The evidence: Hip-spine syndrome leads to failed hip replacement and lumbar spinal fusion

David N. Woznica, MD 

This is an example email we get. “I had lower back pain, I was diagnosed with lumbar spinal stenosis. I had a fusion surgery. After the surgery, I had the same pain. Now my doctors think it was my hip all along.”

This is another: “I had a hip replacement because my MRI showed advanced 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.”

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

Let’s get right to the research:

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

Research from the Vanderbilt Orthopaedic Institute published in the The Journal of the American Academy of Orthopaedic Surgeons 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.”(1)

Doctors at the University Hospitals Cleveland Medical Center wrote in the September 2017 edition of Orthopaedics and Traumatology, surgery and research:

• Researchers have recently proposed the concept of “hip-spine syndrome”, however, there exists limited evidence available to differentiate whether these accompanying or associated hip and spine pain and inflammation are due to anatomic/structural causes, or systemic/metabolic effects.
  • Comment: In other words, the confusion of hip-spine is significant and can lead to poor surgical choices. Not only is hip-spine syndrome a diagnosis for suggesting that the patient’s pain needs to be thought of as possibly coming from the hip, from the spine, and from both, but in addition to, a problem of factors that may include systemic/metabolic factors, such as inflammation from obesity or autoimmune problems and disease. PLEASE NOTE: Again we are being issued warnings of the possibility of continued pain after a complicated surgery was possibly performed on the wrong area.

Here are more factors the doctors discussed:

• Age was the strongest predictor of arthritis at each site (back and hip).
• Anatomic/structural influences about the lumbosacral-pelvic junction contribute towards the development of arthritis (Concurrent structural damage) that is separate from any systemic/metabolic effects.
• Surgeons performing total hip replacement should remain aware of the relationship between low back pain and hip arthritis, although future research is necessary regarding optimal surgical treatment of these patients.(2)

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

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

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, they examined patients who first had the lumbar surgery, then proceeded later to a total hip replacement. Their research conclusions are presented here:

• “Lumbar spinal surgery prior to total hip replacement is associated with:
  • less reduction of pain,
  • worse health-related quality of life,
  • and less satisfaction one year after total hip replacement
•  This is useful information to share in the decision-making process and may help establish realistic expectations of the outcomes of total hip replacement in patients who also have previously undergone lumbar spinal surgery.(3)

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

• The coexistence of degenerative hip disease and spinal pathology is not uncommon for the number of surgical treatments performed for each condition increasing annually.
• The limited research available suggests spinal pathology predicts and warns less pain relief and worse outcomes after total hip replacement.

The UCSF researchers concluded their study with:

• Patients with preexisting lumbar spinal fusion experience worse early outcomes after primary total hip replacement including higher rates of complications and reoperation.
• The complex interplay between the lumbar spine and hip warrants attention and further investigation.(4)

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 The Journal of Orthopaedic and sports physical therapy of patients with hip-spine syndrome with known hip arthritis and reduced range of hip motion.

• They found on examination, 101 patients  with hip arthritis (68 women, 33 men) with an average age of 47.6 years:
  • 81 (80%) had reduced hip flexion;
  • 76 (75%) had reduced hip internal rotation

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.(5)

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 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 benefit in patients with concomitant lower back symptoms.(6)

Non-surgical treatment of hip-spine syndrome

At Caring Medical, we have successfully treated patients with problems of the hip-spine and pelvis complex with Prolotherapy, the video above and below will help demonstrate the technique and answer general questions.

If you have questions about hip spine complex problems, get help and information from our Caring Medical staff

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 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]

4 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]

5 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]

6 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]

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