Dr. Ebraheim’s educational animated video describes if it is a hip pain or spine pain condition? A Diagnostic Dilemma
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Hip and the spine symptoms overlap. Diagnosis and treatment of these patients is difficult and challenging. Due to our aging population, more and more people are having arthritis of the hip and arthritis of the spine, and lumbar stenosis and it may be difficult to differentiate hip pathology from lower spine pathology. Physicians job is to find out the primary source of pain then tackle the primary source of pain. It may be difficult if the patient’s symptoms comes from the hip or from the spine, or is coming from both. Obtain a history and physical exam. You may want to use some imaging, even advanced imaging, and some procedures before you decide to do surgery on the patient because surgery can be complicated. You want to warn the patient that after we take care of this first problem, then the patient may have symptoms from the second problem that we need to address. We strive to diagnose both entities to decrease the chance of any misdiagnosis or delay in treatment. If you have a patient with spine problems, ask the patient if they have a hip problem. Patient should point in the area of the hip pain. MRI of the spine may show positive findings, it doesn’t mean that the patient has a spine problem because there are a lot of patients that have positive MRI findings but are asymptomatic, so it is complicated. The hip/ spine syndrome can be straight forward and you know which is the primary source of the pain, despite the fact that you have hip and lumbar spine pathology. You don’t know which one is the primary source of the pain despite careful history and examination. The patient has x-rays and MRIs with both showing the two conditions and you find that the complaint for these patients with both hip and lumbar spine problems is groin pain, buttock pain, thigh pain, low back pain and maybe knee pain. The patient will need tests such as diagnostic injection or EMG. The patient will be limping and will have antagic gait. A patient with groin pain is 7 times more likely to a hip disorder only or a combined lesion and rarely a spine condition alone. The buttock area is the most common region of refereed pain in an isolated hip pathology followed by combined thigh and groin pain, and never the lumbar spine. Pain radiating below the knee can occur from a spine or a hip arthritis . Pain over the greater trochanter is usually hip pathology and rarely spine pathology. Ask the patient to point to the site of the pain. The patients understanding of the hip is different than our understanding of the hip. The patient with lumbar spine stenosis or a spine condition will have similar problems of difficulty in walking. Paresthesia or radiculopathy, do work-up with emphasis should on the spine. Spinal stenosis patient may have pain down the leg and sometimes below the knee. In spinal stenosis the physical exam may be normal, and the patient rarely has neurological deficit. In lumbar stenosis, the patient will have neurological claudication with back and lower extremity pain that is worse with ambulation and that is relieved by sitting and bending forward (shopping cart sign). Straightening the spine during walking causes increased lumbar lordosis and narrowing the foramen and the spinal canal, causing pain. Patient with foraminal stenosis at the L1-L2 level or with facet arthritis may present with groin pain. Check the clinical alignment. Check the Thomas test to evaluate for hip flexion contracture. The sacroiliac joint pathology symptoms overlap with spine symptoms and the hip symptoms. Common studies or tests that can help?
• MRI
• EMG and nerve studies
You may need to get an x-ray and you may need to give the patient an injection. If the patient gets more than 50% relief from injection, then it is a hip problem, and a total hip may be helpful. No relief from the hip injection, then evaluate the spine and do the appropriated imaging. Lifestyle changes including weight reduction, diet control and aerobic exercises such as swimming are needed. Stop smoking, smoking is harmful to the tissues. Treatment usually starts with physical therapy and anti-inflammatory medication. Patient may need injection or surgery if no response to physical therapy. In lateral hip pain, it may be trochanteric bursitis, do injection. Not every patient will need surgery, such as if it is spine decompression or hip replacement, both surgical procedures are difficult and it may be hard on the patient to have two major surgeries, so you need to space them out. 50% of the patients complain of low back pain before they had the total hip procedure. 60% of the patients had resolution of symptoms after the total hip replacement surgery. Patient with severe lumbar stenosis, decompression of the spine should be done before the total hip.