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Hip Surgery | Spine Surgery » surgery of the spine and hip

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why hip and spine?

My surgical practice emphasizes surgery of the spine and hip.  About 50% of my clinical practice is devoted to the management of arthritis of the hip and 50% is devoted to management of spinal disease.  I have chosen to stay active in both areas because the most common reason that a patient comes to see me is illustrated in this picture of the “C sign”.

 

The “C sign” is demonstrated by a patient who indicates “I have pain here”, touching the groin with the thumb and the buttocks and side of the hip with rest of the hand.  The first question I ask is why does the patient have pain, and what anatomic structure is causing the pain?  The list of possible causes is evenly split between the spine and the hip.  They could have degenerative disease of the lumbar spine or a disk herniation with a pinched lower lumbar nerve root and those are both spinal diseases.  They could also have trochanteric bursitis or osteoarthritis of the hip joint itself, and those are both hip problems.  Often, the patient may have disease affecting both the hip and spine — so called hip spine syndrome.  In an excellent review of this complex of symptoms published in the journal spine, the authors noted that “significant lumbar spinal stenosis and lower extremity arthritis may coexist and this may lead to diagnostic uncertainty.”  I have a saying in my practice that “accurate treatment begins with an accurate diagnosis” and in my experience I have had a number of patients referred to me with an abnormal MRI scan of the spine who turned out to have symptomatic osteoarthritis of the hip, and vice versa.

Here is a typical example of someone who has disease in both areas.  This is a 50 year old woman who is very active, who is bothered by low back pain and left hip pain.  She complains of a limp, less walking endurance than she used to have, pain centered over the greater trochanter, with radiation of the pain down the side of the thigh, occasionally below the knee.   When asked where the pain is most frequently located, she demonstrates a classic “C sign”.

An MRI scan was obtained by her primary care doctor and she was referred to my office for a consultation for spinal disease.  Here is the MRI scan of her lumbar spine which demonstrates a spondylolisthesis at L4/5 as seen on the sagittal on the left and the axial view of the spine on the right.

spondylolisthesis MRI grade 1 saggital spondylolisthesis MRI grade 1 axial at L4.5

Here are the xrays of her left hip which demonstrate a bone spur developing at the edge of the acetabulum (outlined in black dots in the second image)…

left hip early OA AP left-hip-early-OA-annotated

…and her MRI scan which demonstrates moderate femoral acetabular impingement and a degenerative tear of the labrum.

left hip early OA coronal PD FS SM MOV MRI left hip early OA axial MRI annotated

In her case, an intra-articular injection of anesthetic which was performed as part of the MRI arthrogram completely relieved her pain and she was able to walk without a limp.  Since her symptoms were eliminated by the injection, we chose to focus on the hip first.  She underwent an arthroscopic labral debridement and at the time of surgery it was apparent that the arthritis of the hip was more extensive than the MRI scan or the plain xrays revealed.  In the following two pictures we see an image of the arthroscopic shaver being used to clean up the torn and frayed labrum in the hip joint and in the second procedure, the tip of the bent probe is pointing at the area of exposed bone where the cartilage has delaminated from the acetabulum

arthroscopic debridement of the labrum of the hip extensive arthritis of the hip seen at the time of hip arthroscopy

As a result of this diagnostic workup and treatment she was #1 — able to avoid spine surgery, #2 convinced through the process of the intra-articular injection that her hip was the cause of the treatment, and #3 achieve pain relief through a hip arthroscopy.  While she is likely to need a hip replacement as her arthritis progresses, it is comforting for the patient to know that her diagnosis and treatment plan is an accurate one.

 

 

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References:

Hip spine syndrome: management of coexisting radiculopathy and arthritis of the lower extremity.  Spine J. 2003 May-Jun;3(3):238-41, Fogel GR, Esses SI.

CONCLUSIONS: Evaluation of the patient with lower extremity pain in consideration for total joint arthroplasty should include functional inquiry of the spinal nerves. Diagnostic tests and injections may allow an informative weighting of the patient’s symptoms, leading to a better understanding of the patient’s pain syndrome. There is a group of patients who have a total hip arthroplasty and then develop or may continue to have pain of groin and buttock, secondary to sciatica of lumbar spinal stenosis. For the patient undergoing total hip arthroplasty with asymptomatic spinal stenosis, there may be increased neurological risk at surgery, related to the stenosis. The patient with both conditions may require surgical decompression of the lumbar stenosis as well as joint arthroplasty of the arthritic joint.

3 comments

  1. Lily

    My mother of 84 years of age suffers with arthritis in her hip and spine and other parts of her body. At the moment she is bed ridden and going to the hospital by ambulance next week. she is in agony upon moving or walking. Please can you tell me what might happen.

    1. admin

      Dear Lily,
      my condolences that your mother is in such pain. If you would like us to review her xrays and provide you with a more informed opinion, please send a copy of her medical history and her xrays or MRI scan to:
      Monterey Spine and Joint
      attention: Jennifer
      12 Upper Ragsdale
      Suite A
      Monterey, CA 93940

  2. Season

    Hello,
    I’m so thankful for uploads of this kind! Although I’m “just” a patient, I’m interested in Orthopedics – due to the problems I have.
    I haven’t had much luck with MD’s so far… You seem to be an ideal one

    I’m surprised, that even an MRI arthrogram doesn’t always show the real extent of arthritis.
    Most patients here just get x-rays and are sent home with the words, that they had nothing but a strong imagination…

    I’m having knee pain all my life and I had to wait for the end of my 30-ies to get an arthroskopy that destroyed it even more (soft cartilage behind the patella, 2 big plicae not seen in a conventional MRI)… It’s been a good idea though – this arthroskopy, I simply got it 3 decades too late…

    I’m suffering from severe hip-pain for 5 years now. I’m having the same symptoms like the patient mentioned above – I have been without any treatment, no one explained the x-ray… My hips are looking much worse than the one of the patient: Joint gap narrowing, osteophytes (cam and pincer impingement) sclerosis…

    Now I realize, that I’m on my way to a hip replacement – and no one told me anything. A week ago I still thought to have nothing…

    The day the pain started it seems to have been too late already…

    Some of my leg angles aren’t 100% correct. No MD was bothered… I saw my mild knock knees – no MD was bothered. They even liked my idea to jog.

    But the arthritis must be caused by these bad angles… There is no other explanation. I didn’t do much sport. In my family all have/had straight legs and are/were without orthopedic problems…

    I’m still quite young – 45 years old…

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