Hauser had this x-ray when he had acute pain in his left lower back and sciatic-like symptoms.

X-ray reveals:

Hip-Spine Syndrome is born after doctors notice patients still have pain after hip replacement and spinal fusion

Above we described people with hip pain after spinal fusion and back pain after hip replacement because surgery addressed the wrong issue. Let’s let the surgeons take over from here.

Research from the Vanderbilt Orthopaedic Institute published in The Journal of the American Academy of Orthopaedic Surgeons (1) warns doctors about wrong surgeries.

“The incidence of symptomatic osteoarthritis of the hip and degenerative lumbar spinal stenosis is increasing in our aging population. Because the subjective complaints can be similar, it is often difficult to differentiate intra- and extra-articular hip pathology (intra meaning the pain is in the hip joint at the ball and socket location, extra means the supporting ligaments and tendons that lead to hip instability) from degenerative lumbar spinal stenosis.

These conditions can present concurrently, which makes it challenging to determine the predominant underlying pain generator.  . . Determining the potential benefit from surgical intervention and the order in which to address these conditions are of utmost importance for patient satisfaction and adequate relief of symptoms.”

The above study was published in 2012, certainly, things have changed. Let’s start moving towards 2021.

The confusion of hip-spine is significant and can lead to poor surgical choices

Doctors at the University Hospitals Cleveland Medical Center wrote in the September 2017 edition of Orthopaedics and Traumatology, Surgery and Research:(2)

Here are more factors the doctors discussed:

Of course, we believe that future research is necessary regarding optimal NON-surgical treatment of these patients.

What are we seeing in this image? Pelvic pain in a spinal fusion patient

In this x-ray image of a pelvis, we see a previous surgical fusion in a patient. This patient developed severe bilateral sacroiliac pain following the surgery. We can see the close proximity between the fusion instrumentation and the sacroiliac joints.

In this x-ray image of a pelvis, we see a previous surgical fusion in a patient. This patient developed severe bilateral sacroiliac pain following the surgery. We can see the close proximity between the fusion instrumentation and the sacroiliac joints.


A July 2020 study in The American Journal of Sports Medicine (3) noted: “Medical research suggests that lumbar spine disease is an independent risk factor for poorer outcomes following total hip replacement; however, the effect of lumbar spine disease on hip replacement outcomes has not been fully investigated. At present, (July 2020) there is little in the research  investigating the effect of coexisting hip and lumbar spine disease on outcomes after hip replacement.”

Note: Above we started this article with a study from 2012 suggesting that hip-spine pain is an under-investigated phenomenon. This is still so in July 2020. In this study, it was found that Patients with known lumbar spine disease who underwent hip replacement had a significantly greater percentage improvement at 24-month follow-up compared with those without a history of lumbar spine disease, and outcomes were ultimately not significantly different. No increased risk of reoperation was noted in patients with concomitant lumbar spine disease. Hip replacement helped these people’s back pain without the ultimate need for spinal surgery as well.

Patients with Hip-Spine Syndrome made worse by Hip Replacement and Spinal Fusion

We just presented an outcome where patients had a hip replacement and it helped their back pain. Here is a study with non-similar results.

University and hospital researchers in Sweden made the connection between poor hip replacement outcomes and previous lumbar fusion surgery.

Writing in the Joint and Bone Journal(4) they examined patients who first had the lumbar surgery, then proceeded later to a total hip replacement. Their research conclusions are presented here:

The limited research available suggests spinal pathology predicts and warns of less pain relief and worse outcomes after total hip replacement

These same unfortunate results had been previously reported earlier in 2017 by doctors at the Department of Orthopaedic Surgery, the University of California, San Francisco in The Journal of Arthroplasty:(5)

The UCSF researchers concluded their study with:

Understanding reduced range of hip motion causing more lower back pain

Doctors from Washington University School of Medicine in St. Louis and Northwestern University Feinberg School of Medicine wrote in The Journal of Orthopaedic and Sports Physical Therapy (6) of patients with hip-spine syndrome with known hip arthritis and reduced range of hip motion.

The researchers concluded: Physical examination findings indicating hip dysfunction are common in patients presenting with low back pain. Patients with low back pain and positive hip examination findings have more pain and worse function compared to patients with low back pain but without positive hip examination findings.

Hip replacement after spinal fusion

An October 2020 study in the European Spine Journal (7) examined the risk factors for patients in needing to have a second or revision surgery of their hip replacement. The risk factor they examined was if the patient had also had spinal fusion surgery.

Here are the learning points of this study:

So what these researchers tried to determine was if the risk of the need for a replacement or revision of the first hip replacement was greater in patients who had the lumbar fusion first or following the hip replacement.

What did they discover? “Lumbar spinal fusion remains a risk factor for dislocation and revision of total hip arthroplasties (replacements) regardless of whether it is performed prior to or after total hip arthroplasty. Further preoperative assessment and altered surgical technique may be required in patients having total hip arthroplasty who have previously undergone or are likely to undergo lumbar spinal fusion in the future.:

If you have hip pain requiring replacement, and you have back pain requiring fusion surgery, there is a good chance that you will need a hip replacement, spinal fusion, then another hip replacement revision procedure.

Ischiofemoral impingement causing lumbar pathology

In a January 2017 paper entitled: The Hip-Spine Effect: A Biomechanical Study of Ischiofemoral Impingement Effect on Lumbar Facet Joints, Doctors at Baylor University and the University of Texas (8) found a relation between ischiofemoral impingement and lumbar facet joint load during hip extension.

They suggested that limited terminal hip extension due to simulated ischiofemoral impingement significantly increases L3-4 and L4-5 lumbar facet joint load when compared with non-ischiofemoral impingement hips.

This study directly links ischiofemoral impingement to increased lumbar facet loads and supports the clinical findings of ischiofemoral impingement causing lumbar pathology. Assessing and treating hip disorders that limit extension could have benefits in patients with concomitant lower back symptoms.

Is it really the Glutes?

When this patient comes into our clinic, we talk with them about the difficulties in isolating one part of the pelvic-hip-spine complex as the main culprit of their problem. This we find especially true in treating a patient with problems of Gluteus Medius tendinopathy. We are not the only ones to understand this challenge.

A February 2020 study in the Journal of Physical Therapy Science (9) offered this:

“Gluteus medius syndrome is one of the major causes of back pain or leg pain and is similar to greater trochanteric pain syndrome, which also presents with back pain or leg pain. Greater trochanteric pain syndrome is associated with lumbar degenerative disease and hip osteoarthritis. Gluteus medius syndrome is also related to lumbar degenerative disease, hip osteoarthritis, knee osteoarthritis, and failed back surgery syndrome. Accurate diagnosis of gluteus medius syndrome and appropriate treatment could possibly improve lumbar degenerative disease and osteoarthritis of the hip and knee, as well as hip-spine syndrome and failed back surgery syndrome.”

How could my Hip MRI be so wrong?

So again, you went and had an MRI of your hip. Your MRI came back and showed a lot of degenerative problems. You may have been told you have “bone on bone,” nothing can be done for this short of hip replacement. You went in for hip surgery. After months of rehabilitation, you still have the same hip pain. Upon further review and another MRI, it is determined that your pain is actually coming from your SI joint and/or your lower back. You may be finding yourself on this page because you are now researching alternatives to SI joint and low back surgery.

Something we hear, perhaps more often than one would think is, “how was my hip MRI so wrong?”

A Review of Research on the Value of Hip Scans

A person with long-term hip pain management will typically tell us about all the tests, images, scans, CDs, and other digital images they have of their problem hip. They then will ask how can they get these films to us. These patients are very anxious to avoid either a hip arthroscopic surgery or a hip replacement surgery. They sometimes think that the quicker we can review their images, the quicker they can avoid the surgery.

We tell many of these people, “come in for an examination. Let us look at how you walk and what type of range of motion you have in your hip. Then if we need to confirm or dismiss something in your hip, we will take a look at your films.” In our thinking, the quicker we can do a physical examination, the quicker we can assess whether or not we can help them avoid hip surgery.

For some people, telling them that we do not want to see all these imaging studies first, is hard to understand.

For these people, his or her entire problematic hip medical history has been guided by imaging. Some people are so confused by this that they mistake what we are telling them into asking, “Do I need to get a new MRI?” The answer is almost always NO. In our experience, people who have already had a hip replacement on one side, even a successful one, and do not want to “go through all that again,” understand the limitations of film best.

Pictures of the hip, are they worth it?

What are the types of imaging a person can be ordered when they have chronic pain? Are these tests accurate in helping him or her in treatment? Are these tests accurate?

A look at the imaging studies

Usually, a person with chronic hip pain will come into our office and they will have one, two, three, or all four of the following performed over a period of time.

What’s the difference between these imaging techniques?

Perhaps the question is not what is the difference in the techniques, but rather what is the difference in how helpful these images can be.

The x-ray shows:

For the most part, the initial imaging examination will be an X-ray. An X-ray will be most effective in showing degenerative bony abnormalities and loss of joint space, signifying cartilage loss. In degenerative hip disease, it is usually the X-ray that convinces someone with hip pain that they have advancing hip osteoarthritis, bone death or avascular necrosis, bone spurs, and loss of cartilage.

The CT scan shows:

CT or CAT scans are looking for soft tissue damage that the x-rays do not see. This would be muscle, ligaments, and tendons. Because of the complexity of the hip, this imaging test is usually not favored for hip pain patients as images are poorly defined.

The MRI shows:

For some people, the end-all of all end-alls is the MRI image. It is extraordinarily difficult for people to believe that their MRI is not telling the correct story of their hip pain. The research questioning MRI accuracy will be shown below.

An MRI is looking for things the X-ray and the CT scan cannot show. This would be soft tissue damage, fluid buildup, or hidden swelling. The MRI may also reveal bone deformities that the X-ray did not show.

Ultrasound

Ultrasound allows visualization of pathology during motion. In our clinic, we use this tool on selected patients to see directly and immediately into the joint. We can then treat the visualized musculoskeletal condition with Prolotherapy. We also will use this tool in patients seeking treatment for pain following joint replacement.

It is hard to figure out what is causing the patient’s hip pain. It can be any one of a number of things, the MRI seems to be the tool most doctors like to use, but is it any good?

July 2017: Doctors at Queen Elizabeth Hospital in the United Kingdom and the University Medical Centre, Rotterdam, The Netherlands wrote in the European Journal of Orthopaedic Surgery and Traumatology: (10)

“The assessment of a patient with chronic hip pain can be challenging. The differential diagnosis of intra-articular pathology causing hip pain can be diverse. These include conditions such as osteoarthritis, fracture, and avascular necrosis, synovitis, loose bodies, labral tears, articular pathology and, femoroacetabular impingement. Magnetic resonance imaging (MRI) arthrography of the hip has been widely used now for diagnosis of articular pathology of the hip.”

In simpler terms, it is hard to figure out what is causing the patient’s hip pain. It can be any one of a number of things, the MRI seems to be the tool most doctors like to use, but is it any good?

Here are the research findings:

What is happening here is that these patients got an MRI. They went to arthroscopic surgery. Arthroscopic surgery is considered the gold standard of determining what is going on in your hip because there is a camera inside your hip taking pictures. When the MRI is doubted this is the “look-and-see hip surgery,” you may be told to get. In this study, what was seen from the “outside” the MRI was compared to what was seen on the inside “the arthroscopic surgery.”

We are going to talk about two terms sensitivity and specificity in MRI readings. You may have heard your doctor discuss them and may not have been sure what he/she was really talking about. So let’s explain what these terms mean. It may give you a much deeper understanding of the accuracy of what your hip MRI report says:

Hip Labral Tears

Let’s say you went and had an MRI for a hip labral tear. The radiologist tells you, based on this research, that the test has a sensitivity of 84% and specificity of 64%. What does this mean?

Hip delamination

You may have hip delamination. This is where the cartilage separates from the bone.

AN MRI to determine articular cartilage defects

The articular cartilage is the cartilage that wraps the bones of the ball and the socket of the hip. Chondral changes is a term to describe damage to this cartilage. The study results on the accuracy of this MRI test are going to be somewhat surprising.

This is one of the determinates of “bone on bone,” the probable single most diagnosis that sends more people to hip replacement than any other. Accuracy 58%. Let that sink in.

AN MRI to Femoro-acetabular impingement (CAM deformity)

Femoroacetabular Impingement (FAI) or sometimes diagnosed simply as Hip Impingement is a condition where abnormal contact and rubbing of the ball and socket portion of the hip bones create joint-damaging friction. This “bone-on-bone” situation subsequently develops into degenerative osteoarthritis in addition to causing injuries to the labral area. Please see my article for more on this subject Femoroacetabular Impingement and Prolotherapy

It is interesting to note bone on bone diagnosis accuracy of 58% – 66%

We see many patients, who after our examination are told that our treatments can help them say to us, “But I have bone on bone, my only option is a hip replacement.” Remember what we said above. For some people, the end-all of end-alls is the MRI image.  It is extraordinarily difficult for people to believe that their MRI is not telling the correct story of their hip pain.

The conclusion of this study from the research team?

“Our study conclusions are MRI arthrogram is a useful investigation tool in detecting labral tears, it is also helpful in the diagnosis of femoroacetabular impingement. However, when it comes to the diagnosis of chondral changes, defects, and cartilage delamination, the sensitivity and accuracy are low.”

Not the only study

This was not the only study to document the problems of hip MRI. In May 2018, doctors in Australia published these findings in the Journal of Orthopaedic Surgery and Research. (11)

“Conventional non-arthrographic (no contrast dye) MRI offers an accurate non-invasive (non-surgical) method to screen patients with symptoms referable to the hip by revealing the presence of labral tears, chondral defects, and ligamentum teres tears/synovitis. This study demonstrates that tears and synovitis of the ligamentum teres as potential sources of hip pain can be accurately identified on conventional non-arthrographic MRI. However, MRI has poor specificity and negative predictive value, and thus, a negative MRI result may warrant further investigation.”

What does this mean? 

It means that when the MRI looks at your hip it is pretty confident when the labral tears, chondral defects, and ligamentum teres tears/synovitis (the big ligament of the hip) are obvious. BUT, when this damage is not so obvious and the person has hip pain, we should listen to the patient and not rely on the MRI to contradict them. “A negative MRI result may warrant further investigation.” In our office, this further investigation is a physical examination.

So how could my hip MRI be so wrong? Here is a March 2019 study

In March 2019, in the surgeon’s journal Clinics in Orthopedic Surgery, (12) surgeons and radiologists at the  Chung-Ang University College of Medicine in Seoul, Korea shared these findings with the international medical community.

We are going to go back to talking about sensitivity (the test’s ability to identify something that may be causing your pain) and specificity (the MRIs ability to determine that what it thinks is causing your pain is in fact actually causing your pain).

In this research, the doctors and radiologists investigated sensitivity, specificity, and accuracy of magnetic resonance imaging (MRI) and computed tomography arthrography (CTA), on the basis of arthroscopic findings, to diagnose acetabular labral tears and chondral lesions.

The sensitivity, specificity, and accuracy of computed tomography arthrography for detection of acetabular labral tears by two observers were 60%, 80%, and 64%, respectively, and 65%, 70%, and 69%, respectively.

If you think that is bad. Here is the comparison to MRIs

What could the researchers conclude other than:

Injections may help identify the pain source in hip-spine syndrome

In a March 2020 study published in the surgical journal Orthopedics (13), doctors looked at the overlapping symptoms between hip and lumbar spine pathologies and the complication of diagnoses and treatments this problem causes. They suggest that diagnostic injections may help and write: “in hip-spine syndrome when a pain source cannot be elucidated, an ultrasound- or fluoroscopic-guided intra-articular hip injection may be a powerful and reliable diagnostic tool.”

Injections may present a successful non-surgical treatment option for the hip-spine syndrome

We are going to demonstrate Prolotherapy treatments for various disorders around the hip-spine and pelvic complexes. The most important point is that we can treat all these areas in the same visit, we can address the hip and spine together.

Prolotherapy: Treating the ligaments in sacroiliac joint dysfunction
The Spinal ligament repair injection treatment option Prolotherapy

Summary and Learning Points of Prolotherapy to the low back

This is a hip procedure on a runner who has hip instability and a lot of clicking and popping in the front of the hip.

In this video Prolotherapy treatments are demonstrated by Ross Hauser, MD:

For more specific diagnosis of your hip – spine problems please refer to these papers on our site:

Questions about our treatments?

If you have questions about your back and pain and how we may be able to help you, please contact us and get help and information from our Caring Medical staff.

This is a picture of Ross Hauser, MD, Danielle Steilen-Matias, PA-C, Brian Hutcheson, DC. They treat people with non-surgical regenerative medicine injections. Offices are located in Oak Park, Illinois and Fort Myers, Florida.

Brian Hutcheson, DC | Ross Hauser, MD | Danielle Steilen-Matias, PA-C

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References: 

1 Devin CJ, McCullough KA, Morris BJ, Yates AJ, Kang JD. Hip‐spine syndrome. Journal of the American Academy of Orthopaedic Surgeons. 2012 Jul 1;20(7):434-42. [Google Scholar]
2 Weinberg DS, Gebhart JJ, Liu RW. Hip-Spine Syndrome: a cadaveric analysis between osteoarthritis of the lumbar spine and hip joints. Orthopaedics & Traumatology: Surgery & Research. 2017 May 31. [Google Scholar]
3 Haskel JD, Baron SL, Zusmanovich M, Youm T. Does Concomitant Lumbar Spine Disease Adversely Affect the Outcomes of Patients Undergoing Hip Arthroscopy?. The American Journal of Sports Medicine. 2020 Jul;48(9):2178-84. [Google Scholar]
4 Eneqvist T, Nemes S, Brisby H, Fritzell P, Garellick G, Rolfson O. Lumbar surgery prior to total hip arthroplasty is associated with worse patient-reported outcomes. Bone Joint J. 2017 Jun 1;99(6):759-65. [Google Scholar]
5 Barry JJ, Sing DC, Vail TP, Hansen EN. Early Outcomes of Primary Total Hip Arthroplasty After Prior Lumbar Spinal Fusion. J Arthroplasty. 2017 Feb;32(2):470-474. [Google Scholar]
6 Prather H, Cheng A, Steger-May K, Maheshwari V, Van Dillen L. Hip and Lumbar Spine Physical Examination Findings in People Presenting With Low Back Pain, With or Without Lower Extremity Pain. journal of orthopaedic & sports physical therapy. 2017 Mar;47(3):163-72. [Google Scholar]
7 Onggo JR, Nambiar M, Onggo JD, Phan K, Ambikaipalan A, Babazadeh S, Hau R. Comparable dislocation and revision rates for patients undergoing total hip arthroplasty with subsequent or prior lumbar spinal fusion: a meta-analysis and systematic review. European Spine Journal. 2020 Oct 26:1-8. [Google Scholar]
8 Gómez-Hoyos J, Khoury A, Schröder R, Johnson E, Palmer IJ, Martin HD. The Hip-Spine Effect: A Biomechanical Study of Ischiofemoral Impingement Effect on Lumbar Facet Joints. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2017 Jan 31;33(1):101-7. [Google Scholar]
9 Kameda M, Tanimae H, Kihara A, Matsumoto F. Does low back pain or leg pain in gluteus medius syndrome contribute to lumbar degenerative disease and hip osteoarthritis and vice versa? A literature review. Journal of physical therapy science. 2020;32(2):173-91.
10 Rajeev A, Tuinebreijer W, Mohamed A, Newby M. The validity and accuracy of MRI arthrogram in the assessment of painful articular disorders of the hip. European Journal of Orthopaedic Surgery & Traumatology. 2017:1-7. [Google Scholar]
11 Annabell L, Master V, Rhodes A, Moreira B, Coetzee C, Tran P. Hip pathology: the diagnostic accuracy of magnetic resonance imaging. J Orthop Surg Res. 2018;13(1):127. Published 2018 May 29. doi:10.1186/s13018-018-0832-z [Google Scholar]
12 Lee GY, Kim S, Baek SH, Jang EC, Ha YC. Accuracy of Magnetic Resonance Imaging and Computed Tomography Arthrography in Diagnosing Acetabular Labral Tears and Chondral Lesions. Clinics in orthopedic surgery. 2019 Mar 1;11(1):21-7. [Google Scholar]
13 Maldonado DR, Mu BH, Ornelas J, Chen SL, Lall AC, Walker-Santiago R, Rosinsky PJ, Shapira J, Domb BG. Hip-Spine Syndrome: The Diagnostic Utility of Guided Intra-articular Hip Injections. Orthopedics. 2019 Dec 31. [Google Scholar]

This article was updated March 12, 2021

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