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Hip-Spine Syndrome

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Hip-Spine Syndrome Review Article Hip-spine Syndrome Abstract Clinton J. Devin, MD The incidence of symptomatic osteoarthritis of the hip and Kirk A. McCullough, MD degenerative lumbar spinal stenosis 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 lumbar spinal stenosis. These conditions can James D. Kang, MD present concurrently, which makes it challenging to determine the predominant underlying pain 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 contracture. 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- lordosis 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 bursitis 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.
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