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Instructional Course Lecture Differentiating Pathology From Spine Pathology: Key Points of Evaluation and Management

Abstract Aaron J. Buckland, MBBS, The diagnosis and treatment of patients who have both hip and lumbar FRACS spine pathologies may be a challenge because overlapping Ryan Miyamoto, MD symptoms may delay a correct diagnosis and appropriate treatment. Rakesh D. Patel, MD Common complaints of patients who have both hip and lumbar spine pathologies include low with associated buttock, , James Slover, MS, MD , and, possibly, pain. A thorough patient history should be Afshin E. Razi, MD obtained and a complete should be performed in these patients to identify the primary source of pain. Plain and advanced imaging studies and diagnostic injections can be used to further delineate the primary pathology and guide the appropriate sequence of treatment. Both the surgeon and the patient should understand that, although one pathology is managed, the management of the other pathology may be necessary because of persistent pain. The recognition of both entities may help reduce the likelihood of misdiagnosis, and the management of both entities in the appropriate sequence may help reduce the likelihood of persistent symptoms.

ip and lumbar spine patholo- symptoms is clear despite coexistent Hgies often occur in combina- hip and lumbar spine pathologies. In tion, which may result in substantial patients with complex hip-spine syn- disability.1-3 Patients with both hip drome, however, no clear source of and lumbar spine pathology com- symptoms is known despite a detailed monly have low (LBP) physical examination. Patients with with associated buttock, groin, complex hip-spine syndrome require From the NYU Hospital for thigh, and, possibly, knee pain. The additional diagnostic tests, including Diseases, New York, NY (Dr. Buckland, diagnosis and treatment of these diagnostic injections. In patients with Dr. Slover and Dr. Razi), Fair Oaks patients may be a challenge because secondary hip-spine syndrome, both Orthopaedics, Fairfax, VA overlapping symptoms may delay a pathologies are interdependent, and (Dr. Miyamoto), and the Department of Orthopaedic , University of correct diagnosis and, therefore, the symptoms of one region are sec- Michigan Health System, Ann Arbor, MI appropriate treatment. ondary to the pathology of the other. (Dr. Patel). Offierski and MacNab4 originally The authors reported that flexion J Am Acad Orthop Surg 2017;25: described the term “hip-spine syn- of the hip that results in e23-e34 drome” in 1983. The authors clas- compensatory hyperlordosis of the DOI: 10.5435/JAAOS-D-15-00740 sified hip-spine syndrome as simple, lumbar spine, which causes foraminal complex, secondary, or misdiagnosed. , especially at L3-4, is an Copyright 2016 by the American Academy of Orthopaedic Surgeons. In patients with simple hip-spine example of secondary hip-spine syn- syndrome, the primary source of drome. Similarly, that causes

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Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Differentiating Hip Pathology From Lumbar Spine Pathology: Key Points of Evaluation and Management pelvic obliquity and acetabular tilt putting on or getting in and evaluation. Surgeons should observe may result in uncovering of the fem- out of a car are associated with hip a patient’s posture, muscle , oral head. In patients with mis- pathology. A burning or electric previous surgical scars, -length diagnosed hip-spine syndrome, the character to pain may be more sug- discrepancy, pelvic obliquity, and primary source of pain is incorrectly gestive of lumbar spine pathology, lower limb and spinal alignment diagnosed, which results in inappro- especially if accompanied by a - (coronal, sagittal, and rotational). If priate, expensive treatment. root signature or associated numb- a limb-length discrepancy exists, Unsurprisingly, hip and lumbar ness or weakness. The ability of a blocks should be placed under the spine pathologies may mimic one patient to ambulate with a forward patient’s short to obliterate pelvic another. Several studies have reported posture, which is known as the obliquity before observing spinal on the source of referred , shopping cart sign, or improvement alignment. The forward bend test which includes all lumbar nerve roots in pain in a sitting may should be performed to assess spinal via the sciatic, obturator, and femoral indicate lumbar stenosis. The rotational deformity; in a patient’s 5,6 . Surgeons should under- inability of a patient to lie on his or attempt to achieve extension, pain stand how to perform a comprehen- her side is likely caused by trochan- may indicate lumbar stenosis or sive evaluation of and appropriately teric rather than lumbar spinal instability. for areas treat patients with potential hip and or intra-articular hip of tenderness over the greater tro- lumbar spine pathologies. pathology. Clicking, snapping, or chanter, sacroiliac , groin, pain with movement of the hip likely buttock, and lumbar spine and evi- indicates intra-articular hip pathol- dence of step-off between spinous History ogy. Some patients may describe hip processes may be clues to the more pain in which he or she grasps the likely pathology. An observation of a A thorough patient history is crucial lateral aspect of the hip with his or patient’s may help surgeons to differentiate hip pathology from her and index in the assess for or the pres- lumbar spine pathology. A thorough groin (C-sign). Changes in posture ence of an abductor lurch. Walking patient history begins with an may highlight potential psoas on the and may indicate assessment of the temporal onset, pathology if pain is felt in the groin subtle weakness as a result of L4 duration, severity, location, and and thigh or spinal instability if pain through S1 nerve involvement. character of the pain and the ante- is felt in the lower back. A history of The Trendelenburg test should be cedent trauma. Surgeons must deter- startup groin pain (ie, pain that performed. Although a positive mine whether a patient has pain with usually improves after 5 to 10 steps Trendelenburg test has been re- activity, at rest, or both. Pain at night and then gradually returns) may ported to indicate hip pathology, the and the presence or absence of pain- indicate a loose total hip arthro- free intervals may indicate a tumor or plasty (THA) component. Startup Trendelenburg test also may be an infection. Traditionally, groin back or buttock pain may indicate positive in patients with L5 radicul- pain is associated with hip pathology, spinal instability. opathy as a result of the innervation and buttock and back pain is associ- of the and minimus. ated with lumbar spine pathology; Hip testing should however, overlap exists between hip Physical Examination be performed, assessing for loss of and lumbar spine pathologies. Pain internal rotation with pain at termi- from hip (OA) can be The physical examination of a patient nal range of motion, which indicates localized to the groin (84%), buttock with potential hip and lumbar spine hip pathology.9-12 Groin pain and (76%), anterior thigh (59%), poste- pathologies should include inspec- thigh pain have been reported in rior thigh (43%), anterior knee tion and palpation of the affected 55% and 57% of patients with hip (69%), shin (47%), and areas, an observation of gait, and pathology, respectively; however, (29%).7,8 In general, difficulty with a comprehensive hip and spinal buttock pain and pain distal to the

Dr. Miyamoto or an immediate family member serves as a paid consultant to or is an employee of CONMED Linvatec and has stock or stock options held in Tornier. Dr. Patel or an immediate family member is a member of a speakers’ bureau or has made paid presentations on behalf of Stryker Spine, and serves as a paid consultant to or is an employee of Globus Medical and Stryker. Dr. Slover or an immediate family member has received research or institutional support from Zimmer Biomet and DJO Global. Dr. Razi or an immediate family member serves as a board member, owner, officer, or committee member of the American Academy of Orthopaedic Surgeons, the American Orthopaedic Association, and the Brooklyn Orthopaedic Society. Neither Dr. Buckland nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article. e24 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Aaron J. Buckland, MBBS, FRACS, et al

Table 1 Common Provocative Tests for Hip and Lumbar Spine Pathologies Provocative Test Description Common Pathologies

Straight test The examined leg is raised with the Lumbar radiculopathy (lower lumbar knee extended. nerves), with pain elicited from 30° to 60° Contralateral test The contralateral leg is raised with the Lumbar radiculopathy (lower lumbar knee extended. nerves), with pain elicited in the other leg from 30° to 60° stretch test With the patient in the supine position, Lumbar radiculopathy (upper lumbar the hip is extended and the knee is nerves) flexed. In the supine position, the patient grabs Hip flexion contracture of the examined one knee and flexes it to the chest. leg The test is positive if the examined leg does not extend fully. Ober test With the patient lying on the Iliotibial band tightness unaffected side and the knee flexed to 90°, the symptomatic hip is brought from abduction to adduction. Anterior impingement test Hip flexion to 90°, with forced internal FAI, labral tear, or (FADIR test) rotation and adduction with groin pain Posterior impingement test Hip flexion, abduction, and external dysfunction with buttock (FABER test) rotation pain Intra-articular hip pathology (FAI) with anterior and lateral pain Seated piriformis stretch test With the patient in a seated position, A positive test, which recreates posterior flexion and adduction with the internal pain at the level of the piriformis or rotation test external rotators, indicates possible entrapment. Active piriformis contraction test The patient pushes the down into Pain and weakness may indicate sciatic the table, abducting and externally nerve entrapment. rotating against resistance as the examiner monitors the piriformis. Trendelenburg test With the patient standing on one leg, Weakness of gluteus medius on the the opposite hemipelvis drops. standing leg

FABER = flexion, abduction, external rotation; FADIR = flexion, adduction, internal rotation; FAI = femoroacetabular impingement knee have been reported in 71% and crucial. Several provocative tests can abduction, external rotation) test; 22% to 47% of patients with hip help clarify whether symptoms are the snapping test; and pathology, respectively.5 The sensi- caused by hip or lumbar spine instability tests. Compression at tivity and specificity of groin pain for pathology (Table 1). Positive pro- the sacroiliac joint and a positive hip dysfunction has been reported to vocative tests that likely indicate FABER test may indicate sacroiliac be 84.3% and 70%, respectively. On lumbar spine pathology include the joint . physical examination, patients with straight leg raise, contralateral pain caused by hip pathology are straight leg raise, and femoral nerve Diagnostic Tests seven times more likely to have a stretch tests. Surgeons should and report groin pain and are observe patients with hip flexion Plain is the first-line 14 times more likely to have limited contracture, which may result in a imaging modality that should be internal rotation compared with false-positive femoral nerve stretch performed to determine the likely patients with pain caused by lumbar test. Positive provocative tests that source of pathology. AP radiographs spine pathology.9 likely indicate hip pathology include of the and cross-table lateral A thorough neurologic examina- hip impingement tests, such as the radiographs should be obtained in tion of the upper and lower extremi- FADIR (flexion, adduction, internal patients in whom hip OA is sus- ties for upper motor neuron signs is rotation) test or the FABER (flexion, pected. In addition to standing AP

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Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Differentiating Hip Pathology From Lumbar Spine Pathology: Key Points of Evaluation and Management radiographs of the pelvis, 45°-or If the etiology of a patient’spain although these pathologies are less 90°-Dunn lateral or -lateral remains unclear or coexistent hip probable in patients with back and radiographs of the hip are useful to and lumbar spine pathologies are lower extremity pain. assess for asphericity, suspected, additional information and false-profile radiographs are may be required. Electrophysiologic Hip Pathology useful to assess for acetabular dys- studies can help differentiate radi- plasia. Radiographs of the spine culopathy from peripheral nerve Arthritic Hip Pathology should be obtained with the patient disorders, such as neuropathy, if Hip OA is diagnosed as either pri- in a standing position, depending on other diagnostic tests are equivocal. mary or secondary as a result of pathology. If lumbar spine pathol- Normal electrophysiologic findings entities such as gout, chondrocalci- ogy is suspected, AP and lateral do not eliminate the possibility of nosis, or hemochromatosis. Often, radiographs should be obtained; radiculopathy.13,14 Leriche syndrome, hip OA occurs in combination with however, lateral flexion-extension which is a form of internal iliac lumbar stenosis and back pain (Fig- radiographs can help identify insta- stenosis, can result in buttock and ure 1). Studies have reported that bility or . If spinal thigh pain. In patients with vascular patients with persistent back pain malalignment is present, 36-inch AP , symptoms typically are after THA who undergo management and lateral standing radiographs relieved with standing alone and may of the lumbar spine have improved should be obtained to assess align- be located below the .15 Patients symptoms.19-22 Other studies have ment from the femoral heads to the with vascular claudication may have reported the resolution of back pain lower cervical spine. diminished , discoloration, after the management of hip disease in Although MRI and CT can help and loss of extremity . Vascular patients undergoing THA or arthro- differentiate hip pathology from lum- studies, including the -brachial scopic hip surgery, such as that for the bar spine pathology, they are not first- index, duplex ultrasonography, and management of a labral tear.23-25 line imaging modalities. MRIs of the magnetic resonance angiography, can In a study of 25 patients with hip spine can demonstrate nerve-root help rule out peripheral vascular dis- OA and LBP who underwent THA, compression, epidural lesions, infec- eases. Selective nerve-root injections Ben-Galim et al23 reported improve- tion, disk and soft-tissue pathology in (transforaminal), epidural injections, ment in both hip and back scores at a the lumbar spine, and the paraspinal and intra-articular hip injections can follow-up of 2 years. In a retro- muscles (including the psoas muscles). be used as a diagnostic or therapeutic spective study of 3,206 patients with MRIs of the hip (6 MRI arthrograms modality. Hip injections have an 87% hip OA (566 of whom also had LBP) or delayed gadolinium-enhanced sensitivity and a 100% specificity for who underwent THA, Prather et al24 MRIs of ) can demonstrate hip pathology and can help predict the reported that, although all of the chondrolabral pathology, cartilage success of surgical interventions such patients had improved pain and hip lesions, the ligamentum teres, and as THA.16-18 The sensitivity of epidu- scores, the patients without LBP had extra-articular soft-tissue pathology. ral injections for lumbar spine greater improvement in function and CT scans of the lumbar spine aid in pathology in the setting of hip-spine pain relief, incurred fewer medical the evaluation of fusion, spondylol- syndrome has been less well defined.6 charges per episode of care, and ysis, stress fractures, or bony tumors spent fewer days in the hospital per and can be used in combination with episode of care compared with the CT myelograms for patients in whom patients who had LBP. In a study of MRI is contraindicated. Three- 113 patients with pain extending dimensional CT reconstructions of The development of differential into the back (21%), shin (7%), and the hip allow surgeons to better assess diagnoses for hip, spine, and other calf (3%) who underwent THA, for camshaft and pincer deformities, pathologies is based on the principles Hsieh et al26 reported complete pain acetabular morphology, and sus- of probability and importance (Table relief in 110 of the patients within 12 pected femoral stress fractures. 2). More common pathologies, such weeks postoperatively. In a study of CT scanograms can be used to assess as hip OA or lumbar radiculopathy, 344 patients with hip OA (170 of for femoral rotational deformities. are more probable in patients who whom also had LBP) who underwent Care should be taken to correlate a have back and lower extremity pain. THA, Parvizi et al25 reported on the patient’s diagnostic tests with his or However, some pathologies, such as resolution of LBP in 66.4% of the her history and physical examination tumors, stress fractures, and infections, 170 patients in whom it was noted because positive findings increase cannot be missed because they may preoperatively. Conversely, LBP with patient age. result in substantial consequences, developed in 20% of the 174 e26 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Aaron J. Buckland, MBBS, FRACS, et al

Table 2 Differential Diagnoses for Hip, Spine, and Other Pathologies That May Mimic One Another Intra-articular Hip Extra-articular Hip Pathologies Pathologies Spinal Pathologies Other Pathologies

Hip osteoarthritis Lumbar stenosis with or Sacroiliac joint pathology without spondylolisthesis Greater trochanteric bursitis Lumbar disk herniation Sciatic nerve tumor Stress fracture Iliotibial band tendinitis Foraminal stenosis Intrapelvic tumors Osteonecrosis Gluteus medius or Facet cyst Insufficiency fracture of the tear Failed total hip arthroplasty Iliopsoas tendinitis Nerve-root sheath tumor Peripheral vascular diseases (including Leriche syndrome) Labral tear Coxa sultans (internal or and isthmic Osteitis external snapping hip) spondylolisthesis Femoroacetabular Piriformis syndrome Iatrogenic causes (ie, Paget disease impingement misplaced pedicle screw) Loose bodies (synovial Subgluteal space syndromes Sagittal spinal malalignment chondromatosis, pigmented (deep gluteal, villonodular , pathology, , osteochondritis dissecans) and ischiofemoral impingement) Chondral damage Adductor Psoas pathology (abscess, hematoma, malpositioned hardware, transpsoas approach) Capsular laxity ——Meralgia paresthetica Ligamentum teres rupture ——Sports patients in whom it was not noted proximal and/or , patients with FAI, and a positive preoperatively within 1 year post- which leads to a conflict between the anterior impingement test has been operatively, which suggests that the and acetabular rim. reported in as many as 88% of management of hip pathology may Long-standing symptomatic FAI may patients with FAI. Lateral hip pain, exacerbate lumbar spine pathology. result in labraltearsand, subsequently, buttock pain, knee pain, and LBP In a study of a cohort of patients who intra-articular chondral damage and have been reported in as many as had exacerbated lumbar spine early-onset OA. Camshaft impinge- 67%, 29%, 27%, and 23% of symptoms after THA, McNamara ment results from femoral head-neck patients with FAI, respectively. et al19 reported improved symptoms junction abnormality, which affects Imaging studies that should be ob- in the patients who underwent the acetabulum. Pincer impingement tained in patients in whom FAI is decompression. Pritchett27 reported results from acetabular overcoverage. suspected include plain radiographs that 21 patients with lumbar stenosis Coexistent pathology is common in and MRI arthrograms. Studies have who underwent THA had drop patients with FAI. reported that the intra-articular postoperatively. Therefore, decom- Clohisy et al3 and Burnett et al28 injection of bupivacaine during mag- pression of symptomatic severe described the standard physical netic resonance arthrography is 92% lumbar stenosis occasionally is rec- examination for patients in whom sensitive, 97% specific, and 90% ommended before THA. FAI is suspected, which includes hip accurate for the diagnosis of FAI.29-32 range of motion, anterior impinge- MRI can be used to assess asphericity Nonarthritic Hip Pathology ment (FADIR test), and posterior (a angle) of the femoral head. impingement (FABER) tests. Isometric Femoroacetabular Impingement strength testing and a gait analysis are Greater Trochanteric Pain and Labral Tears the mainstays of a comprehensive Syndrome Femoroacetabular impingement (FAI) physical examination. Groin pain has Greater trochanteric pain syndrome refers to altered geometry of the been reported in as many as 92% of includes disorders that cause pain

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Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Differentiating Hip Pathology From Lumbar Spine Pathology: Key Points of Evaluation and Management

Figure 1

AP (A) and lateral (B) radiographs of the spine demonstrating pelvic tilt (PT) of 36°, pelvic incidence (PI) of 89°, lumbar of 259°, and pelvic incidence-lumbar lordosis of 30° in a 75-year-old who had with associated left groin, lateral thigh, and knee pain. In panel B, the yellow line indicates cervical spine alignment, the blue line indicates thoracic spine alignment, and the green line indicates lumbar spine alignment. AP radiograph of the pelvis (C) and lateral radiograph of the left hip (D) demonstrating of the left femoral head with collapse and secondary arthritis of the left hip. Midline sagittal T2-weighted MRI of the lumbar spine (E), left of midline sagittal T2-weighted MRI of the lumbar spine (F), and axial T2-weighted MRI of the lumbar spine through L4-5 (G) showing broad-based disk herniation with moderate to severe central and lateral recess lumbar stenosis. The patient was diagnosed with left hip osteoarthritis and L4-5 spondylolisthesis in combination with lateral recess and L4-5 foraminal stenosis left of midline. The patient underwent total hip arthroplasty of the left hip and had substantial pain relief in her back and lower extremity.

e28 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Aaron J. Buckland, MBBS, FRACS, et al over the lateral hip, including tro- lateral to the linea aspera, and THA. In most of these patients, a chanteric bursitis, external snapping medial to the sacrotuberous and thorough history with regard to the hip, and gluteus minimus/medius falciform below the sciatic surgery, the perioperative period, and dysfunction (/tears). notch. Deep gluteal syndrome the patient’s recent health; a com- Classic findings of greater trochan- involves sciatic nerve entrapment, plete physical examination; and teric pain syndrome include pain which is most commonly caused by appropriate imaging studies will with palpation over the lateral hip, a the piriformis and results in diffuse allow surgeons to correctly identify positive Ober test, the Trendelen- buttock or posterior thigh pain and the source of pain. Early-onset pain burg sign, a , and occasional radiating symptoms. A may indicate an infection, instability advanced abductor dysfunction. positive seated piriformis stretch test of the implant, or heterotopic ossi- Hip abduction weakness and pain and a positive active piriformis fication. Late-onset pain may indi- with resisted external rotation or contraction test are key physical cate an infection, synovitis, pain with standing on one leg also examination findings of deep gluteal , osteolysis, instability or are key physical examination syndrome. Ischiofemoral impinge- loosening of the implant, inadequate findings of greater trochanteric pain ment refers to the narrowing of the hip biomechanics (eg, inadequate syndrome. In a study of 24 patients ischiofemoral space between the offset, limb-length discrepancy), or with refractory greater trochanteric and the ischial soft-tissue (psoas, rectus femoris) pain syndrome, et al33 reported tuberosity. Patients with ischiofe- or impingement. Ace- that gluteus medius tears were moral impingement have atypical tabular loosening commonly results observed on the MRIs of 45.8% of groin and/or posterior buttock pain, in groin pain and buttock pain. the patients. and pain in these patients is repro- Thigh and or knee pain may be duced via a combination of hip caused by femoral loosening. extension, adduction, and external Activity-related pain or startup pain Coxa Saltans (Snapping Hip rotation. MRIs of patients with is- are caused by component instability. Syndrome) chiofemoral impingement often Plain radiographs always are indi- Internal snapping syndrome refers to demonstrate narrowing of the is- cated in patients with pain after the abrupt snapping of the iliopsoas chiofemoral space and an abnormal THA. Serial radiographs allow sur- tendon over the iliopectineal emi- signal or in the quadratus geons to assess changes in implant nence as the hip moves from flexion femoris muscle.36 positioning, which may help isolate into extension, which is accompanied the source of pain. More advanced by an audible snap, apprehension, imaging studies, such as MRI, CT, and groin pain. External snapping Stress Fractures and nuclear imaging, allow for a syndrome refers to the snapping of Stress fractures are classified as more detailed evaluation and should the iliotibial band over the greater insufficiency fractures or fatigue be obtained in patients in whom the trochanter as the hip moves from fractures. The femoral neck is the source of pain is unclear. Laboratory extension into flexion. External rota- most common site of stress fractures. studies (eg, complete blood count, tion of the leg in extension followed by A stress fracture should be suspected erythrocyte sedimentation rate, internal rotation of the hip as it moves in long-distance runners; patients C-reactive protein levels) and hip into flexion can accentuate the snap- with metabolic diseases; aspiration should be obtained in ping. Trochanteric bursitis is common patients being treated with long-term patients in whom they are warranted. in patients with snapping hip syn- diphosphate therapy; and patients drome as a result of the thickened, who report groin, thigh, or knee pain. tight iliotibial band. Pain in patients with a stress fracture Lumbar Spine Pathology is worse with weight bearing and improves with periods of rest. Tech- Subgluteal Space Syndromes may mimic referred netium TC-99m bone scan and MRI Subgluteal space syndromes include hip pain in the groin, thigh, or but- are imaging modalities that are sen- deep gluteal syndrome, hamstring tock. Radiculopathy from the L1 sitive for the diagnosis of stress pathology, pudendal nerve impinge- through L3 nerve roots is more likely fractures. ment, and ischiofemoral impinge- to mimic referred hip pain in these ment.34,35 The subgluteal space is areas; however, L5 radiculopathy bordered by the posterior aspect of Painful Total may result in in the the femoral neck and is located Several unique factors must be con- buttock, lateral aspect of the hip, and anterior to the , sidered in patients with pain after thigh. L5 radiculopathy may mimic

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Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Differentiating Hip Pathology From Lumbar Spine Pathology: Key Points of Evaluation and Management meralgia paresthetica. Radiculo- result of leg pain, patients with lum- with walking down a hill and with a pathy may occur as a result of several bar stenosis can continue to ambulate tight belt. Physical examination pathologies, including disk hernia- by leaning forward with an ambula- findings of sacroiliac joint pathology tion, spondylolisthesis, foraminal tory support, which is known as the include tenderness to palpation, pain stenosis, iatrogenic injury (ie, mis- shopping cart sign. Trochanteric with compression over the sacroiliac placed pedicle screw), facet cysts, or bursitis is common in patients with joint, and a positive FABER test. The nerve sheath tumors. Typically, lumbar stenosis and spondylolis- FABER test also may be positive in patients with radiculopathy report an thesis; therefore, it must be consid- patients with posterior chondrola- electric character to lower extremity ered in the differential diagnosis. bral pathology of the hip. A sacroiliac pain, which may be worse in a sitting joint injection can aid in differentiat- position, in a standing position, or ing posterior chondrolabral pathology with a change in posture; however, Spondylolysis and Isthmic of the hip from other hip pathology the pain may not always have a Spondylolisthesis and lumbar spine pathology. nerve-root signature. Motor weak- Typically, spondylolysis occurs in ness, sensory deficits, and absent young athletes, especially those who Psoas Pathology reflexes likely indicate radiculo- participate in sports that require Psoas pathology can manifest as pathy rather than hip pathology. repeated hyperextension of the lum- groin and thigh pain and weakness on The straight leg raise test and the bar spine. Patients with spondylolysis hip flexion. Causes of psoas pathol- contralateral straight leg raise test have unilateral or bilateral LBP that ogy include psoas abscess, hema- are specific but less sensitive for the may radiate to the buttock. The pain toma, malpositioned devices (ie, diagnosis of radiculopathy from may improve with periods of rest, pedicle screw), and the transpsoas the L4 through S1 nerve roots, and with bracing, or by avoiding hyper- approach for lumbar fusion. Patients the femoral nerve stretch test is a extension. Oblique lumbar radio- with psoas pathology may report provocative test for the diagnosis of graphs may demonstrate a pars difficulty in standing up from a chair L2 and L3 radiculopathy. Imaging defect; however, CT often is or pain with full hip extension. studies that can be obtained to con- required to confirm a diagnosis of Physical examination findings of firm radiculopathy include MRI, CT spondylolysis. Pars defects can be psoas pathology include pain with , and/or electromyog- active or inactive; therefore, techne- resisted flexion and a positive psoas raphy. A diagnostic or therapeutic tium bone scans or single photon stretch test. MRI with contrast and nerve-root block can be performed emission CT scans should be ob- laboratory tests (eg, erythrocyte sed- to further confirm radiculopathy; tained. Selective injection of a pars imentation rate, C-reactive protein however, Saito et al6 reported defect can help surgeons determine if level, complete blood count) are use- that nerve-root blocks mask hip the lesion is substantial. ful to assess for a suspected abscess, pathology by interfering with sen- Isthmic spondylolisthesis refers to and CT is useful to assess for malpo- sory nerve pathways. an anterior translation of the ceph- sitioned devices. alad in patients with a pars defect. Patients with unstable isth- Neurogenic claudication can mani- mic spondylolisthesis may report Sagittal Spinal Deformity fest as buttock and posterior thigh startuppainwhentheyfirstgetout Adult degenerative scoliosis, which pain with ambulation; however, ofabedorstandupfromachair includes sagittal spine deformity patients with neurogenic claudica- that improves after a period of (SSD), is a common pathology that tion also may have thigh and leg walking. Radiculopathy as a result affects 60% of individuals aged .65 aching or heaviness/weakness with of foraminal stenosis is common in years.37 SSD may result in substantial ambulation, which are symptoms patients with isthmic spondylolis- pain and disability.38,39 Hip OA is similar to those of patients with hip thesis. Standing, flexion-extension common in many patients with SSD. OA. Lumbar stenosis, with or with- radiographs of the lumbar spine can Although SSD is most commonly out spondylolisthesis, is the underly- aid in the evaluation of subtle degenerative, it also may result from a ing pathology in patients with instability. fracture, Scheuermann , neurogenic claudication. Vascular spondylolisthesis, iatrogenic flatback, claudication must always be ruled Sacroiliac Joint Pathology or neuromuscular disorders. Patients out. Although patients with neu- Patients with sacroiliac joint pathol- with SSD use several compensatory rogenic claudication may have ogy may have unilateral or bilateral mechanisms, including lordosis of decreased ambulation tolerance as a buttock pain. Typically, pain is worse flexible spine segments, increased e30 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Aaron J. Buckland, MBBS, FRACS, et al

42,43 pelvic tilt (posterior tilt), posterior lar anteversion and a nonlinear Figure 2 pelvic shift, and hip and knee flexion, increase in functional inclination. in an attempt to stand in an upright Pelvic tilt changes with posture. position40 (Figure 2). The abnormal Several studies have suggested that mechanics of the , pelvic tilt is similar in the supine and paraspinal muscles, and quadriceps standing positions; however, this is not true in patients with SSD, and, may result in back, buttock, and thigh therefore, supine radiographs of the pain. A fixed flexion deformity of the pelvis in patients with SSD may not hip may prevent a patient from using indicate the true functional position hip extension to compensate for SSD. of the pelvis. In a sitting position, The pelvis is the common vital entity pelvic tilt increases approximately in SSD and hip OA. 22°,44 and acetabular anteversion Pelvic tilt can be measured using increases approximately 15° (Figure two different methods; however, the 4). This increase in acetabular ante- relationship of the two methods has version improves posterior coverage yet to be defined (Figure 3). Pelvic tilt of the femoral head, which reduces can be determined by measuring the the risk for dislocation and prevents angle between the anterior pelvic anterior femoroacetabular implant plane (from the anterior superior impingement. Spinopelvic fusion iliac spine to the pubic )41 eliminates the flexibility of the lum- and a vertical line to the floor. Hip bar spine and a patient’s ability to arthroplasty surgeons favor this alter pelvic tilt during postural Illustration of a lower extremity method for the measurement of changes.45 Similarly, a patient with showing how lower limb pelvic tilt because subcutaneous increased pelvic tilt as a result of SSD compensatory mechanisms that are used by patients who have a sagittal landmarks of the anterior pelvic will have less postural variation in spine deformity are measured. Pelvic plane aid in acetabular component pelvic tilt. Although a fixed flexion tilt (PT) is the angle between a line orientation. However, the accuracy contracture may theoretically pre- drawn from the center of the femoral of the anterior pelvic plane has been vent a patient from increasing pelvic head to the midpoint of the sacral plate and a vertical line to the floor. called into question because of var- tilt to compensate for SSD and result Posterior pelvic shift (P shift) is the iable overlying soft tissues. Alterna- in decompensation of a patient’s offset between a vertical line from the tively, pelvic tilt can be determined SSD, pelvic tilt has not been reported posterosuperior corner of the sacral by measuring the angle between the to substantially change after THA.46,47 end plate to the floor and anterior cortex of the distal . The plane from the bicoxofemoral axis to We cannot recommend THA as a sacrofemoral angle (SFA), which the center of the sacral plate and a surgical method to improve sagittal measures hip extension, is the angle vertical line to the floor. This method spine posture. between a line drawn from the middle for the measurement of pelvic tilt has Pelvic tilt and acetabular ante- of the sacral end plate to the center axis of the hip and a line drawn from been reported to correlate with pre- version increase as the severity of a the center axis of the hip to the operative and postoperative health- patient’s SSD increases. In a study of femoral axis. The knee flexion angle related quality-of-life scores in 33 patients (41 ) with adult spine (KA) is the angle between the patients with adult spine deformity. deformity who underwent spinal mechanical axis of the femur and the , ° 48 mechanical axis of the tibia. The Spine surgeons aim for 20 of deformity correction, Buckland et al ankle flexion angle (AA) is the angle pelvic tilt in patients who undergo a reported that excessive acetabular between the mechanical axis of the spinal realignment procedure. prosthetic anteversion (.25°)was tibia and a vertical line to the floor. Acetabular anteversion is altered by observed on the preoperative standing the position of the pelvis. A reduction radiographs of 68% of the hips (Fig- in pelvic tilt (anterior tilt) will func- ure 5). Excessive acetabular prosthetic deformity correction is to increase tionally retrovert the acetabulum. anteversion likely accounts for the lumbar lordosis and reduce pelvic tilt Conversely, an increase in pelvic tilt increased risk for anterior dislocation via instrumentation and fusion. Ace- (posterior tilt) will functionally in patients with ankylosing spondyli- tabular anteversion decreases as pel- antevert the acetabulum. A 1° increase tis49 and may result in edge-loading, vic tilt decreases (Figure 5). Buckland in pelvic tilt (posterior tilt) will result in ceramic squeak, and increased - et al48 reported that the surgical a0.7° increase in functional acetabu- ing surface wear. The goal of spinal realignment of SSD resulted in a mean

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Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Differentiating Hip Pathology From Lumbar Spine Pathology: Key Points of Evaluation and Management

Figure 3 Figure 4

Lateral radiograph of a pelvis demonstrating that pelvic tilt (PT) can be determined by measuring the anterior pelvic plane (APP; denoted in yellow) or the position of the sacrum relative to the center of the hip (denoted in orange). (Reproduced with permission from Buckland AJ, Vigdorchik J, Schwab FJ, et al: Acetabular anteversion changes due to spinal deformity correction: Bridging the gap between hip and spine surgeons. J Bone Joint Surg Am 2015;97[23]:1913-1920.)

decrease in acetabular anteversion of 5°; however, the authors reported that acetabular anteversion can decrease as much as 23°. The authors also re- ported that an iatrogenic increase in lumbar lordosis of 3.2° or a reduction in pelvic tilt of 1.1° resulted in 1° of acetabular retroversion. Lateral radiographs of the pelvis in two different patients demonstrating changes The decision of whether to perform in pelvic tilt (PT) between standing (A and B) and sitting (C and D) positions. a spinal realignment procedure or Note that, in both patients, pelvic tilt increases in the sitting position as a result of decreasing lumbar lordosis (LL); however, the increase in pelvic tilt is different in THA as the initial intervention in each patient. patients in whom hip and lumbar spine pathologies occur in combina- tion is a challenge. A thorough patient after THA, the surgeon should con- history and a comprehensive physical history should be obtained and a sider the effect of the spinal surgery examination are necessary to identify complete physical examination of the on the orientation of the acetabular the principal cause of pain. Diagnos- spine and both of the hips should be component in the preoperative plan- tic imaging studies and injections are performed to identify the primary ning for THA. Spinal deformity cor- used to further define the primary source of a patient’spain.Patient rection should be performed before source of symptoms and guide the preferences may guide whether the THA in patients in whom SSD is appropriate sequence of treatment. spine or the hip is managed first. If substantial and considerable spinal Although one pathology is managed, THA is being considered as the initial deformity correction is required. secondary causes of pain may need to intervention in a patient with be addressed if symptoms persist. The asymptomatic SSD, a pelvic tilt– identification of both causes of pain adjusted acetabular orientation may Summary may help reduce the likelihood of help avoid excessive prosthetic ante- misdiagnosis and unnecessary treat- vertion.50 If a spinal realignment In patients who have back and lower ment and, thus, reduce the likelihood procedure is likely to be performed extremity pain, a systematic patient of persistent symptoms. e32 Journal of the American Academy of Orthopaedic Surgeons

Copyright ª the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Aaron J. Buckland, MBBS, FRACS, et al

Figure 5

Preoperative (A) and postoperative (B) AP radiographs and preoperative (C) and postoperative (D) lateral radiographs of a spine demonstrating changes in acetabular anteversion after sagittal spine deformity correction. Note that the size of the acetabular ellipse (red oval) in panel A is decreased after deformity correction (B), which indicates decreased anteversion. The ante-inclination of the acetabulum (red angle) in panel C also is decreased after deformity correction (D). (Reproduced with permission from Buckland AJ, Vigdorchik J, Schwab FJ, et al: Acetabular anteversion changes due to spinal deformity correction: Bridging the gap between hip and spine surgeons. J Bone Joint Surg Am 2015;97[23]:1913-1920.)

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