James D. Kang, MD
Hip-spine syndrome is a distinct syndrome where both hip and spinal problems are occurring in concert or in tandem or together. Many patients suffer with this syndrome because the basic pathophysiology behind both entities is very similar.
When these two entities occur in tandem or in combination or in some degree overlap each other, it can become a large conundrum for us orthopedic surgeons—mainly because hip and spine problems can overlap in many ways and confused the clinician as to what's causing what clinical symptoms to become the disabling problem.
If you are evaluating a patient with hip osteoarthritis, their classic presentation is hip and groin pain. A patient starts limping and they can't walk very far because the cartilage has been worn out. It starts affecting their gait and, at a certain point, they're unable to walk very far at all. It's very disabling.
Patients with spinal stenosis or lumbar spinal conditions can also have similar walking difficulties. Their problems usually manifest with hip pain—not in the front part of this hip, but mostly on the back or buttock part, so it's a different type of a hip problem. And patients with spinal stenosis will often get pain down the leg, sometimes below the knee.
There are often neurologic symptoms like numbness and tingling and some weakness feeling but, believe it or not, hip patients can have these symptoms as well. So the two can merge together and cause very confusing clinical questions for the practitioner.
So if there are some clinical symptoms that are consistent with spinal stenosis and hip arthritis, one must be evaluated by both specialties so that the entity is picked up early and patient expectations are met.
Rehabilitation and physical therapy are very important aspects of the global treatment process in patients with hip-spine syndrome. In early evolution of the syndrome, where some patients get hip problems and spinal problems, not everybody will need surgery because their problems just haven't evolved to a severe degree as of yet. Therefore, in that group of patients, it's imperative to do physical rehabilitation, to do core strengthening, to do hip abductor and hip girdle strengthening to optimize their function so that, whatever arthritis they have, they can function at a higher level.
If the patients have progressive disease and they need to have surgery, then it's absolutely critical to have physical rehabilitation and physical therapy subsequent to their surgery—mainly because you have to rebuild and you have to re-strengthen those somewhat damaged muscles from the surgeries itself.
If the patient fails conservative therapies, then, of course, surgery is now something that has to be considered. So the first order of business as I stated is to make sure that the clinical entity hip-spine syndrome is considered in the first place by the treating physician. Once it is identified that both problems exist, the trick in trying to get a good outcome is to identify which problem is causing the most problems first.
That's because the hip replacement as well as a lumbar spinal operation are both somewhat invasive, and to put both surgeries on the patient at the same time simultaneously will be exceedingly hard on them, functionally, to recover from. So we generally do one first followed by the other perhaps three to six months later. It all depends on how severe the problem is.
The innovative treatments that are offered here at Brigham and Women's Hospital for hip-spine syndrome is the very fact that we are in the forefront of not only public awareness but also of academic awareness of this entity. Many centers are so sub-specialized that hip surgeons only see hip problems, and spine surgeons only see spine problems. Our department has brought it to an awareness level where the entire faculty is now fully aware and engaged. So the patient expectations of this surgery or this entity are met more fully and in a more comprehensive manner.
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