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Editorial Commentary: Hip–Spine Syndrome: When the Hip Does Not Move, the Spine Labors Double

      Abstract

      When the hip does not move, the spine labors double. For example, limited hip extension results in lumbar spine hyperextension and an increase in spinal facet joint loading due to premature coupling. Patients who undergo hip surgery show significant improvement in concomitant lower back problems, and symptomatic low back pain resolves in approximately 80% of patients after total hip arthroplasty. When an impairment in hip range of motion (limitation or asymmetry) is identified, a logical relationship to lumbar pathology should be explored, and treatment options may include interventions that improve hip joint range of motion.
      Advances in orthopaedic surgery are undeniable nowadays; however, there is still a sense of pursuit for a local disorder explaining the symptoms of a given patient. Practicing an orthopaedic surgery–specific field has enormous advantages: a better understanding of the detailed function and anatomy of a particular joint, the learning curve for surgical procedures, and the ability to treat minor and major complications. Nonetheless, in my opinion, this comes to a cost: we have fragmented the human body so much that we do not completely understand the relationship between 2 pathologies unless they occur in the same joint we treat. There are a number of examples of this situation that are showing up recently in hip surgery. Two of the most important ones are: (1) core muscles and femoroacetabular impingement and (2) lower back pain (LBP) and limited hip range of motion due to any cause.
      Hammoud et al.
      • Hammoud S.
      • Bedi A.
      • Magennis E.
      • Meyers W.C.
      • Kelly B.T.
      High incidence of athletic pubalgia symptoms in professional athletes with symptomatic femoroacetabular impingement.
      described a consecutive series of 38 professional athletes who were treated for symptomatic femoroacetabular impingement, with 12 (32%) of those patients identified as having previous surgical intervention for core muscle injury/athletic pubalgia. After additional treatment for femoroacetabular impingement, all 12 patients were subsequently able to return to play. In addition, of the 26 remaining patients, 15 had symptoms of core muscle injury/athletic pubalgia that resolved with isolated treatment of their hip pathology.
      In a similar direction, Redmond et al.
      • Redmond J.M.
      • Gupta A.
      • Hammarstedt J.E.
      • Stake C.E.
      • Domb B.G.
      The hip-spine syndrome: How does back pain impact the indications and outcomes of hip arthroscopy?.
      reported patients undergoing hip surgery with coexisting lumbar spine disease showing significant improvement in lower back–specific functional scores like the Oswestry Disability Index. This finding has been confirmed by a recent study revealing that symptomatic LBP resolved in 82% of patients after total hip arthroplasty.

      Vigdorchik J, Shafi K, Buckland A, et al. Does low back pain improve following total hip arthroplasty? Presented at the AAOS 2020 Virtual Education Experience.

      The majority of studies investigating the relationship between hip range of motion and LBP have focused on hip flexion and rotation.
      • Redmond J.M.
      • Gupta A.
      • Hammarstedt J.E.
      • Stake C.E.
      • Domb B.G.
      The hip-spine syndrome: How does back pain impact the indications and outcomes of hip arthroscopy?.

      Vigdorchik J, Shafi K, Buckland A, et al. Does low back pain improve following total hip arthroplasty? Presented at the AAOS 2020 Virtual Education Experience.

      • Lee S.W.
      • Kim S.Y.
      Comparison of chronic low-back pain patients hip range of motion with lumbar instability.
      • Prather H.
      • van Dillen L.
      Links between the hip and the lumbar spine (hip spine syndrome) as they relate to clinical decision making for patients with lumbopelvic pain.
      • Ben-Galim P.
      • Ben-Galim T.
      • Rand N.
      • et al.
      Hip-spine syndrome: The effect of total hip replacement surgery on low back pain in severe osteoarthritis of the hip.
      While this is important in most cases, the study by Hatem and Martin is making us think out of the box. They recognize the limited hip extension as another cause of lumbar pain due to kinematic disturbances.
      This clinical confirmation of the relationship between limited hip extension and lumbar symptoms is supported by a recent biomechanical study demonstrating how hip extension block resulted in lumbar spine extension and an increase in spinal facet joint loading due to premature coupling.
      • Gómez-Hoyos J.
      • Khoury A.
      • Schröder R.
      • Johnson E.
      • Palmer I.J.
      • Martin H.D.
      The hip-spine effect: A biomechanical study of ischiofemoral impingement effect on lumbar facet joints.
      Recent research aims to address specific contributors to lumbar pathology arising from the hip, as opposed to the classical definition in which the disease occurs independently. The authors of the biomechanical studies instead propose a unique categorization of flexion, extension, or flexion and extension hip–spine effects.
      • Gómez-Hoyos J.
      • Khoury A.
      • Schröder R.
      • Johnson E.
      • Palmer I.J.
      • Martin H.D.
      The hip-spine effect: A biomechanical study of ischiofemoral impingement effect on lumbar facet joints.
      ,
      • Martin H.
      • Khoury A.
      • Gomez-Hoyos J.
      • Helal A.
      • Fincher C.
      • Jones A.
      Outcomes of femoral derotational osteotomy for decreased femoral anteversion: a case series.
      Hatem and Martin’s study in this issue, “Low Back Pain Improves After Surgery for Lesser Trochanteric-Ischial Impingement,”
      • Hatem M.
      • Martin H.D.
      Low back pain improves after surgery for lesser trochanteric-ischial impingement.
      reminds us that during the examination of a patient with LBP, when an impairment in hip range of motion (limitation or asymmetry) is identified, a logical relationship to lumbar pathology should be explored and treatment options may include interventions that improves hip joint range of motion.
      All these data should make everyone realize that sometimes when other local causes of pain have been ruled out and a biomechanical hypothesis is sound, operating away from the location of the pain is not crazy. Improving lower back symptoms after hip surgery should not be considered a collateral effect or secondary outcome anymore. Doctors around the world having a broader biomechanical approach to chronic pain, and, when indicated, performing hip surgeries to treat athletic pubalgia, derotational osteotomies to improve gait and lower back kinematics, and decompressing ischiofemoral spaces looking for functional improvement of patients with chronic lumbar pain are not out of their mind. They are probably a few steps ahead.

      Supplementary Data

      References

        • Hammoud S.
        • Bedi A.
        • Magennis E.
        • Meyers W.C.
        • Kelly B.T.
        High incidence of athletic pubalgia symptoms in professional athletes with symptomatic femoroacetabular impingement.
        Arthroscopy. 2012; 28: 1388-1395
        • Redmond J.M.
        • Gupta A.
        • Hammarstedt J.E.
        • Stake C.E.
        • Domb B.G.
        The hip-spine syndrome: How does back pain impact the indications and outcomes of hip arthroscopy?.
        Arthroscopy. 2014; 30: 872-881
      1. Vigdorchik J, Shafi K, Buckland A, et al. Does low back pain improve following total hip arthroplasty? Presented at the AAOS 2020 Virtual Education Experience.

        • Lee S.W.
        • Kim S.Y.
        Comparison of chronic low-back pain patients hip range of motion with lumbar instability.
        J Phys Ther Sci. 2015; 27: 349-351
        • Prather H.
        • van Dillen L.
        Links between the hip and the lumbar spine (hip spine syndrome) as they relate to clinical decision making for patients with lumbopelvic pain.
        PM R. 2019; 11: S64-S72
        • Ben-Galim P.
        • Ben-Galim T.
        • Rand N.
        • et al.
        Hip-spine syndrome: The effect of total hip replacement surgery on low back pain in severe osteoarthritis of the hip.
        Spine (Phila Pa 1976). 2007; 32: 2099-2102
        • Gómez-Hoyos J.
        • Khoury A.
        • Schröder R.
        • Johnson E.
        • Palmer I.J.
        • Martin H.D.
        The hip-spine effect: A biomechanical study of ischiofemoral impingement effect on lumbar facet joints.
        Arthroscopy. 2017; 33: 101-107
        • Martin H.
        • Khoury A.
        • Gomez-Hoyos J.
        • Helal A.
        • Fincher C.
        • Jones A.
        Outcomes of femoral derotational osteotomy for decreased femoral anteversion: a case series.
        International Society for Hip Arthroscopy, Santiago2017
        • Hatem M.
        • Martin H.D.
        Low back pain improves after surgery for lesser trochanteric-ischial impingement.
        Arthroscopy. 2021; 37: 1503-1509