Review Article Hip-spine Syndrome

Abstract Clinton J. Devin, MD The incidence of symptomatic osteoarthritis of the hip and Kirk A. McCullough, MD degenerative is increasing in our aging population. Because the subjective complaints can be similar, it is Brent J. Morris, MD often difficult to differentiate intra- and extra-articular hip pathology Adolph J. Yates, MD from degenerative . These conditions can James D. Kang, MD present concurrently, which makes it challenging to determine the predominant underlying generator. A thorough history and physical examination, coupled with selective diagnostic testing, can be performed to differentiate between these clinical entities and help prioritize management. 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.

ubjective reports of pain in the cases. The prevalence of radio- From the Vanderbilt Orthopaedic Sbuttock, thigh, and/or knee, with graphic hip OA is 27% in adults Institute, Nashville, TN (Dr. Devin, or without a limp, are common in aged ≥45 years.6 However, not all Dr. McCullough, and Dr. Morris) and patients with degenerative changes patients with radiographic hip OA the Department of Orthopaedic 1-3 Surgery, University of Pittsburgh of the hip and spine. Failure to ap- are symptomatic. Symptomatic hip Medical Center, Pittsburgh, PA propriately diagnose the primary OA is reported in 9.2% of adults (Dr. Yates and Dr. Kang). source of pain can result in delayed aged ≥45 years.6 Thus, the treating Dr. Devin or an immediate family relief of symptoms and patient frus- physician must correlate the radio- member has received research or tration. A structured history and graphic findings with subjective institutional support from DePuy and Stryker. Dr. Yates or an immediate physical examination, along with the symptoms and physical examination family member serves as a board use of specific diagnostic modalities, findings consistent with hip arthritis. member, owner, officer, or can help differentiate between symp- DLSS can also present with ex- committee member of the American tomatic osteoarthritis (OA) of the tremity pain and limitations in walk- Association of Hip and Knee Surgeons. Dr. Kang or an immediate hip and degenerative lumbar spinal ing. DLSS is the most frequent indi- family member has received stenosis (DLSS). cation for spinal surgery in persons research or institutional support from Degenerative pathology of the hip aged >65 years.7,8 In the aging popu- Stryker. Neither of the following and lumbar spine is common in the lation, approximately 1.2 million authors nor any immediate family member has received anything of aging patient. OA is the most com- physician office visits per year in the value from or owns stock in a mon musculoskeletal disease of ag- United States are believed to be re- commercial company or institution ing and the most frequent cause of lated to symptoms of lumbar spinal related directly or indirectly to the musculoskeletal disability.4 It is sec- stenosis.7 Many types of lumbar subject of this article: Dr. McCullough and Dr. Morris. ond only to heart disease as the pre- stenosis exist, including congenital, dominant cause of functional decline iatrogenic, degenerative, and post- J Am Acad Orthop Surg 2012;20: 5 434-442 among the elderly. Hip OA is typi- traumatic. The degenerative type is cally characterized as either primary the one most frequently observed in http://dx.doi.org/10.5435/ JAAOS-20-07-434 (ie, idiopathic) or secondary, caused this patient population. by entities such as gout, chondrocal- The clinical scenario of concurrent Copyright 2012 by the American Academy of Orthopaedic Surgeons. cinosis, and hemochromatosis. Pri- hip OA and DLSS, or hip-spine syn- mary hip OA accounts for most drome, was first described by Offier-

434 Journal of the American Academy of Orthopaedic Surgeons Clinton J. Devin, MD, et al ski and MacNab3 in a retrospective common anatomic location of re- don. Lumbar pathology and primary review published in 1983. They cate- ferred pain in patients with isolated hip OA can also cause referred pain gorized patients as having simple, hip pathology (71%), followed by in this region, resulting in an overlay complex, or secondary hip-spine syn- combined thigh and groin pain of potential etiologies. drome. In simple hip-spine syn- (55%). No patient with hip pathol- drome, pathologic changes exist in ogy had pain referred to the lumbar Physical Examination the hip and lumbar spine, but only spine. Although pain referred distal A thorough physical examination is one clear source of disability is pres- to the knee joint is classically be- required to further differentiate the ent. Persons with complex hip-spine lieved to be a result of lumbar steno- primary pain generator. Reproduc- syndrome present with coexisting sis, Khan et al9 found that 47% of tion of the pain in the affected ex- pathologic changes but with no clear patients with isolated hip arthritis re- source of disability. Ancillary investi- ported pain radiating below the tremity on weight bearing is consis- gations are required to further dif- knee. tent with hip OA. Direct physical ferentiate between the two. In sec- Symptomatic lumbar stenosis typi- examination may elicit pain with ondary hip-spine syndrome, the cally presents with neurogenic clau- manipulation, including internal or pathologic processes are interrelated, dication with back and lower ex- external rotation and log roll, antal- with each exacerbating the other. For tremity pain that begins and worsens gic gait, and decreased hip range of example, a patient who stoops for- with ambulation and is relieved with motion, which most commonly pre- ward may do so because of a positive sitting. Functionally, this presenta- sents as loss of internal rotation. sagittal balance deformity and con- tion can be explained by the dynam- Brown et al10 demonstrated that pri- current hip arthritis with a flexion ics of the spinal column in the sagit- mary hip pathology was routinely . tal plane. With upright activity, there predicted by the presence of a limp, is a compensatory increase in lumbar groin pain, or limited internal rota- to maintain sagittal align- tion of the hip. Additionally, they Diagnosis ment and balance, resulting in nar- found that groin pain elicited by in- rowing of the spinal canal.12 The ternal rotation of the hip was both History pain often resolves or improves on sensitive and specific in the diagnosis Obtaining a thorough history is es- bending forward or sitting. The of hip pathology. sential to understand the pathology. shopping cart sign is a good clinical Cam and pincer impingement are Radiating pain involving the lower indicator of lumbar stenosis. Patients evaluated with the anteroposterior extremity is common secondary to with this sign find comfort ambulat- and posteroinferior impingement hip and spine pathology. Hip OA is ing while leaning over a shopping tests.14 The anteroposterior impinge- often associated with groin and but- cart. Groin pain is uncommon in pa- ment test (ie, FADIR [flexion adduc- tock pain, a limp, referred knee pain, tients with lumbar stenosis; however, tion internal rotation in extension] and pain with hip range of motion. it can be the presenting complaint test) is performed by first placing the Khan et al9 reported 84.3% sensitiv- with foraminal stenosis at the L1 or patient supine on the examination ity and 70.3% specificity for groin L2 level secondary to a far lateral table with the hip in 90° of flexion. pain in patients with hip OA. Pa- disk herniation or facet arthropa- Symptoms are then elicited with tients with groin pain have been thy.13 Regardless of the location of combined adduction and internal ro- shown to be seven times more likely the pain, it often worsens on ambu- tation of the hip. The posteroinferior to have a hip disorder only or a hip- lation or standing and improves on impingement test is performed with plus-spine disorder than a spine-only leaning forward and/or sitting. the patient supine and the hip ex- disorder.10 Lesher et al11 evaluated Lateral hip pain poses a unique di- tended over the edge of the examina- pain referral patterns in patients un- agnostic dilemma. Such pain can be tion table. In this position, pain is dergoing fluoroscopically guided a common presenting complaint, caused on external rotation of the intra-articular injections for known with radiation to the buttock and/or hip. Pain on direct palpation over the hip pathology. They assessed visual lower back region and down the lat- trochanter is most often associated analog pain score and the location of eral leg. It may be secondary to sev- with local pathology rather than the pain before and after anesthetic eral different pain generators associ- with radicular symptoms. injection. In contrast to previous re- ated with greater trochanteric pain Physical examination findings are ports, Lesher et al11 demonstrated syndrome, including and in- less predictable in persons with spi- the buttock region to be the most flammation or tear of the gluteal ten- nal stenosis. A minority of patients

July 2012, Vol 20, No 7 435 Hip-spine Syndrome

Figure 1 Subchondral lucency in the femoral head, which has the potential to progress to collapse and deforma- tion, is indicative of more advanced osteonecrosis. However, early os- teonecrosis can be visualized only on MRI. Radiographic findings of cam and pincer impingement include a bony prominence near the anterolat- eral head and neck junction, anterior overcoverage, acetabular retrover- sion, coxa profunda, and protrusio acetabuli. Minimal joint space nar- rowing may be evident in the early stages. The labrum, which is often the first structure to fail, is best visu- alized on MRI arthrogram. Labral tears are often asymptomatic, so it is important to ensure that the patient’s complaints correlate with the labral Photograph demonstrating patient positioning in the Thomas test, which is tear visualized on MRI. MRI can used to evaluate for the presence of hip-flexion contracture. The patient lies also be helpful in ruling out an oc- supine with the pelvis near the edge of the examination table. The hip to be examined is maintained in extension, and the contralateral hip is flexed, cult femoral neck or pelvis fracture, bringing the knee up toward the chest. Inability to maintain the hip of the infection, or tumor as the cause of down leg in extension denotes a positive test, as shown here. pain. Fluoroscopically guided hip anes- thetic injections can help further elu- may exhibit radicular findings such The patient’s clinical alignment in cidate the primary pain generator. as a positive straight leg raise or fem- the sagittal and coronal planes Given the potential toxicity of anes- oral stretch test. Other findings in- should be carefully evaluated. Any thetics on chondrocytes, these injec- clude decreased reflexes; diminished spine patient who is being considered tions should be reserved for persons sensation, particularly in a dermato- for a long lumbar fusion or osteot- with radiographic evidence of hip 18 mal distribution; a positive Romberg omy to correct a positive sagittal bal- OA. This test should be performed test; and, less frequently, decreased ance should undergo the Thomas in persons with a history and physi- strength with or without muscle at- test, which evaluates for the presence cal examination that implicate the rophy. A positive femoral tension of a hip flexion contracture (Figure hip as the primary pain generator. sign is nearly five times more likely 1). Many studies have demonstrated to be noted in persons with lumbar that patients who experience ≥50% stenosis than in those with hip pa- Diagnostic Tests pain relief following an intra- thology only.10 However, the Spine articular hip injection are likely to Patient Outcomes Research Trial Plain radiography is the initial ancil- have a successful outcome following (SPORT) demonstrated that <20% lary study obtained in the workup of total hip arthroplasty (THA). of persons with lumbar stenosis had hip OA. Radiographic findings con- Crawford et al19 followed 42 pa- either a positive straight leg raise test sistent with hip OA include femoral tients who were being considered for or femoral tension sign.15 Persons and/or acetabular , sub- primary THA and in whom it was with hip flexion contracture can chondral cysts, and joint space nar- unclear whether the hip was the have a false-positive femoral tension rowing on weight-bearing views.17 source of their pain. Of the 33 pa- sign; thus, this test is unreliable in Osteonecrosis and cam or pincer im- tients who experienced pain relief the setting of hip-spine syndrome. pingement are painful precursors to following intra-articular injection of The physical examination rarely OA. These may be seen on radio- bupivacaine, 32 went on to a suc- demonstrates a neurologic deficit, es- graphic studies obtained prior to pre- cessful THA (sensitivity, 96%). In a pecially in those with mild stenosis.16 sentation with hip-spine syndrome. study of 18 patients with radio-

436 Journal of the American Academy of Orthopaedic Surgeons Clinton J. Devin, MD, et al graphic evidence of hip-spine syn- Normal findings on electrophysio- improvement was found in the ste- drome, Kleiner et al20 reported that logic studies do not rule out DLSS, roid group with regard to leg pain (P relief of symptoms following an whereas findings of bilateral polyra- = 0.02), the straight leg raise test (P intra-articular hip bupivacaine injec- diculopathy at multiple levels can be = 0.03), lumbar flexion (P = 0.05), tion had a sensitivity of 87% and suggestive of this process.23 Electro- and overall satisfaction (P = 0.03). specificity of 100% in diagnosing hip physiologic studies are especially However, this difference in therapeu- OA as the primary pain generator. helpful in distinguishing the neuro- tic efficacy between groups was lost For pain that is primarily lateral, an logic changes of spinal stenosis from after 4 weeks. Botwin et al27 fol- injection of the trochanteric bursa either peripheral compression lowed elderly patients with spinal can be diagnostic and frequently or diabetic peripheral neuropathy.24 stenosis after an average of 1.9 trans- serves as definitive therapy. If injec- The treadmill test provides a func- foraminal injections and demon- tion and/or other empiric interven- tional assessment of lumbar stenosis. strated statistically significant im- tions (eg, therapy, phonophoresis) do Similar to treadmill testing for coro- provements in pain (P < 0.0004) and not provide pain relief, imaging of nary artery disease, treadmill testing function (P < 0.0004) at 2 and 12 the spine should be considered. for DLSS is performed by having the months following injection. In a In persons with suspected DLSS, patient walk on a treadmill for a set study of 140 patients with lumbar imaging typically begins with upright time period or distance, or until the spinal stenosis, 32% had >2 months plain radiographs, including AP, lat- onset of of relief from their symptoms follow- eral, flexion, and extension views. symptoms. However, because both ing ESI.28 These views allow assessment of spi- conditions can result in limited am- Because ESI has the potential for nal alignment, signs of radiographic bulation, this test is not useful in dif- complications and lacks long-term instability, and identification of de- ferentiating lumbar stenosis from hip efficacy, it should be done as a diag- generative changes at the disk space OA.25 nostic or confirmatory test only in and posterior elements. If the clinical Fluoroscopically guided epidural patients with a history and physical examination findings or lumbar ra- steroid injections (ESIs) may be diag- examination that indicate lumbar diographs are suggestive of spinal de- nostic or confirmatory. Improvement stenosis as the primary pain genera- formity, an upright 36-inch radio- in the primary symptoms following tor. In the patient who does not ex- graph should be obtained to ESI can help confirm stenosis as the perience relief following lumbar ESI, accurately assess the deformity and primary pain generator. However, an intra-articular hip injection can be evaluate for compensatory curves lack of improvement following ESI considered before deciding which pa- along the length of the spine. MRI or does not definitively rule out lumbar thology to manage first. CT myelography is used to identify stenosis as the primary pain genera- neural impingement. MRI is the tor. Persons with isolated lumbar study of choice in those without a stenosis can have a minimal response Differential Diagnosis contraindication given that it pro- to an injection yet have significant vides superior detail of the soft tis- improvement following decompres- In the patient with hip-spine syn- sues. CT myelography is invasive sive surgery.15 Although injection is drome, it is essential to rule out and exposes the patient to radiation; useful to manage neurogenic pain other causes of lower extremity pain. therefore, it should be reserved for that is secondary to an inflammatory These include clinical entities such as patients with preexisting spinal hard- process, it is not helpful in managing peripheral vascular disease, diabetic ware that would distort the MRI ischemic processes. Many studies peripheral neuropathy, and pelvic quality and in patients with implants have demonstrated the efficacy of pathology. Sources of pain about the for which MRI is contraindicated fluoroscopically guided injections in pelvis are numerous. Labral tears of (eg, pacemaker). Positive findings on managing radicular leg pain second- the hip are an underappreciated MRI or CT myelography in asymp- ary to lumbar stenosis; however, the source of pain and can be difficult to tomatic patients increase with age; improvement is often temporary. diagnose; they often present with thus, it is important to correlate the Karppinen et al26 randomized 160 normal or osteoarthritic radio- history and physical examination patients with lumbar radicular pain graphs. Painful osseous pathology findings with findings on ancillary to saline control transforaminal includes metastases, Paget disease, studies.21,22 injection or methylprednisolone bu- occult hip fractures, insufficiency Electrophysiologic studies are used pivacaine injection. At 2-week fractures of the sacrum, and osteone- when the diagnosis remains unclear. follow-up, a statistically significant crosis. Neurologic etiologies include

July 2012, Vol 20, No 7 437 Hip-spine Syndrome meralgia paresthetica and shingles. hip OA and DLSS. Patients with pro- erator. This is important because fail- More lateral pain can be secondary gressive neurologic deficits require ure to restore appropriate sagittal to greater trochanteric bursitis or urgent consultation with a spine balance during instrumented lumbar gluteal tendinitis/tendon ruptures. specialist. In the absence of a pro- fusion predicts a poor outcome.30 Vascular claudication should be gressive neurologic deficit, the pre- The hip surgeon must be cognizant evaluated in persons with skin dis- dominant patient complaint guides of the patient’s pelvic tilt while per- coloration, skin ulcers, lower ex- treatment. forming the corrective THA because tremity alopecia, and diminished or A subjective report of primarily a hip flexion contracture with inade- absent pulses. The ankle brachial in- groin pain warrants further evalua- quate corrective lordosis to compen- dex is the most reliable and least in- tion of intra-articular hip pathology. sate for upper sagittal deformity can vasive objective assessment of pe- Radiographic changes that are con- contribute to pelvic extension and ripheral arterial disease. A value of sistent with mild OA warrant further relative acetabular retroversion.31 <0.90 has been reported to be 89% workup with an MRI arthrogram. Pelvic tilt also has been shown to be sensitive for isolated femoropopliteal Intra-articular injection of local anes- dynamic and can change following disease and 97% sensitive for iso- thetic at the time of the arthrogram THA, thereby confounding attempts lated aortoiliac disease.29 Claudica- should be strongly considered as a to appropriately place the acetabular tion of the internal iliac artery can therapeutic and a diagnostic tool to component.32 result in Leriche syndrome, of which elucidate the primary pain generator. In the absence of a hip flexion con- one symptom is buttock pain. If con- Most positive intra-articular findings tracture, lumbar MRI is recom- fusion persists, further vascular stud- on MRI require referral to a hip spe- mended to confirm the diagnosis of ies can be obtained, including duplex cialist to address labral tears and the lumbar spinal stenosis. CT myelogra- ultrasonography. cam and/or pincer deformities that phy may be done in the patient for Knee OA is a common cause of can contribute to these injuries. Pa- whom MRI is contraindicated. A flu- lower extremity pain, especially in tients with obvious radiographic oroscopically guided ESI can be ad- the aging population. DLSS and hip findings of hip OA should undergo ministered, with the patient carefully OA can both present with referred fluoroscopically guided intra-articu- documenting pain relief. If an ESI knee pain. History, physical exami- lar hip injection. THA may be con- does provide relief, then the surgeon nation, and knee radiographs, in- sidered if the patient has relief of the can proceed with decompression, cluding standing AP, standing lateral, primary pain generator following in- with or without fusion, as war- and patellofemoral joint views, are jection. Conversely, if the patient ranted. routinely used in the clinical diagno- does not have pain relief following THA is considered to be a bench- sis. Further imaging modalities are intra-articular hip injection, she or mark for a surgical treatment that rarely necessary. As with hip OA, he should proceed to workup of achieves a statistically and clinically intra-articular injections can be diag- spine pathology. relevant improvement in health- nostic and therapeutic for pain A subjective report that primarily related quality of life. In a recent symptoms that are primarily related consists of paresthesias or radiculop- prospective cohort study, Mokhtar to knee OA and can help identify the athy warrants further workup of et al33 demonstrated that decompres- primary pain generator. spine pathology. Hip OA with a flex- sion and fusion for lumbar stenosis ion contracture and concurrent and acquired degenerative spon- symptoms of lumbar spinal stenosis dylolisthesis results in significant im- Management is a potential confounding variable. provement in quality of life and In secondary hip-spine syndrome, the yields health-related quality of life After the predominant pain-gen- processes are interrelated and exacer- levels comparable to those of THA. erating pathology has been deter- bate one another. For example, in the In some cases, surgical management mined, nonsurgical management is patient with positive sagittal balance of one complaint alleviates the symp- attempted (eg, ESI, fluoroscopic deformity and concurrent hip OA toms caused by another pathology. guided hip injection). Surgical man- with a flexion contracture, we rec- This was well demonstrated recently by agement is considered when non- ommend addressing the hip flexion Parvizi et al,34 who indicated that 170 surgical measures are unsuccessful contracture first with preoperative of 344 patients slated to undergo THA (Figure 2). History, physical exami- physical therapy or surgical interven- reported low preoperatively nation, and radiographs are used to tion, even if lumbar stenosis is (49%). Of these 170 patients, 113 confirm the diagnosis of concurrent thought to be the primary pain gen- (66%) experienced resolution of low

438 Journal of the American Academy of Orthopaedic Surgeons Clinton J. Devin, MD, et al

Figure 2

Treatment algorithm for hip-spine syndrome for patients in whom appropriate history and physical examination have been performed and in whom radiographs of the hip and spine demonstrate concurrent degenerative findings. + = findings on imaging studies or a response to treatment,–=imaging studies were normal or there was no response to treatment, EMG = electromyography, OA = osteoarthritis, PT = physical therapy, THA = total hip arthroplasty back pain following THA. Bohl and Steffee35 first detailed this hip OA and lumbar stenosis initially Surgical management should be di- in 1979 in a series of eight patients underwent THA. Following THA, rected at the primary pain generator. with persistent pain following THA. two of the five patients who initially It is important, however, to make These patients had resolution of presented with hip OA and DLSS re- sure that the patient understands groin and anteromedial thigh pain, quired subsequent lumbar decom- that treatment of one condition can but posterior thigh pain became pression. The second group in the improve activity level and make the more symptomatic postoperatively. study consisted of nine patients untreated condition more symptom- The symptoms resolved in six of the whose symptoms of DLSS were atic. Thus, the patient must be coun- patients who underwent decompres- masked by hip pain and were subse- seled that he or she may not get full sive lumbar laminectomy. These quently exacerbated following THA. relief of symptoms despite the identi- findings were further substantiated Seven of these nine patients under- fication and management of the pri- in a study by McNamara et al,1 in went lumbar decompression, and mary pain generator. which five patients with concurrent 85% had good or excellent results.

July 2012, Vol 20, No 7 439 Hip-spine Syndrome

Figure 3

A, Hip AP radiograph demonstrating left hip osteoarthritis in the setting of degenerative lumbar spinal stenosis in a 52- year-old woman. Sagittal (B) and axial (C) magnetic resonance images demonstrating degenerative lumbar spinal stenosis at L4-5 (arrows) with an associated acquired degenerative .

In the setting of severe lumbar plaint. Additionally, the patient had hip flexion contracture on the stenosis, evidence exists that decom- received an ESI, which relieved a sig- Thomas test. Plain radiographs of pression should be performed before nificant portion of her symptoms. the pelvis demonstrated severe right addressing the hip. Pritchett12 re- After failing nonsurgical care, the pa- hip OA (Figure 4, C). This was felt ported on 21 patients with severe tient underwent L4-5 laminectomy to be the cause of her sagittal plane spinal stenosis who developed foot and instrumented posterior spinal fu- deformity. The patient was subse- drop after THA. Of the 16 patients sion. The patient became more am- quently referred to a total joint sur- who underwent lumbar decompres- bulatory postoperatively, and the hip geon for right THA, which signifi- sion, only 6 had complete recovery OA became more symptomatic, with cantly improved her sagittal balance. of extensor function. The five pa- resultant groin pain. The patient was tients who were treated nonsurgi- referred to a total joint surgeon for cally did not demonstrate neurologic THA, after which her symptoms im- Summary improvement. proved significantly. In our own practice, a 52-year-old In another case, a 66-year-old pre- The patient who presents with lower woman presented with left hip OA sented with complaints of right extremity pain and radiographic evi- and DLSS. Evidence of left hip OA lower extremity pain and a feeling of dence of hip-spine syndrome should was noted radiographically (Figure stooping forward, with associated be managed with a thorough history 3, A), along with forma- back pain and fatigue. She had a his- and physical examination as well as tion and joint space narrowing. Evi- tory of two previous surgeries (Fig- specific diagnostic tests aimed at de- dence of lumbar spinal stenosis and ure 4, A and B), the first of which termining the predominant pain gen- degenerative spondylolisthesis are was lumbar laminectomy and unilat- erator. CT and/or MRI of the spine noted, as well (Figure 3, B and C). eral L3-5 instrumentation, with min- along with other diagnostic modali- The patient presented to the spine imal relief of her symptoms. She sub- ties can be used to help further delin- clinic following a lumbar MRI that sequently underwent L1-S1 Smith- eate the primary pathology and demonstrated findings of lumbar spi- Petersen osteotomies to better guide the order of surgical manage- nal stenosis and an acquired degener- correct her sagittal plane deformity, ment. However, the physician and ative spondylolisthesis. Although his- which she felt did little to improve patient should be aware that a sec- tory and physical examination her posture. Her examination dem- ond surgery may be necessary to ad- revealed that neurogenic claudica- onstrated groin pain on hip internal dress the untreated entity should tion was the primary subjective com- and external rotation and a severe pain persist beyond the normal ex-

440 Journal of the American Academy of Orthopaedic Surgeons Clinton J. Devin, MD, et al

Figure 4

A 66-year-old woman presented with persistent back fatigue and positive sagittal balance following two prior spinal surgeries. A, AP lumbar spine radiograph demonstrating prior lumbar laminectomy and unilateral instrumented posterior spinal fusion from L3-5 with minimal improvement in her back fatigue or right leg pain. B, Lateral spine radiograph demonstrating a positive sagittal balance after a second surgery consisting of multiple Smith-Petersen osteotomies and L1-S1 segmental instrumentation was performed in an attempt to correct her sagittal alignment. C, AP pelvis radiograph combined with focused examination of the hip revealed severe right hip OA with an associated hip flexion contracture. Following hip replacement, the patient’s sagittal alignment returned to neutral, and her mobility improved.

pected course of postoperative recov- References printed in bold type are et al: Estimates of the prevalence of ery. Identification of the presence those published within the past 5 years. arthritis and other rheumatic conditions in the United States: Part II. Arthritis and significance of both diseases and Rheum 2008;58(1):26-35. 1. McNamara MJ, Barrett KG, Christie management of them in the appro- MJ, Spengler DM: Lumbar spinal 7. Markman JD, Gaud KG: Lumbar spinal priate order can decrease the likeli- stenosis and lower extremity stenosis in older adults: Current hood of an inadequate diagnosis and arthroplasty. J Arthroplasty 1993;8(3): understanding and future directions. 273-277. Clin Geriatr Med 2008;24(2):369-388, persistent postoperative pain. viii. 2. Fogel GR, Esses SI: Hip spine syndrome: Management of coexisting 8. Katz JN, Harris MB: Clinical practice: and arthritis of the lower extremity. Lumbar spinal stenosis. N Engl J Med References Spine J 2003;3(3):238-241. 2008;358(8):818-825.

3. Offierski CM, MacNab I: Hip-spine 9. Khan AM, McLoughlin E, Giannakas K, Evidence-based Medicine: Levels of syndrome. Spine (Phila Pa 1976) 1983; Hutchinson C, Andrew JG: Hip evidence are described in the table of 8(3):316-321. osteoarthritis: Where is the pain? Ann R Coll Surg Engl 2004;86(2):119-121. contents. In this article, reference 25 4. Dagenais S, Garbedian S, Wai EK: is a level I study. References 14, 20, Systematic review of the prevalence of 10. Brown MD, Gomez-Marin O, Brookfield radiographic primary hip osteoarthritis. KF, Li PS: Differential diagnosis of hip and 33 are level II studies. Refer- Clin Orthop Relat Res 2009;467(3):623- disease versus spine disease. Clin Orthop ences 4, 5, 9, 12, 15, 18, 19, 23, 24, 637. Relat Res 2004;(419):280-284. 26, 28, and 32 are level III studies. 5. Wright AA, Cook C, Abbott JH: 11. Lesher JM, Dreyfuss P, Hager N, Kaplan References 1, 3, 8, 10, 11, 21, 27, Variables associated with the progression M, Furman M: Hip joint pain referral of hip osteoarthritis: A systematic patterns: A descriptive study. Pain Med 29-31, and 34 are level IV studies. review. Arthritis Rheum 2009;61(7):925- 2008;9(1):22-25. 936. References 2, 6, 7, 13, 16, 17, and 12. Pritchett JW: Lumbar decompression to 22 are level V expert opinion. 6. Lawrence RC, Felson DT, Helmick CG, treat foot drop after hip arthroplasty.

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Clin Orthop Relat Res 1994;(303):173- NJ, Wiesel SW: Abnormal magnetic- 2004;85(3):479-484. 177. resonance scans of the lumbar spine in asymptomatic subjects: A prospective 29. Collins TC, Suarez-Almazor M, Peterson 13. Yukawa Y, Kato F, Kajino G, Nakamura investigation. J Bone Joint Surg Am NJ: An absent pulse is not sensitive for S, Nitta H: Groin pain associated with 1990;72(3):403-408. the early detection of peripheral arterial lower lumbar disc herniation. Spine disease. Fam Med 2006;38(1):38-42. (Phila Pa 1976) 1997;22(15):1736-1740. 22. Beattie PF, Meyers SP, Stratford P, Millard RW, Hollenberg GM: 30. Kwon BK, Elgafy H, Keynan O, et al: 14. Parvizi J, Leunig M, Ganz R: Associations between patient report of Progressive junctional at the Femoroacetabular impingement. JAm symptoms and anatomic impairment caudal end of lumbar instrumented Acad Orthop Surg 2007;15(9):561-570. visible on lumbar magnetic resonance fusion: Etiology, predictors, and imaging. Spine (Phila Pa 1976) 2000; treatment. Spine (Phila Pa 1976) 2006; 15. Weinstein JN, Lurie JD, Tosteson TD, 25(7):819-828. 31(17):1943-1951. et al: Surgical compared with nonoperative treatment for lumbar 23. Spivak JM: Degenerative lumbar spinal 31. Legaye J: Influence of the sagittal degenerative spondylolisthesis: Four-year stenosis. J Bone Joint Surg Am 1998; balance of the spine on the anterior results in the Spine Patient Outcomes 80(7):1053-1066. pelvic plane and on the acetabular Research Trial (SPORT) randomized and orientation. Int Orthop 2009;33(6): observational cohorts. J Bone Joint Surg 24. Adamova B, Vohanka S, Dusek L: 1695-1700. Am 2009;91(6):1295-1304. Differential diagnostics in patients with mild lumbar spinal stenosis: The 32. Parratte S, Pagnano MW, Coleman- 16. Egli D, Hausmann O, Schmid M, Boos contributions and limits of various tests. Wood K, Kaufman KR, Berry DJ: The N, Dietz V, Curt A: Lumbar spinal Eur Spine J 2003;12(2):190-196. 2008 Frank Stinchfield award: Variation stenosis: Assessment of cauda equina in postoperative pelvic tilt may confound involvement by electrophysiological 25. Deen HG, Zimmerman RS, Lyons MK, the accuracy of hip navigation systems. recordings. J Neurol 2007;254(6):741- McPhee MC, Verheijde JL, Lemens SM: Clin Orthop Relat Res 2009;467(1):43- 750. Use of the exercise treadmill to measure 49. baseline functional status and surgical 17. Lane NE: Clinical practice: outcome in patients with severe lumbar 33. Mokhtar SA, McCombe PF, Williamson Osteoarthritis of the hip. N Engl J Med spinal stenosis. Spine (Phila Pa 1976) OD, Morgan MK, White GJ, Sears WR: 2007;357(14):1413-1421. 1998;23(2):244-248. Health-related quality of life: A comparison of outcomes after lumbar 18. Chu CR, Coyle CH, Chu CT, et al: In 26. Karppinen J, Malmivaara A, Kurunlahti fusion for degenerative spondylolisthesis vivo effects of single intra-articular M, et al: Periradicular infiltration for with large joint replacement surgery and injection of 0.5% bupivacaine on : A randomized controlled trial. population norms. Spine J 2010;10(4): articular cartilage. J Bone Joint Surg Am Spine (Phila Pa 1976) 2001;26(9):1059- 306-312. 2010;92(3):599-608. 1067. 34. Parvizi J, Pour AE, Hillibrand A, 19. Crawford RW, Gie GA, Ling RS, 27. Botwin KP, Gruber RD, Bouchlas CG, Goldberg G, Sharkey PF, Rothman RH: Murray DW: Diagnostic value of intra- et al: Fluoroscopically guided lumbar Back pain and total hip arthroplasty: A articular anaesthetic in primary transformational epidural steroid prospective natural history study. Clin osteoarthritis of the hip. J Bone Joint injections in degenerative lumbar Orthop Relat Res 2010;468(5):1325- Surg Br 1998;80(2):279-281. stenosis: An outcome study. Am J Phys 1330. Med Rehabil 2002;81(12):898-905. 20. Kleiner JB, Thorne RP, Curd JG: The 35. Bohl WR, Steffee AD: Lumbar spinal value of bupivicaine hip injection in the 28. Delport EG, Cucuzzella AR, Marley JK, stenosis: A cause of continued pain and differentiation of coxarthrosis from Pruitt CM, Fisher JR: Treatment of disability in patients after total hip lower extremity neuropathy. lumbar spinal stenosis with epidural arthroplasty. Spine (Phila Pa 1976) J Rheumatol 1991;18(3):422-427. steroid injections: A retrospective 1979;4(2):168-173. outcome study. Arch Phys Med Rehabil 21. Boden SD, Davis DO, Dina TS, Patronas

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