LBP AND SPINAL STENOSIS: CLINICAL DECISION MAKING IN PATIENTS WITH HIP-SPINE SYNDROME, JAMES D. KANG, MD 1

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1 WITH HIP-SPINE SYNDROME, JAMES D. KANG, MD 1 Hello, my name is Dr. James D. Kang and I will be giving a lecture on low back pain and spinal stenosis, a clinical decision making in patients with hip and spine syndromes. I do not have any relevant disclosures. Our institution gets some basic science research from Stryker Company and Synthes but should not have any effect on this discussion. So the objective and the outline of this talk will focus in on the pathophysiology of lumbar spinal stenosis and hip osteoarthritis since these two conditions oftentimes coincide and present to the clinician with some difficult clinical scenarios. Then we will move forward with clinical presentations of the hip and spine syndrome and then discuss examination and clinical workup., and finally treatment considerations and then we will sum up by highlighting some case examples that discuss the principles that I will be discussing. So when one looks at the epidemiology of lower back pain and lumbar spinal problems it is extremely prevalent, it has an 85% lifetime incidence in human beings, there is 40% lifetime incidence of sciatica or leg pain due to pinched nerves, and it's a huge multi-tens of billion dollars of per year cost to society. And low back pain is in terms of disability claims are currently at epidemic proportions. And this is a graph demonstrating the percentage increase of low back pain disability compared to other medical conditions such as heart disease, lung cancer and you can see the bar on the right is truly at epidemic proportions. It's 2 to 3000% higher increase compared to in the 1980s.

2 WITH HIP-SPINE SYNDROME, JAMES D. KANG, MD 2 Similarly the epidemiology of osteoarthritis, particularly hip and knee arthritis, is becoming more and more significant especially in our elderly populations. Hip arthritis is seen in 20% of patients over the age of 45 years of age, symptomatic hip osteoarthritis occurs in 9.2% of adults older than 45 years of age. And interestingly lumbar spinal stenosis is the most frequent reason for surgery in patients older than the age of 65. And likewise there is approximately 1.2 million office visits to doctors for lumbar spinal stenosis problems. So as you can see, hip and lumbar spinal problems are rampant in our society, particularly in our more mature and aging population. So let's go back to some of the basic science of why the disc and cartilage can degenerate and creat this type of problems for the clinician. So the lumbar spine is made up of a functional spinal unit, it's a 3 joint complex made up of the intervertebral disc as you see in this slide as well as 2 facet joints. The lumbar disc is a unique structure in its own right and it's one of the largest avascular structures in the body. So without appropriate blood supply any tissue probably goes through more significant degeneration. The 2 facet joints that I point to with the arrows are lined with articular cartilage and it's very similar to the cartilage that's present in the hip joint or the knee joint, so there is a lot of commonalities. The disc and articular cartilage is made up of this very rich extracellular matrix and its predominant component is that of aggregating proteoglycans. It's rich with hyaluronic acid, core protein and glycosaminoglycans, it's complex matrix biology but more or less it has heavy negative charges and it can imbibe and hold onto a lot of water, so it acts as a good shock absorbing mechanism for the lumbar spine. As you can see here the collagen fibers and the proteoglycans

3 WITH HIP-SPINE SYNDROME, JAMES D. KANG, MD 3 hold onto that water very tightly and it acts as a shock absorber to allow the lumbar spine to withstand vertical and torsional loading. Now with aging and degeneration there is loss of this proteoglycan and there is changes in the balance of the different glycosaminoglycans and due to the loss of these proteoglycans it now does not hold the water in as much, so you get the loss of water content. And then finally the collagens change and so you have a situation like you see on the MRI scan where the disc is collapsed and degenerated and partially herniated. So degenerative spondylosis is defined as the progressive changes that occur to a disc as it's going through the aging degenerative process. When the disc starts losing its height and the integrity of the disc collapses you start seeing secondary changes in the neighboring structures, particularly in the vertebral bodies and the end plates. And the other joints such as the joints of Luschka in the neck, the facet joints become more arthritic and the spinal canal and the neural foramen can start getting affected when these osteophytes or bone spurs starts impinging into the adjacent neurologic tissue. Similarly in hip osteoarthritis as the cartilage is lost and the matrix is lost you get the wear and tear of the articular surfaces and then as soon as the articular surfaces disappear you have bone grinding on bone and in many patients that end up with this end stage cartilage wear and tear you get horrible hip arthritic symptoms where a patient can't walk. And that is manifested with various clinical syndromes which we will go over.

4 WITH HIP-SPINE SYNDROME, JAMES D. KANG, MD 4 In the lower back pain as the disc is degenerating there are clinical disorders that classically present to the clinician. So early on in the aging individual, in your 20s and 30s as the disc starts going through some degenerative processes you'll get little tears inside the disc and patients can present with discogenic back pain syndrome and these are patients that predominantly have back pain alone with no radiation or referred pain down into the legs or lumbar radiculopathy. However as the degenerative cascade proceeds or progresses the neurologic structures start getting involved and the patient can now start getting leg pain or radiculopathy. This is due to disc failure or herniation or later in life as the spine becomes arthritic the spinal canal can narrow and then the nerves can concentrically get pinched and so people get more classic neurogenic claudication symptoms. To touch upon the back pain aspects alone because it is probably the most common symptom but fortunately people with lower back pain alone without radiation into the legs I say that it's a relatively benign process because many of the patients that look horrible with spasms and suffer and run to the emergency room will actually get better the majority of the time. So these patients really don't need treatment from a surgeon. So when we look at axial low back pain alone without any leg pain it rarely needs surgical treatment. So I counsel the patient on favorable natural history, relax, we do some core strengthening, physical rehabilitation and treat conservatively. It's rare to see patients older than 60 presenting with acute lower back pain alone because the early disc degeneration processes causes pain in the young adults typically. As the disc gets older the discs can stabilize themselves and the back pain actually typically starts going away later in life. However in

5 WITH HIP-SPINE SYNDROME, JAMES D. KANG, MD 5 the younger years chronic lower back pain is more problematic in patients who smoke and as we know people with secondary gain issues with workman's compensation, some may have narcotic dependency, others may have psychosocial issues that become a problem, but back pain alone without radicular leg pain is a condition that does not need surgical treatment. That has been tested actually and we surgeons have tried, or attempted to cure back pain with various procedures as you see on these x-rays such as lumbar fusions, which is in the middle slide and even disc arthroplasty, which is a disc replacement.?but clinical follow-up data would support the fact that surgical treatment is very unpredictable and the outcomes are generally not very positive. So I recommend to patients that they avoid these surgeries if possible. Now the clinical problems in the lumbar spine that are more appropriate for surgical treatment, and these are patients that present with degenerative disc processes that start affecting the neurologic system adjacent to where the disc and the facet joints are. So these are patients that start developing neurologic syndrome such as lumbar radiculopathy or sciatica, and patients who develop severe spinal stenosis or spinal instability that causes these neurologic impairments. So let's talk about lumbar spinal stenosis because that's the more common surgical procedures that we spine surgeons need to perform on some of our senior citizens. The definition of lumbar stenosis is what we call an incongruency between the capacity and the contents of the lumbar spinal canal that may give rise to compression of the nerve roots of the cauda equina. And the cardinal

6 WITH HIP-SPINE SYNDROME, JAMES D. KANG, MD 6 symptoms are neurogenic claudication, which means patients start getting pain down their leg when they walk. The pathophysiology involved in ischemic vascular phenomena of the cauda equina due to concentric squeezing or compression also involves venous congestion, lack of oxygenation and dynamic loading with extension of the spine. But the exact pathophysiology is the completely understood but these are the commonalities of most of what people have studied. There is different types of canal stenosis. There is a central canal stenosis which you see on the top right where the entire center of the spinal canal gets narrow due to various degenerating anatomic structures that influence it. And then there is lateral recessed stenosis that is underneath the facet joint as you see in the middle diagram. And then foraminal stenosis where the nerve roots that exit the spinal canal which are called the neural foramen get narrower and narrower as the disc collapses and the nerve roots themselves get pinched. So patients with spinal stenosis typically complain of these types of subjective statements. My legs are rubbery. My legs go numb. I have pins and needles. I can't walk very far anymore. I have to sit down to get rid of my hip and leg pain. I have to lean on a grocery cart which is a very classic presentation. And lower back pain typically is mild because the majority of their symptoms are referable down to their legs.

7 WITH HIP-SPINE SYNDROME, JAMES D. KANG, MD 7 Because this lecture is on hip-spine syndrome we have to discuss what are the commonalities between patients that have hip problems that also have spine problems because it becomes a conundrum due to the fact that the subjective complaints that the patients present to us with such as buttocks, spine, groin and knee pain, are common to both in hip pathology. Therefore a careful history and physical examination needs to be done but oftentimes it's hard to distinguish which problem is causing what for the patient, and oftentimes both diseases are present in the same patient. This hip-spine syndrome was first described by Dr. Offiermanski and Dr. MacNab back in And they described 3 different syndromes that make-up the hip-spine syndrome. First is a rather simple variety in which the pathology exists in the hip and lumbar spine but only one clear source of disability is present. Whereas the complex syndrome is a coexisting pathology but no clear source of disability, so we need further studies to differentiate. And then secondary hip-spine syndrome or the pathologic processes are interrelated. Many times in my experience it's been either simple or secondary. What's confusing about this syndrome is that in hip osteoarthritis typically patients complain of groin, buttock pain, they tend to limp and they get referred pain down into the knee. And they get pain with range of motion. However what's confusing is that studies such as done by Dr. Lesher in 2008 have shown that buttock pain is the most common anatomic location of referred pain in patients with hip-osteoarthritis. Now buttock and hip pain is also the most common symptoms for lumbar spinal stenosis as well. So you can already see the most common symptom is shared by both hip and lumbar spinal stenosis issues. And in 2004 Dr. Khan demonstrated that 47% of patients

8 WITH HIP-SPINE SYNDROME, JAMES D. KANG, MD 8 with isolated hip osteoarthritis reported pain radiating below the knee, which we typically attribute to a radiculopathy nerve problem from the spine, but patients with hip arthritis can have neurologic-like symptoms. Vice-versa, patients with lumbar spinal stenosis can mimic patients with hip problems too because if you have a disc at the upper lumbar segment in the L1-2 region those are the nerve roots that supply enervation to the hip and groin area. So if you have a herniated disc or a pinched nerve in the L1-2 distribution patients can come in limping and having terrible pain in the groin which for all intents and purpose look like someone with hip osteoarthritis. Now as we stated anterior groin pain is more often due to hip osteoarthritis and posterior gluteal buttock pain is most often due lumbar spinal stenosis issues, although there can be interplay between. There are patients that present with lateral hip pain where this patient is pointing to and that's what I call no man's land because it can be due to hip problems or spinal problems but it can also be due to trochanteric bursitis but the etiology of this lateral hip pain is not as clear. When one does a physical exam in patients with lumbar spinal stenosis it's more confusing because there is oftentimes no hard neurologic findings that's consistent with people with severe spinal stenosis. So the physical exam findings are less predictable. Sciatic and straight leg raising tests which is what we do for patients with acute herniated discs are not often present in patients with chronic spinal stenosis in the elderly. So that test doesn't always

9 WITH HIP-SPINE SYNDROME, JAMES D. KANG, MD 9 work. And neurologic findings are only found in about 25 to 30% of the patients with severe spinal stenosis. And hip flexion contractors can occur in chronic lumbar spinal stenosis patients who sit all day. So it may again confuse us with patients with hip pathology. It's important to understand the sensory dermatomes of all the nerve roots in the lumbar spine because various nerves of the lower lumbar segment enervate different portions of the body in the lower extremities. So as I pointed out already the L1 and L2 nerve roots seen in the dermatomes on your right demonstrates that it enervates the hip and groin area. Again those are the areas where we have patients present with hip arthritis, so that's where the confusion arise. In the L3 and L4 dermatomes it goes more periphery down into the lower extremities in to the knee and the ankle region. Again as I stated, the more important disc in terms of its relation to the hip pain is the L1-2 disc or the L1-2 radiculopathy can mimic hip osteoarthritis and groin pain. When we examine patients with hip osteoarthritis one of the more positive findings is that of pain in the groin with hip range of motion. So when we orthopedic surgeons range their hip inflexion, internal, external rotation there will be a loss of internal rotation due to the arthritis stiffness and pain will be replicated in the groin area. Many of these patients will limp and one of the distinguishing factors that is helpful to us is that patients with lumbar spinal stenosis interestingly do not limp. So when you see a patient that limps think osteoarthritis first. And finally some younger patients that have some congenital dysplasia of the hip can display the so-called CAM lesions and pincer impingement symptoms that can cause some hip and groin pain. Hip flexion contracture is very

10 WITH HIP-SPINE SYNDROME, JAMES D. KANG, MD 10 important because patients with severe hip osteoarthritis can have this contracture which makes it difficult but again as I stated patients who have lumbar stenosis and sit all day can also get secondary hip flexion contracture due to the capsular tightening because they are not using their leg very often. So in patients with lumbar spinal problems if they get hip flexion contracture or lumbar spinal stenosis they get what's called a flat back syndrome, or they have trouble straightening up their lower back. That's due to the loss of natural lumbar lordosis and also due to hip flexion contracture. Patients with spinal stenosis also tend to walk with their lumbar spine flexed because it temporarily opens up their spinal canal just enough to give them some relief. It is actually accentuated if the patients also have hip osteoarthritis. When we talk about all of these hip and spine syndromes we also have to of course talk about differential diagnosis to make sure that we're not overlooking something beyond the hip and the spine because many of these symptoms that are already confusing can also be due to other medical entities such as vascular claudication so people with severe peripheral vascular disease can have hip, groin, buttock and leg pain all due to a artery that's being blocked off. So they can get vascular ischemia. If we overlook that people can lose their leg due to a lack of blood flow. So it's very important. And more importantly a abdominal aortic aneurism can cause a tremendous amount of back pain in patients and cause a lot of leg aching, especially if the aneurism is rupturing or leaking. So that can be life threatening. So there are other spinal tumors, arterial venous malformations and

11 WITH HIP-SPINE SYNDROME, JAMES D. KANG, MD 11 some patients with peripheral neuropathy can have similar symptoms that we discussed. So all of those things have to go into the differential diagnosis. So when there is a lot on the plate we have to look for imaging studies and diagnostic studies to help us delineate what is causing what. So we have to methodically go through the various diagnostic workup. If one is concerned about lumbar spinal stenosis we do x-rays, MRI scans, CT myelograms and then we do epidural injections and selective nerve root block to determine where the pain might be coming from. And then we can do electrical studies such as EMGs and nerve conduction studies but that's lower on the list because that's only predominantly helpful if you are looking for some type of a diabetic neuropathy or other unusual neuropathic disorders. So when we do flexion/extension x-rays that can tell us like in this particular patient you can see the L4 vertebral bodies that have slipped significantly here compared to that one. So it's what's called an anterolisthesis or a degenerative spondylolisthesis. When we see this we know the spinal canal can start getting stenotic and this also represents spinal stenosis. MRIs are the best diagnostic tests because they can immediately tell us the caliber of the spinal canal. And you can see on this MRI the patient's spinal canal is open here but as we go down to the L4-5 segment right there the spinal canal is very narrow and the patient has very bad pinching of their cauda equina, or the nerve root. This is compared to an MRI of a 25 year old normal patient. You can see how wide open the spinal canal is here, whereas in this more older geriatric patient how the spinal canal is narrowed significantly.

12 WITH HIP-SPINE SYNDROME, JAMES D. KANG, MD 12 And then sagittal images on the MRI can show us the neural foramen where the nerve root is getting pinched as it leaves the central spinal canal and MRIs are very good for discerning a certain specific nerve root dysfunction. Finally CT myelograms are very helpful because it shows us all the bony osteophytes, MRIs do not typically show us the bone detail, however CT scans do. But we still have to use CT myelogram in patients for instance who have pacemakers who cannot get MRI scans. So you can see on this myelogram the dye fills but here it looks like an hourglass constriction of the L3-4 segment and the L4-5 segment. Now these diagnostic tests are probably the most helpful in determining clinical entities that differentiate hip and spine syndromes. So first you get x-rays and MRIs and you can always see that the hip joint is arthritic and that's a fairly easy diagnosis, but sometimes it's not very clear where the pain is coming from if you see both MRI evidence of spinal stenosis and hip osteoarthritis. So this is where - that is when we start doing injection studies for diagnostic purposes. So the hip surgeons can inject various anesthetic agents into the joint and see if it gets rid of their component of pain. If their groin and hip pain disappear and their pain is relieved by their injection we know that the hip is probably the main component - main driver of the patient's dysfunction. You have to be a little careful injecting too much at local anesthetic, it is toxic to the chondrogenic cells within the articular cartilage.

13 WITH HIP-SPINE SYNDROME, JAMES D. KANG, MD 13 So if the patient responds well to injection of the hip in spite of the fact that the patient has spinal stenosis one can decide to proceed with a hip replacement. However, if the patient gets no relief from the injection into the hip one must surmise that it may be coming from the spine, so that's when you can move towards a lumbar spinal injections or other treatment towards that end. But when patients have this type of spinal stenosis and osteoarthritis issues we do conservative treatment for as long as we can. So although we spine surgeons and orthopedic surgeons do these surgeries for a living we still treat many patients conservatively. So when I see patients with spinal stenosis of even concomitant osteoarthritis we explain the natural history, we do relative rest, we use antiinflammatory medications, physical therapy and then we can also provide steroids whether it's injections or oral therapy, and we do this for 6 to 8 weeks or even longer depending on how much patients can tolerate their symptoms. So when patients start developing more progressive symptoms then they are failing all of these conservative options and they will come to us saying it's time. So what's the indication for spinal stenosis surgery? Absolute indication is the patient has bladder and bowel dysfunction. It is not often encountered but in some instances a very severe stenosis that can present with a clinical entity. So if the patient also has progressive neurologic weakness in the lower extremities with motor dysfunction and muscle atrophy that's a relative indication. And finally patients who have failed all the conservative therapies are the ones that present to us with pain syndrome and they can't get rid of their pain with all the conservative management, so that' when we electively consider surgery. So the indication for a laminectomy which is a common procedure we spine surgeons do is severe disabling sciatica unresponsive to conservative therapy,

14 WITH HIP-SPINE SYNDROME, JAMES D. KANG, MD 14 persistent or progressive leg weakness and persistent disabling neurogenic claudication, which means they can't walk very far. This slide shows an intraoperative photograph of a patient with severe canal stenosis right in this region. Indication for a fusion is predominantly for those patients that have "unstable spine." So as I stated on flexion/extension x-rays if the disc starts sliding back and forth unnaturally or they have a degenerative spondylolisthesis or a slipped disc a lumbar fusion is often necessary. And also patients with degenerative scoliosis is someone that we consider a lumbar fusions for as well. The slipped disc is a phenomenon that can occur due to facet arthritis or due to a part fracture, or a stress fracture in the lower back that can start making the spine move very unnaturally as you see on this x- ray. So when we do lumbar fusions we make a midline incision, you can see on this slide these are the facet joints, these are the little mounds and the spinal canal, the spinal canal is right in the middle. This it he dura, these are the transverse processes way out to the lateral side. And so when we do lumbar fusions we go in and first of all remove all the pressure on the nerve root and then we put these little screws in, as you can see here, and then we put bone graft into the side to do the fusion. That's the prototypical lumbar fusion and two years later you see the screws are embedded into this big mass of bony fusion that I did on this patient two years prior to this x-ray. And the clinical outcomes are usually very good.

15 WITH HIP-SPINE SYNDROME, JAMES D. KANG, MD 15 So what are the clinical outcomes? There are many physicians and patients worried that they've heard nothing but bad things about spinal surgery. I would say that spinal fusion for back pain alone is a bad operation. Spinal surgery for spinal stenosis is relatively a good operation. This study called the SPORT Study, which is called the Spine Patient Outcomes Research Trial funded by the NIH was one of the largest FDA - I'm sorry, largest NIH sponsored studies that cost $14 million of taxpayer money to do the study. And it was a multicenter study around the U.S, 3,000 patients were enrolled with spinal stenosis symptoms. It was a randomized controlled trial. And these are all the centers that were involved but suffice it to say it was multiple surgeons collecting data on patients and their outcomes. And this slide just generally shows you that the patients in the upper bar here where the red arrows are are the patients that had mean scores of their outcome or their SF36 bodily pain was substantially improved over those patients that had conservative management with no surgery with spinal stenosis. There were some statistical calculations that were done but suffice it to say the general consensus in the conclusion of the SPORT Study was that patients with neurogenic claudication from degenerative spondylolisthesis or spinal stenosis treated surgically showed substantial greater improvement in pain and function as well as satisfaction at 2 years. And there has been subsequent studies of 5 years outcome which has maintained the good outcomes. So this is what we call Level I evidence, the randomized controlled trial demonstrating that patients with surgery do much better than patients who do not have surgery.

16 WITH HIP-SPINE SYNDROME, JAMES D. KANG, MD 16 So what about patients with spinal stenosis that have hip pain as we talked about? That's the conundrum that we spine surgeons and hip surgeons face. Well what do you treat first if you have a concomitant problem? That's been debated between the orthopedic and the spine surgeons. Well there are certain matters that make the decision easy. If the patient has a hard neurologic deficit like a foot drop, muscle weakness, motor progression then lumbar spine surgery probably takes first priority. Otherwise it's determined by the patient's complaint and some of those diagnostic tests that we already discussed. The problem of course is that when you have blinders on and you treat only the hip problem thinking there is no spine problem because oftentimes one will do the appropriate treatment for one entity but the other entity persists and the patient's outcomes are poor because the other entity persists. So it's very important for the patients to understand these things to make sure these issues are clearly delineated prior to undergoing any treatment for either problem. We do know that hip arthroplasty and lumbar spine surgery as I just pointed out has excellent clinical outcomes. So most patients should be relieved to know that if you have a hip or a spinal problem we surgeons can generally take care of this very well surgically with very predictable outcomes. Interestingly 66% of patients who have total hip replacement reported improvement of their lower back pain after a hip surgery. So treatment of one condition will improve activity levels but may make the untreated condition actually more symptomatic because if you have hip arthritis and you feel now you can move your hip and you start walking well your lumbar spinal stenosis and the neurogenic claudication may start getting more activated because with your hip you weren't able to walk before, but now you are able to walk your spinal stenosis will become symptomatic. So in

17 WITH HIP-SPINE SYNDROME, JAMES D. KANG, MD 17 essence what I'm saying is that the majority of patients with both hip osteoarthritis and lumbar spinal stenosis will eventually need both surgeries. You just have to educate the patient to make sure they understand that potentially. There are some special considerations so lumbar spinal surgery may be warranted first even if hip pain is more symptomatic because there are certain patients with severe stenosis that if left untreated and they have a hip replacement a patient can suddenly wake up with unexplained foot drop because when he hip surgeon does their hip replacement they have to dislocate the hip and pull on the sciatic nerve which stretches and if it's tethered by the lumbar spinal stenosis you can get what's called a double crush phenomenon and the nerve can fail leading to a foot drop. And that is a hip surgeon's nightmare, so it is imperative that you look into this prior to undergoing a hip replacement if there are signs of spinal stenosis. And finally if patients have hip replacement there are some patients who will spontaneously dislocate their hip for no reason in spite of a well placed hip. And that's probably due to the fact that severe spinal stenosis leads to hip abductor muscle weakness and we do know when you have a weak hip abductor it cannot hold that ball in that cup very well and so no matter how well the carpentry was the hip will dislocate. So it's imperative to think about these issues when one is considering hip arthroplasty. And again vice-versa, lumbar spine surgery will only be successful if the hip is normal. So here is a patient on the very far left that had some not conventional lumbar fusion, still had severe spinal stenosis alignment issues so the patient was revised to a longer fusion, but he still struggled mightily

18 WITH HIP-SPINE SYNDROME, JAMES D. KANG, MD 18 because of an ankylosed severe hip osteoarthritis. So again the problems can be in both directions in terms of both the hip and the spine syndrome. So having gone through all of that and the general principles I'd like to go through two patient cases that will highlight some of the issues more clearly. So MH is a 46 year old white female who presents with low back pain and left hip pain, known to have early osteoarthritis by the local orthopedic surgeon. The pain was in the groin and had difficulty walking. She had some other fibromyalgia issues and was seen, chronically seen by a pain management specialist. If you look at her x-rays on January of 2013, look at the hips you will see some very mild early hip osteoarthritic changes, but nothing severe. You can see maybe some sclerosis. The patient actually had an MRI scan to make sure that she didn't have any vascular necrosis. It was read out as being some mild synovitis, nothing significant; so patient was treated with physical therapy, weight loss and antiinflammatory agents. Six months later the patient was having some further hip issues so she underwent hip steroid injections. It helped the hip pain but the pain returned, so the patient was actually about to undergo a total hip replacement; however a few months after that in September of 2013 she began to have severe lower back pain and buttocks pain radiating down to the knee and the foot. She also noted some bladder incontinence occasionally and was asked to see me as a spine surgeon prior to considering her total hip replacement.

19 WITH HIP-SPINE SYNDROME, JAMES D. KANG, MD 19 When I examined her she had an antalgic gait, she was limping and favoring her left hip. Her pain full range of motion of the left hip was present and she had limited internal rotation. Motor examination generally was normal in the lower extremities bilaterally. Sensation was subjectively decreased in the perigenital region but she could feel a pinprick in her thigh. Her normal sphincters were intact to exam. When one looked at the plain x-rays you could see that she has a degenerative spondylolisthesis right here with a vertebrae that slipped forward. Her MRI showed severe canal stenosis at the L4-5 interval. So as we stated, this patient has a combined problem, has a hip problem as well as the spinal stenosis problem. It was felt that due to some early bladder dysfunction and severe stenosis that we should proceed with the laminectomy and fusion first, which is what I did in January of She initially did well, felt her leg pain did improve but postoperatively when she began to try to ambulate she was having trouble walking again. And she was in horrible groin and hip pain and couldn't really walk, and so she felt the surgery that I did didn't help her at all. Now when we got a new plain x-ray we see that her osteoarthritis has significantly worsened, s he has a large cystic collapse of the femoral head and bone on bone so this is why she progressed after my lumbar surgery. So she obviously about 3 to 6 months later had a hip replacement and she was finally a happy camper. So the next patient is JG who was a 70 year old white male who presented with low back pain and right hip pain. The hip pain was groin and lateral hip area into the thigh. I had actually done his lumbar surgery more than 15 years ago with an L5-S1 fusion for spondylolisthesis and he did very well with that surgery. However in January, 2013 he fell and his pain started at that point. He went

20 WITH HIP-SPINE SYNDROME, JAMES D. KANG, MD 20 to see his local orthopedic surgeon who felt this was mostly a spinal issue and then he was sent to me to get his spine evaluated. So this was my old fusion that I did on this gentleman 15 years ago, it's an older technique, so I did an L5-S1 fusion for a spondylolisthesis and again the fusion had healed beautifully. But what was of interest when I examined him was that he had had multiple left total knee replacement and some chronic knee problems due to these complications that arising from his total knee replacement, he had some infection issues, multiple debridement, and he had some biomarkers demonstrating possible chronic infection but the long and short of it there was some concern he had some allergies to these metals. It was undetermined. So his x-rays of his knee shows all the complications that he endured. He had a knee replacement which was infected so they took it out and put various cement antibiotic beads and then they revised it later and then finally his legs were working better. And this was after another operation that he had in the same knee but you can see the complexity of this patient's knee problem. So when I examined him he was having pain in his hip area, not the knee. It was antalgic gait, limping due to pain in both extremities. There was some swelling in the left knee for obvious reasons as we pointed out. He had pain in the right hip with range of motion with moderate pain with internal rotation, he had some posterior buttock pain with internal rotation, and his motors were somewhat - was normal but decreased sensation in the L2-3 dermatome distribution. When I did a CT myelogram of his lumbar spine I noted that he had severe stenosis at the L2-3 interval here. As we talked about, the L2 nerve root can enervate the hip and groin area, so I felt

21 WITH HIP-SPINE SYNDROME, JAMES D. KANG, MD 21 maybe that was explaining his hip and groin pain. But he also had a little bit of a spondylolisthesis at L4-5 right above the old fusion. So based on the fact that he was sent to me by his hip surgeon I felt we should move forward with his back surgery so I did a laminectomy from L2 through 5, I took the old hardware out and did a fusion at L4-5. Unfortunately after all that reconstructive surgery he told me, Dr. Kang, my right hip still is killing me, I can't walk. So after I did all of this surgery which I was fairly sure I helped him with, he felt that this was not helpful to him. Lo and behold when we did a hip x-ray you could see that his hip was evolving into loss of cartilage and there was bone on bone there. It didn't look severe but ultimately based on this finding and the fact that he was so miserable with his hip I sent him back to his hip surgeon who originally sent him to me first. So this patient felt like a ping pong ball. So he had a hip replacement and lo and behold all of his pain went away. Now one might look at this case and say maybe he didn't even need the back surgery after all, but I would submit that even if he had his hip surgery first he would have ben back with more radicular symptoms and then ultimately he would have had his back surgery also. So the case in point is that these patients are complicated, but if you explain to the patient that there are concomitant problems their outcomes will be better tolerated. So in conclusion, one must have high index of suspicion for hip/spine syndrome, one must do careful clinical examination which is critical, must educate the patient about concomitant problems and eventually if they truly have structural issues they may need both hip and spine surgery down the road. So if you want to get a good review we wrote this manuscript in he Journal of American

22 WITH HIP-SPINE SYNDROME, JAMES D. KANG, MD 22 Academy of Orthopedic Surgery in 2012, which gives a nice review of what I just discussed. You'll have a happy patient if you follow these principles. Thank you.