Hip-spine syndrome: before and after failed hip replacement and lumbar spinal fusion

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

This article will present various scenarios in regard to someone’s combined problem of the lumbar spine and hip degenerative disease. In this article, you will see research that suggests a lumbar fusion can cause hip replacement dislocations if the hip replacement followed the fusion. You will see research that suggests that hip replacement may alleviate low back pain without the need for a lumbar fusion. You will see research on positive outcomes and the development of low back and hip pain after surgery. You will also see research that suggests you may have had the wrong surgery. 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.

This article is part of a series of articles for patients suffering from hip and low back pain.

Article outline:

Part 1: Many people can have a successful lumbar fusion before or after hip replacement and vice-versa.
Part 2: The complexity of the hip, pelvic, and low back instability. Misdiagnosis and surgical complications.

Part 3: Hip-Spine Complex and failed surgery

Part 1: Many people can have a successful lumbar fusion before or after hip replacement and vice-versa

Before we discuss research that indicates concerns with hip-spine issues and lumbar fusion and hip replacements, let’s look at research that suggests the concerns are not completely warranted and that many people can have a successful lumbar fusion before or after hip replacement and vice-versa.

Doctors at the Department of Orthopaedic Surgery, Rush University Medical Center wrote in the International Journal of Spine Surgery (1) that hip or knee pain requiring a joint replacement does not always negatively impact the ability of patients to improve following lumbar fusion. In this December 2022 paper, the researchers evaluated the impact of a prior lower extremity joint replacement on the improvement of patient-reported outcome measures following lumbar fusion surgery. After examining the records of 335 patients the conclusion reached was: “Prior surgical history of lower extremity arthroplasty should not discourage the use of lumbar fusion when properly indicated, as patients reported clinical improvement regardless of history of hip or knee arthroplasty.”

In August 2020, doctors in Germany wrote in the journal Orthopedic Reviews (2): “There is certainly a degree of mutual influence of lumbar spine disease and hip disorders. (In patients getting a hip replacement) Surgeons should be well aware of patients with lumbar spine disease and need to check the pelvic position carefully prior to surgery. ” In this paper, 203 consecutive patients were examined following hip replacement. Of these patients, 51.0% were diagnosed with lumbar spine disease. These hip replacement patients with low back problems were seen as being on average four years older and carried a little more weight than patients without lumbar spine problems. A critical aspect of the hip replacement success was the cup positioning. In this paper, no hip dislocations nor clinical signs of impingement were seen. The researchers concluded, while “there is a high degree of co-existence of lumbar spine disease and hip disorders . . .a strong negative impact of lumbar spine disease to clinical or radiologic results could not be confirmed in our study.” In other words, the lumbar spine disease did not negatively impact hip replacement.


Part 2: The complexity of the hip, pelvic, and low back instability. Misdiagnosis and surgical complications.

The complexity of the hip, pelvic, and low back instability. Misdiagnosis and surgical complications.


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

Continued pain after a spinal fusion or hip surgery is not a rare occurrence. Depending on the research, chronic pain after these procedures can impact a small portion or a medium portion of patients. However, it does impact some as suggested by the emails we receive. Here is a small sample of what we hear.

Wrong surgery: 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.

Wrong surgery: 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 my doctors are telling me I should consider spinal fusion.

Here we have people who, neither they nor their doctors, realized they were getting the wrong surgery for the wrong problem. As mentioned above, some people do very well with lumbar fusion and hip replacement. These are not the people who are reaching out to us. We see the people with the problems we described above, 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.

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.

Misdiagnosis: “Disorders of the hip and spine commonly coexist and are difficult to disentangle.”

Published by the American Academy of Orthopaedic Surgeons 2022 Instructional Course Lectures (3) is a discussion that suggests: “Disorders of the hip and spine commonly coexist and are difficult to disentangle. When they do occur together, the pathology is often referred to as hip-spine syndrome. When hip-spine syndrome is suspected, it is critically important to properly identify the relative contributions that the hip and spine each provide to a patient’s overall clinical presentation. To focus on the incorrect anatomic site would be a disservice to the patient.” In other words, the patient can be led down a surgical path that is the wrong surgery.

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:

The confusion about Hip-Spine Syndrome 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:(4)

Here are more factors the doctors discussed:


Part 3: Hip-Spine Complex and failed surgery


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 (5) 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 between 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 2023.

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

A 2017 paper by doctors at the Department of Orthopaedic Surgery, the University of California, San Francisco in The Journal of Arthroplasty (6) suggested:

The UCSF researchers concluded their study with:

A July 2020 study in The American Journal of Sports Medicine (7) 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.” 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.

Does having a hip replacement first prevent the need for lumbar fusion?

An August 2021 paper in the journal Orthopaedic Surgery (8) suggests that hip replacement can alleviate low back pain. In this paper, researchers investigated the relief of low back pain after hip arthroplasty in patients with hip joint and spinal degenerative diseases and discussed the effects of unilateral and bilateral hip surgery on the relief of low back pain.

Of the 153 patients, only nine patients still had persistent or aggravated low back pain after hip replacement. Among them, six patients underwent subsequent lumbar surgery (five patients had pain relieved after reoperation and one patient had not) and the other three patients chose conservative treatment for pain.

Conclusion: Total hip replacement can relieve low back pain while relieving hip pain and restoring hip function in patients with both hip and lumbar degenerative disease, thus possibly avoiding further spinal surgery.

Ninety-five patients (62.9%) were classified into the low back pain improved group after hip replacement, and 37.1% were not. Which patients did not have low back pain improvement after hip replacement?

A January 2022 study published in The Journal of Arthroplasty (9) comes from Japanese researchers looking to be able to predict which patients would have more successful surgeries by way of pre-surgery spinal examination. The researchers noted that spinal disorders and low back pain have been associated with worse clinical outcomes of total hip replacement. In this study, 151 patients had a total hip replacement and before the surgery, they had a low back pain visual analog pain scale score of greater than 2 on a scale of 0-10.

Was the sequence of surgery incorrect? Is there a sequence of surgery recommended? “There is no consensus on which pathological (hip or spine) condition should be addressed first”

An October 2021 paper from the Department of Orthopedics, the University of Colorado published in The Journal of Bone and Joint Surgery. American Volume, (10) offered these learning points to doctors:

Does having lumbar fusion or hip replacement first increase the risk of greater pain or surgical failure if you have the other procedure later?

Spinal fusion is the first, higher risk factor for hip replacement complications

Let’s follow a path of research over the last few years:

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

Writing in 2017 in the Joint and Bone Journal(11) they examined patients who first had lumbar surgery, then proceeded later to a total hip replacement. Their research conclusions are presented here:

A May 2019 paper in The Journal of Arthroplasty (12) led by doctors at the Department of Orthopaedic Surgery, University of Louisville demonstrated that “sequence of surgical intervention for concomitant lumbar and hip pathology requiring lumbar spinal fusion and total hip replacement respectively significantly impacts the fate of the total hip replacement performed. Patients with prior lumbar spinal fusion undergoing total hip replacement are at significantly higher risk of dislocation and subsequent revision compared to those with total hip replacement first followed by delayed lumbar spinal fusion.”

A May 2020 paper from the Alpert Medical School of Brown University published in the medical journal Spine (13) suggests: “Patients with degenerative hip and lumbar spine pathology who undergo total hip replacement prior to lumbar spinal fusion have a significantly increased risk of postoperative dislocation, infection, revision surgery, and prolonged opioid use compared with total hip replacement after lumbar spinal fusion.

A February 2021 paper in the European Journal of Orthopaedic Surgery & Traumatology (14) cited this research in exploring the high dislocation rates following total hip replacement before or after spinal surgery in extensive spinal corrective fusion with pelvic fixation for adult spinal deformity.

This study followed 23 adults (27 hips) who underwent both extensive spinal corrective fusion with pelvic fixation and total hip replacement between 2010 and 2018. The rate of total hip replacement dislocations was extremely high-22% (6 of 27 hips) of patients. All dislocations occurred posteriorly in patients with prior total hip replacements that were performed using the posterior approach. The pelvic tilt was significantly greater in patients with total hip replacement dislocations than in those without. Conclusion: “Total hip arthroplasty concurrent with extensive spinal corrective fusion with a pelvic fixation for adult spinal deformity has an extremely high rate of posterior hip dislocation. The posterior surgical approach and prior total hip replacement were high-risk factors for dislocation. Hip and spine surgeons need focused pre-surgical planning to account for this risk.”

Spinal fusion creates a higher risk factor of hip replacement complications whether the fusion comes first and after hip replacement

A January 2021 paper in the European spine journal (15) suggests: “Lumbar spinal fusion remains a risk factor for dislocation and revision of total hip arthroplasties regardless of whether it is performed prior to or after THA. Further preoperative assessment and altered surgical technique may be required in patients having THA who have previously undergone or are likely to undergo LSF in the future.

Having lumbar fusion first increases the risk of hip replacement dislocation rates

A September 2021 paper from Massachusetts General Hospital, Harvard Medical School, published in The Journal of the American Academy of Orthopaedic Surgeons (16) examined the medical records of 505 patients who underwent revision total hip replacement. These patients were also diagnosed with degenerative lumbar spinal stenosis with spondylolisthesis. The patients were classified into two groups:

Patients who underwent revision total hip replacement with previous lumbar spinal fusion demonstrated significantly higher dislocation rates and re-revision rates compared with patients who underwent revision total hip replacement, followed by lumbar spinal fusion, at the 1-year follow-up.

Patients who underwent revision total hip replacement, followed by lumbar spinal fusion within 1 year demonstrated significantly higher dislocation and re-revision rates. The greater the intervals between revision total hip replacement and lumbar spinal fusion, the lower the postoperative dislocation rates and re-revision rates.

Does spinal fusion increase the need for hip replacement?

An August 2021 paper in the Journal of Neurosurgery. Spine (17) comes to us from the Pritzker School of Medicine, Feinberg School of Medicine, Northwestern University, and the Department of Orthopaedic Surgery and Rehabilitative Medicine, University of Chicago.

In this paper, the researchers say “strong evidence links symptoms of hip and spine pathology to postsurgical outcomes.” In other words, the level of spine or hip degeneration and the history of spinal fusion or hip replacement can greatly impact surgical outcomes. To continue with this study: “Recent studies have reported increased rates of hip dislocation in patients previously treated with total hip arthroplasty who had undergone lumbar fusion procedures. However, the effect of this link on native hip-joint degeneration remains an area of ongoing research.” The question being asked is, while it is known that spinal fusion can increase the risk of hip replacement dislocation, what is spinal fusion’s impact on a hip that has yet to be replaced, does it accelerate the hip damage?

The answer according to this paper: “Although lumbar fusion was initially hypothesized to have a significant effect on the rate of total hip arthroplasty, lumbar fusion was not associated with an increased need for future total hip arthroplasty in patients with preexisting hip osteoarthritis. Additionally, there was no relationship between fusion construct length (the amount of fused lumbar segments) and the rate of total hip arthroplasty. Although lumbar fusion reportedly increases the risk of hip dislocation in patients with prior total hip arthroplasty, these data suggest that lumbar fusion may not clinically accelerate native hip degeneration.”

Does having more levels fused in lumbar fusion worsen outcomes for a total hip replacement performed later?

Does having more levels fused in lumbar fusion worsen outcomes for a total hip replacement performed later? That was the question asked by researchers at the Rothman Orthopaedic Institute at Thomas Jefferson University and the Department of Orthopedic Surgery, NYU Langone Health. (18) The researchers divided patients into three groups:

The patients were then asked, with various outcome surveys, including the Hip Disability and Osteoarthritis Outcome Score, (following) Joint Replacement (HOOS-JR) test, how were their post-surgery function and overall satisfaction with the procedure. The researchers found that while survey results were similar among the three groups, patients who had three-or-more-level level lumbar fusion had significantly lower HOOS-JR scores than patients who had a two-level or one-level level lumbar fusion. . .Patients who had three-or-more-level level lumbar fusion had a significantly lower rate of achieving minimal clinically important difference and the patient acceptable symptom state for the HOOS-JR, compared to patients who had two-level or one-level LSF, respectively.

Conclusions: Surgeons should counsel patients who have had three-or-more-level lumbar fusion that they may have a lower rate of hip function improvement and symptom acceptability after total hip replacement, compared to patients who have had a less number of levels fused during lumbar fusion.

A December 2023 paper in The Journal of Orthopaedics and Traumatology (19) suggested the “rate of joint space narrowing after long fusions (more than four levels) was significantly higher than that after short fusions (up to three levels) and no fusion. . . surgeons should pay attention to the fact that more than four interbody fusions worsen joint space narrowing of the hip.”

Can spinal fusion create hip pain when there was none before?

In February 2021 (20) surgeons looked at “unexpected complications” after spinal fusion in patients already suffering from little or no pain hip problems. As we will see, what makes this patient’s case history of interest is that the patients who had the spinal fusion did not have hip pain before the surgery, but they did have hip pain after the surgery.

Here is what the surgeons wrote: “In cases with markedly decreased hip function (patients had both spine and hip problems at the same time), patients predominantly utilize spine movement while standing up to compensate for the hip malfunction. However, spinal fusion surgeries might lead to the disruption of this compensatory mechanism, resulting in difficulties in walking and standing up as well as proximal junctional failure (a new and abnormal bend in the spine following surgery) due to the excessive stress on the spine caused by the pendulum-like motion needed for standing up. Hence, in patients with severe hip pathology, surgeons should be cautious about the indication for spinal fusion, which inevitably affects spinal mobility.” The researchers conclude: “Conclusion: Spinal fusion surgeries performed on patients with severe hip pathology could cause early proximal junctional failures and unexpected decline in activities of daily living. Patients with such risks often do not complain of hip symptoms before spinal correction surgery. Surgeons should routinely evaluate hip joints and be cautious about the indication for spinal fusion which inevitably affects spinal mobility.”

Does a shorter time between hip replacement and spinal fusion worsen the risks of hip pain?

A December 2020 paper in the journal World Neurosurgery (21) from The Warren Alpert Medical School of Brown University/Rhode Island Hospital suggests that patients who undergo lumbar spinal fusion with a history of total hip replacement may be at increased risk of postoperative complications, revision lumbar spinal fusion, and prolonged opioid use if their total hip replacement was performed for concurrent hip-spine disease in the recent past (less than 2 years).

Pelvic tilt was the most common factor measured in patients who had a total hip replacement

A March 2022 scoping review study of 5185 patients who had a total hip replacement published in the journal BioMed Central Musculoskeletal Disorders (22) found pelvic tilt was the most common factor measured in patients. Decreased sacral slope and lower pelvic incidence were associated with an increased risk of dislocation in patients with total hip replacement. Lumbar spine scoliosis did not change significantly after total hip replacement in patients with bilateral hip osteoarthritis. Finally, one study indicated that low back pain improvement was not correlated with postoperative changes in spinopelvic alignment parameters. Conclusion: “Changes in spinopelvic alignment may occur after total hip replacement and may improve with time. Patients with a total hip replacement dislocation usually show abnormal spinopelvic alignment compared to patients without a total hip replacement dislocation. Low back pain usually improves markedly over time following total hip replacement.”

An August 2022 paper (23) in the journal Arthroplasty today. suggested: “It is essential to appreciate the relationship between pelvis, spine, and hips, as well as the impact of pathology on the movement occurring at the spinopelvic junction and in turn on pelvic tilt. This is particularly important to understand when planning a total hip replacement, as both spinal pathology and surgery will have an effect on pelvic tilt and complication rates of total hip replacement. . . (causing complications such as) dislocation, impingement, aseptic loosening, and wear of components.”

Summary

Above you read some of the research in regards to lumbar fusion and hip replacement. We invite you to continue with your research to better understand your options or the options you are looking into for a loved one. If you would like to get more information specific to your challenges please email us: Get help and information from our Caring Medical staff

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Related articles

Alternatives to spinal fusion surgery and revision spinal fusion surgery

Spinal fusion complication: Post-surgical pelvic pain in women and the post-surgical treatment options

What causes long-term hip pain after hip replacement?

Failed Back Surgery Syndrome treatment options

References

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