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

Ross Hauser, MD, Caring Medical Florida, Fort Myers
David N. Woznica, MD, Caring Medical Regenerative Medicine Clinics, Oak Park, Illinois
Danielle R. Steilen-Matias, MMS, PA-C, Caring Medical Regenerative Medicine Clinics, Oak Park, Illinois

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 this one surgery, you now need the other.

This is an example email we receive. “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 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.”

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.

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

Learning points summary:

Hip-spine syndrome is a pain syndrome characterized by injuries in both the hip and the low back that impact each other.
At 0:27 of the video, the interactions of the hip and the spine is demonstrated with a model of the pelvis.
Hip-spine syndrome commonly involves your hip and your sacroiliac joint or even your low back part of your spine. When you develop injuries or degenerative wear and tear in both the hips and the low back, these injuries impact each other. The back pain can make the hip pain worse, the hip pain can make the back pain worse as degenerative disease is accelerating in both areas.
Many times we will see a patient in the office. They will have a very specific diagnosis that their problems all come from the hip, or they will have a very specific diagnosis that their problems are all coming from the lower back. After we do a physical examination and talk to the patient about their medical history, it is clear that this patient has issues in both hip and spine.
Often we find that patients have completed a conservative care treatment course for their lower back or they have completed a conservative care treatment course for their hip, yet they still have pain. In this situation, conservative care may have been directed at the wrong pain triggers.
In patients like this, we treat the hip, spine, sacroiliac joint, sacrum areas with Prolotherapy to bring stability into the area by restoring normal function to damaged or weakened spinal and hip ligaments. (The treatment is explained below in greater detail).
At Caring Medical we have a very high success rate treating patients effectively and alleviating their chronic pain with Prolotherapy.

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

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. Lets 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.”

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

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 the optimal surgical treatment of these patients.

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

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.

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, (3) 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.

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:(4)

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.

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 (5) 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.

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 (6) 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.

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

In a March 2020 study published in the surgical journal Orthopedics (7), 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 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

In this video Danielle R. Steilen-Matias, MMS, PA-C ., explains and demonstrates a Prolotherapy treatment into the lumbar spine.

Video Summary and Learning Points

Prolotherapy is multiple injections of simple dextrose into the damaged spinal area.
Each injection goes down to the bone, where the ligaments meet the bone at the fibro-osseous junction. It is at this junction we want to stimulate repair of the ligament attachment to the bone.
We treat the whole low back area to include the sacroiliac or SI joint. In this video, the patient’s sacroiliac area in being treated to make sure that we get the ligament insertions and attachments of the SI joint in the low back.
I’ve marked with a black crayon all down the midline of this patient’s back and then I have a horizontal line drawn where her pain stops. This patient has a curvature of her spine, scoliosis, so it is important to understand where the midpoint (center) of her spine is. In this patient, we are going to go up to the horizontal line into the thoracic area which is usually not typical of all treatments.
It’s important to note that this particular patient is actually not sedated in any way so even though it is a lot of shots and a lot of injections through the skin which can be painful, patients tend to tolerate it really well the whole procedure goes relatively quickly
At 2:20 I’m just making sure that I get the sacroiliac or SI ligaments as well as the iliolumbar ligament to help strengthen the low back.
After treatment we want the patient to take it easy for about 4 days.
Depending on the severity of the low back pain condition, we may need to offer 3 to 10 treatments every 4 to 6 weeks.

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:

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.
This patient has a suspected labral tear and ligament injury.
The injections are treating the anterior part of the hip which includes the hip labrum and the Greater Trochanter area, the interior portion, the gluteus minimus is treated.
The Greater Trochanter area is where various attachments of the ligaments and muscle tendons converge, including the gluteus medius.
From the front of the hip (1:05) we can treat the pubofemoral ligament and the iliofemoral ligaments.
From the posterior approach, I’m going to inject some proliferant within the hip joint itself, and then, of course, we’re going to do all the attachments in the posterior part of the hip and that will include the ischiofemoral ligament, the iliofemoral ligaments. We can also treat the attachments of the smaller muscles too including the Obturator, the Piriformis attachments onto the Greater Trochanter
Hip problems are ubiquitous, the hip ligament injury or hip instability is a cause of degenerative hip disease and it’s the reason why people have to get to get hip replacements.

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

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]
7 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]

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