HIP and SPINE Syndrome

Steffi Andrat

One of the more challenging tasks for clinicians is determining where lower extremity

pain originates -

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SPINE

HIP

The term hip-spine syndrome has been

used to describe patients with

coexisting osteoarthritis (OA) of hip and degenerative

lumbar spinal stenosis (DLSS)

Introduced by Offierski and MacNab in 1983

OA

DLSS

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Can also present with extremity pain and limitations in walking. Most frequent indication for spinal surgery in persons aged >65 years.Many types of lumbar stenosis –

• Congenital• Iatrogenic• Degenerative (most frequently )

Posttraumatic

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• Primary (ie, idiopathic) accounts for most cases• Secondary (gout, chondrocalcinosis, and hemochromatosis)

Prevalence of radiographic hip OA is 27% in adults aged ≥45 years Symptomatic hip OA is reported in 9.2% of adults aged≥45 years.Thus one should correlate the radiographic findings with subjectivesymptoms and physical examination findings consistent with hip arthritis

?OA

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They categorized patients as

Simple

Pathologic changes exist in the hip and lumbar spine, but only one clear source of disability is present.

Coexisting pathologic changes but with no clear source of disability.

Pathologic processes are interrelated, with each exacerbating the other.

Seco

ndar

y

Complex

History

• Radiating pain involving the lower extremity is common secondary to hip and spine pathology.

• Hip OA - groin and buttock pain, a limp, referred knee pain, and pain with hip ROM

• Patients with groin pain have been shown to be 7 times more likely to have a hip disorder only or a hip plus-spine disorder than a spine-only disorder

History

• Symptomatic lumbar stenosis - neurogenic claudication with back and lower extremity pain that begins and worsens with ambulation and is relieved with sitting.

• The pain often resolves or improves on bending forward or sitting.

• The shopping cart sign - comfort ambulating while leaning over a shopping cart.

History

• Groin pain is uncommon in patients with lumbar stenosis

• However, it can be the presenting complaint with foraminal stenosis at the L1 or L2 level

History

• Lateral hip pain - diagnostic dilemma– can be a common presenting complaint, with

radiation to the buttock and/or lower back region and down the lateral leg

– May be secondary to greater trochanteric pain syndrome, including bursitis and inflammation or tear of the gluteal tendon.

– Lumbar pathology and primary hip OA can also cause referred pain in this region

Physical Examination

• Reproduction of the pain in the affected extremity on weight bearing - consistent with hip OA– Direct physical examination may elicit pain with

manipulation, including internal or external rotation and log roll, antalgic gait

– Decreased hip ROM, which most commonly presents as loss of internal rotation

– Cam and pincer impingement are evaluated with the anteroposterior and posteroinferior impingement tests (described later)

Physical Examination

Physical examination findings are less predictable in persons with spinal stenosis

– Minority of patients - radicular findings such as a positive SLR or FNST, decreased reflexes; diminished sensation, decreased strength with or without muscle atrophy.

– A positive femoral tension sign is nearly five times more likely to be noted in persons with lumbar stenosis than in those with hip pathology only

Diagnostic Tests

• Plain radiography is the initial ancillary study obtained in the workup of hip OA. Radiographic findings – Femoral and/or acetabular osteophytes– Subchondral cysts– Joint space narrowing on weight-bearing views.

• Cam or pincer impingement may be seen on radiographic studies

Diagnostic Tests

• MRI– Subchondral lucency in the femoral head, which

has the potential to progress to collapse and deformation implies more advanced osteonecrosis (can be visualized only on MRI)

– The labrum (often first structure to fail) is best visualized on MRI arthrogram.

– MRI can also be helpful in ruling out an occult femoral neck or pelvis fracture, infection, or tumor as the cause of pain

Diagnostic Tests

• Fluoroscopically guided hip anesthetic injections can help further elucidate the primary pain generator– Many studies have demonstrated that patients

who experience ≥50% pain relief following an intraarticular hip injection are likely to have a successful outcome following THA

Diagnostic Tests

• For pain that is primarily lateral, an injection of the trochanteric bursa can be diagnostic and frequently serves as definitive therapy. – If injection and/or other empiric interventions (eg,

therapy, phonophoresis) do not provide pain relief, imaging of the spine should be considered.

Diagnostic Tests

• In persons with suspected DLSS– imaging typically begins with upright plain

radiographs, including AP, lateral, flexion, and extension views

– MRI or CT myelography is used to identify neural impingement.

Diagnostic Tests

• Electrophysiologic studies are used when the diagnosis remains unclear– Findings of bilateral polyradiculopathy at multiple

levels can be suggestive of this– Helpful in distinguishing neurologic changes of

spinal stenosis from either peripheral nerve compression or diabetic peripheral neuropathy

Diagnostic Tests

• Fluoroscopically guided epidural steroid injections (ESIs) – may be diagnostic or confirmatory – Improvement in the primary symptoms following

ESI can help confirm stenosis as the primary pain generator.

– However, lack of improvement following ESI does not definitively rule out lumbar stenosis as the primary

D/d-Rule out other causes of lower extremity pain

• Peripheral vascular disease• Diabetic peripheral neuropathy• Pelvic pathology - Sources of pain about the pelvis

are numerous. Labral tears of the hip, Painful osseous pathology includes metastases, Paget disease, occult hip fractures, insufficiency fractures of the sacrum, and osteonecrosis.

• More lateral pain -secondary to greater trochanteric bursitis or gluteal tendinitis /tendon ruptures.

• Vascular claudication• Knee OA

• Knee OA is a common cause of lower extremity pain, especially in the aging population.

• DLSS and hip OA can both present with referred knee pain

• History, physical examination, and knee radiographs

D/d-Rule out other causes of lower extremity pain

The value of bupivicaine hip injection in the differentiation of coxarthrosis from lower extremity neuropathy.Kleiner JB, Thorne RP, Curd JG.

A series of 18 consecutive patients with roentgenographically proven osteoarthrosis of the hip and spine were evaluated because of concomitant lower extremity pain below the knee.

• To determine whether the leg symptoms were coxalgic or neuropathic, intraarticular hip bupivicaine was injected as a provocative test.

• This test allowed correct identification of the source of the pain with a sensitivity of 87%, a specificity of 100%, and an efficiency of 88%.

• This office test also provides significant savings in terms of diagnostic tests and patient discomfort.

Results from several studies have shown that, in the presence of concomitant disease, treatment of the spine does not alleviate

pain in patients with hip arthritis, and vice versa

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Whereas McNamara reporting on patients with concomitant hip and spinal disease, found that most who underwent THA followed by spinal decompression had excellent results

More prudent in the presence of spinal stenosis to treat the spinal condition first, as there is a risk for neurologic sequel.

McNamara MJ, Barrett KG, Christie MJ, Spengler DM. Lumbar spinal stenosis and lower extremity arthroplasty. J Arthroplasty.1993;8(3):273-277.

Brown MD, Gomez-Martin O, Brookfield KF, Li PS. Differential diagnosis of hip disease versus spine disease. Clin Orthop. 2004;(419):280-284

Femoroacetabular impingement

• Femoroacetabular impingement (previously “acetabular rim syndrome” or “cervicoacetabular impingement”)

• Major cause of early osteoarthritis of the hip, especially in young and active patients

• It is characterized by an early pathologic contact during hip joint motion between skeletal prominences of the acetabulum and the femur that limits the physiologic hip ROM, typically flexion and internal rotation.

Depending on clinical and radiographic findings

Two types of impingement 1. Pincer impingement is the acetabular cause of

FAI and is characterized by focal or general overcoverage of the femoral head.

2. Cam impingement is the femoral cause of FAI and is due to an aspherical portion of the femoral head–neck junction

3. Most patients (86%) have a combination of both called “mixed pincer and cam impingement,” with only a minority (14%) having the pure FAI

(A) In “cam” FAI, there is decreased offset at the femoral head/neck junction.

(B) With flexion and internal rotation, this aspherical portion of the femoral head produces shear forces at the cartilage/labrum transition zone causing damage to the peripheral cartilage

(C) In “pincer” FAI, there is a local or global acetabular overcoverage.

(D) As the hip is flexed the femoral neck abuts the anterosuperior acetabualar rim, crushing the labrum.

The proposed mechanisms of joint damage

Complaints

• Groin pain with hip rotation, in the sitting position, or during or after sports activities.

• Describe a trochanteric pain radiating in the lateral thigh.

• Typically, they are aware of their limited hip mobility long before symptoms appear.

Examination

• Restricted ROM, particularly flexion and internal rotation

• A positive impingement sign is present for anterior FAI if the forced internal rotation/adduction in 90°of flexion is reproducibly painful, and for posterior impingement with painful forced external rotation in full extension

In extreme forms, unavoidable passive external rotation of hip during hip flexion (“Drehmann's” sign).

“Posterior impingement” sign is positive when there is painful forced external rotation in maximal extension

Anterior impingement sign is positive, with painful forced internal rotation in 90° of flexion.

Diagnosis - Clinical

• Insidious onset of groin pain caused by repetitive impingement between the acetabulum rim and femoral head-neck junction.

• Initially the pain is intermittent• Exacerbated by high demand activities that

require forceful hip flexion and internal rotation.

Diagnosis - Clinical

• Pincer-type more common in women • often presents as activity-related groin pain

(caused by the innervated labrum being crushed between the acetabular rim and femoral neck)

• This symptom often acts as a warning sign, causing pincer-type patients to seek earlier mx before significant chondral damage occurs

Diagnosis - Clinical

• Cam type- Deep and extensive chondral lesions that are seen with cam-type

• More common in young males. • Group has often developed significant

chondral injury by the evaluation time they present for symptomatic

Radiographic evaluation

Correct setting for anteroposterior and strong lateral (left) pelvic radiography. Cross-table axial radiograph of hip (right) is needed to visualize anatomy of anterior femoral head–neck junction, which is not visible on anteroposterior pelvic radiograph.

Radiographic evaluation

• The next step in assessment should evaluate for pincer-type which can occur as a result of either global or local overcoverage of the acetabulum.

• A femoral head or medial acetabular wall that is medial to Kohler’s line is characteristic for protrusio acetabuli and coxa profunda respectively.

Radiographic evaluation

• The anterior and posterior acetabular walls should then be outlined. These lines should maintain a separation throughout their entire course.

• Overlap of the anterior and posterior walls at the superolateral margin of the acetabulum is called a “crossover sign”

Radiographic evaluation

• The next step - assess for cam FAI• Given its anterosuperior location, it is

underappreciated on a standard AP radiograph and may be obstructed by the greater trochanter on a frog-leg lateral view.

• The aspherical head-neck junction is best visualized on either Dunn view or a cross-table lateral view with the leg in 15°of IR

Radiographic evaluation

• The Dunn view, it is an anteroposterior view of the hip with the patient supine and with the hips and knees flexed at 90°, the legs abducted 15°-20° from the midline, and the femur in neutral rotation.

The internally rotated cross-table lateral view is often more practical for routine use, because positioning for the Dunn view requires a leg holder or assistant.

Radiographic evaluation - General Acetabular Overcoverage

• Normally, general acetabular overcoverage is correlated with the radiologic depth of the acetabular fossa

• A normal hip appears on an AP pelvic radiograph with the acetabular fossa line lying laterally to the ilioischial line – Coxa profunda = floor of the fossa acetabuli

touching or overlapping the IIL medially.– Protrusio acetabuli = femoral head is overlapping

the IIL medially

Coxa profunda - Acetabular fossa (F) is touching or overlapping ilioischial line (IIL). A' = covered portion of the femoral head, E' = uncovered portion of the femoral head.

Protrusio acetabuli Femoral head line (H) is crossing ilioischial line (IIL)

Radiographic evaluation - Focal Acetabular Overcoverage

• Focal overcoverage can occur in the anterior or the posterior part of the acetabulum.

• Anterior overcoverage is called “cranial acetabular retroversion” or “anterior focal acetabular retroversion” and causes anterior FAI that can be reproduced clinically with painful flexion and internal rotation.

• A normal acetabulum is anteverted and has the anterior rim line projected medially to the posterior wall line

• A focal overcoverage of the anterosuperior acetabulum causes a cranially retroverted acetabulum.

• Anterior rim line being lateral to the posterior rim in the cranial part of the acetabulum and crossing the latter in the distal part of the acetabulum. This figure-8 configuration is called the “cross-over” sign

Radiographic evaluation - Focal Acetabular Overcoverage

Focal anterior overcoverage of hip Acetabular retroversion is defined as anterior wall (AW) being more lateral than posterior wall (PW), whereas in normal hip anterior wall lies more medially. This cranial acetabular retroversion can also be described by figure-8 configuration.

Other modalities

• Magnetic resonance (MR) arthrogram with cartilage sequences – to determine the extent of existing cartilage injury – assess for labral pathology– subtle signs of impingement such as fibrocystic

changes at the head neck junction, formerly named herniation pits

• CT can be used as adjunct to assess for structural abnormalities

Non operative management1. Activity modifications2. Short course of NSAIDs - symptomatic relief in the acute

setting, however, their long-term use may mask the symptoms of FAI despite progressive labral and chondral injury

3. Physical therapy may have a role by improving core and hip flexor strength.

Nevertheless, restricted motion in FAI is due to an abnormal bony morphology. Attempts to improve PROM are often not beneficial and may be counterproductive.

Operative management

Arthroscopic hip surgery • Indications

– symptomatic patient– mechanical symptoms

• outcomesrecent literature supports arthroscopy shows equivalent results to open hip surgery

Operative management

open surgical hip dislocation • Indications

– gold standard for management of FAI if clinical signs and structural evidence of impingement and preserved articular cartilage, correctable deformity, reasonable expectations

• Contraindications– age >55, morbid obesity, advanced joint disease

Operative management

periacetabular osteotomy • indications

– structural deformity of acetabulum with poor coverage of femoral head

• technique– osteotomy and fixation

total hip arthroplasty• Indications

– age >60 years and end-stage hip degeneration

Thank you

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SPINE

HIPOA

DLSS