Does misdiagnosed hip pain lead to unnecessary spinal fusion?

Many people email us about their hip and back pain. Some have been recommended to a hip replacement, some have been recommended to a spinal surgery. Some have been recommended to both surgeries and they are in the process of choosing between one or the other and exploring options to help them avoid one or the other surgery, even both. Some at this point are not even deciding which to get first, they may simply take the first one that is available. Now these people are trying to decide between one or the other surgery and exploring options to help them avoid one or the other surgery, even both. The problem for some of these people is that they may get a back surgery for a hip problem and a hip surgery for a back problem. Doctors have noted that the symptoms of hip arthritis pain and spinal stenosis leg pain can be very similar, with only subtle differences in both history and clinical physical examinations. Spinal stenosis is classically diagnosed in patients with leg pain that occurs during standing or walking and is relieved when the individual sits down. This is a clinical diagnosis that doctors say can only be confirmed by MRI.

In as many as 50% of elderly patients, MRI gave a false positive diagnosis of spinal stenosis.

However, in one paper, researchers showed that in as many as 50% of elderly patients, MRI gave a false positive diagnosis of spinal stenosis. Those MRI results might prompt a surgeon to perform spinal surgery. MRI causes more problems. When the hip arthritis symptoms persist and remain undetected, it is even possible that a second unnecessary back surgery could be performed. The following paper reported on patients who had MRI scans and multiple epidural injections and were subjected to repeat back surgeries, all while continuing to complain of their leg pain—the source of which was hip pathology.(1)

This is why some patients continue to experience hip pain after elective hip replacement surgery. One research study advised doctors to look for pain originating from different sources not directly linked to the replacement hardware, as something else must have been the problem.(2) This revelation comes a little late. I see patients who were misdiagnosed and their pain generators overlooked. They have hip pain and an MRI in their chart showing a herniated disc in the lower back. After they had back surgery, the hip arthritis pain remained.

This article should provide a cautionary note for patients who insist that the MRI is providing the evidence needed to end their arthritis pain. In one study of patients who received a hip replacement, researchers noted postoperative complications occurring in almost 20% of the patients. Dislocation was the most common complication, followed by wound infection.(9)

Research: The question of which to have surgery on first, the hip or the spine, is much more complex and risky than thought

The option to have lumbar spinal surgery and hip replacement at the same time is clearly one that is not recommended for obvious reasons. So a decision has to be made. Spinal surgery or hip replacement surgery? One has to come first and one has to wait.

At Washington University School of Medicine, Departments of Orthopaedic Surgery and Neurology and Physical Therapy, surgeons and therapists wanted to examine patients who had hip osteoarthritis and back pain. The hip-spine complex can be a tricky and complex area to diagnose. Finding the true source or sources generating a patient’s pain can be equally complex. This makes the first surgery decision even more difficult.

In this study, the hip was the true disguised pain generator in back pain patients

In their 2018 study presented in the journal PMR, (1) the Washington University team found links between the hip and the spine affecting pain and function. The key finding was that hip disease, before it was even evident on an MRI as osteoarthritis, could cause problems in the lower back. The hip was the true disguised pain generator in back pain patients.

• What is this research telling us? If you had an MRI of your hip, and nothing presented itself as obvious, then the doctor may chase something in the spine that is not causing the pain. You may get a back surgery that you did even need.

Research: A patient presenting with low back pain should be examined for hip osteoarthritis

The same team of researchers, publishing research earlier in March 2017 (2) were also able to conclude that physical examination findings indicating hip osteoarthritis (loss of range of motion and acute pain) are common in patients who also have low back pain. A patient presenting with low back pain should be examined for hip osteoarthritis.

Research: Source of pain location confusion: Is it from inside the hip joint, outside the hip joint, is it from lumbar stenosis?

Similar findings were reported in a study from doctors at Vanderbilt Orthopaedic Institute (3) the incidence of symptomatic osteoarthritis of the hip and degenerative lumbar spinal stenosis were examined because the subjective complaints can be similar, and it is often difficult to differentiate intra- and extra-articular hip pathology from degenerative lumbar spinal stenosis. These conditions can present concurrently, which makes it challenging to determine the predominant underlying pain generator. A thorough history and physical examination, coupled with selective diagnostic testing, can be performed to differentiate between these clinical entities and help prioritize management.

It should be noted that a physical examination was called for. In the above study “selective diagnostic testing.”

Hip or spine surgery first? Research says there is confusion and controversy even among the most experienced surgeons

Because you cannot do a spinal surgery and a hip replacement at the same time the patient and their surgeons need to pick the one that helps the most. If you went to your hip surgeon, he/she may recommend the hip first, if you went to your spinal surgeon he/she may recommend spinal surgery first. So you have 2 different “first surgery,” recommendations. Sometimes, there is agreement, sometimes there is conflicting opinions.

A June 2019 published in the Bone and joint journal (4) suggests controversy in the decision making process of the patient with hip and spinal degenerative disease. Here is what the surgeons are struggling with.

• Patients who are being recommended to both hip replacement and lumbar spinal surgery have to make a choice which surgery to do first. Recommendations from their surgeons as to which surgery should be performed first remain uncertain and can confuse the patient.

A survey of hip and spinal surgeons asked the question: “When do you do the hip replacement first?” In all 88, surgeons, 51 hip surgeons and 37 spinal surgeons were asked.Here is how the survey went

First case: Patient has painful hip osteoarthritis and lumbar spinal stenosis with neurological claudication. (Pain radiating into the legs caused by a “pinched, inflamed nerve.”

• Hip surgeons: 59% say do the hip first
• Spinal surgeons 49% say do the hip first

Second case: Patient has painful hip osteoarthritis and lumbar degenerative spondylolisthesis (slipped disc) with leg pain

• Hip surgeons: 73% say do the hip first
• Spinal surgeons 70% say do the hip first

Third case: Patient has painful hip osteoarthritis and lumbar disc herniation with leg weakness

• Hip surgeons: 47% say do the hip first
• Spinal surgeons 19% say do the hip first

Fourth case: Patient has painful hip osteoarthritis and lumbar scoliosis with back pain

• Hip surgeons: 47% say do the hip first
• Spinal surgeons 78% say do the hip first

Fifth case: Patient has painful hip osteoarthritis and thoracolumbar disc herniation with myelopathy (spinal cord pressure).

• Hip surgeons: 0% say do the hip first
• Spinal surgeons: 0% say do the hip first

In only one scenario, spinal cord compression, is there 100% agreement.

Back surgery? Hip Surgery? Do you need either? Both? Neither?

In my article When surgeons question spinal surgery I discuss the documented problems of spinal MRIs sending people to a surgery they do not need. Here are some of the highlights of that article:

• A study that appeared in the medical journal Radiologia (Radiology) where researchers had concerns about the enthusiasm some surgeons had for surgery that was likely inappropriate.

This is from the study:

• Most imaging findings (Scans and MRIs), find degenerative changes that reflect anatomic peculiarities or the normal aging process and turn out to be clinically irrelevant.
• Imaging tests have proven useful only when systemic disease is suspected or when surgery is indicated for persistent spinal cord or nerve root compression.
• Many treatments (surgeries) have proven inefficacious, and some have proven counterproductive, but they continue to be prescribed because patients want them and there are financial incentives for doing them.”(5)

The keywords of the research are “ineffective,” and “counterproductive,” for the patient.

Below is research that appeared in the Annals of the New York Academy of Sciences (6)

Summary findings:

• Numerous imaging studies (MRIs and Scans) have attempted to determine a definitive association between Intervertebral disc degeneration (Degenerative disc disease) and low back pain.- However, disc degeneration is not a sufficient diagnosis for pain development, as evidenced by large numbers of asymptomatic patients with abnormal findings on MRI or CT.
• Using MRI, Intervertebral disc herniations are seen in 22–67% of asymptomatic adults and spinal stenosis in 21% of asymptomatic adults over 60, and CT evidence of spinal facet joint osteoarthritis was shown to have no correlation with low back pain. Abnormal findings on MRI scans were not predictive of the development or duration of low back pain.

This is what I tell patients every day: Do not assume your pain is coming from what the MRI shows you. Your pain may not be captured on this film.

In a study published in the Journal of Neurosurgery, Spine that examined patients with back pain, investigators found that patients in fact did expect to get an MRI when they have back pain and that the MRI will reveal exactly what the cause of their pain is. Not only that but:

• more than 50% of the patients would have a spinal surgery if their doctor told them they had an abnormal spinal MRI, even if they had no pain or restricted movement.
• “Patients overemphasize the value of radiological studies and have mixed perceptions of the relative risk and effectiveness of surgical intervention compared with more conservative management.”(7)

In our practice we often see patients who have severe back pain and carry with them an MRI, X-ray and/or scan that are inconclusive. Doctors writing in the European Journal of Pain agree and say while controversial, research supporting MRI use do not permit definite conclusions.(8) This supports recent findings that say despite doctors frequently requesting MRIs for the lumbar spine, sometimes for weak or various reasons, that imaging performs poorly and it is not likely to identify the anatomical structures that are the source of pain.(9)

Perhaps this is why hip surgery is more routinely recommended first form any back pain patients

Having unnecessary surgery, it happens quite often, especially when the hip is involved.

In a study published in the medical journal Modern Rheumatology, (10) surgeons discussed the complexity of hip disease and how it impacts other joints and areas of the body.

Here the surgeons found that:

• Hip disease was the cause of knee pain in 29 % of patients.
• Hip disease was the cause of low back pain in 17 % of patients.

Their warning to their fellow surgeons?

• “be aware of hip disease masquerading as knee pain or low back pain” That is how wrong surgeries may be performed.

Here is study from surgeons in the United Kingdom. Published in the medical journal International Orthopaedics, (11) the surgical team of this study wanted to answer the question as to why up to 20% of total knee replacement patients complain of persisting pain after the knee replacement. Here was there answer:

The investigators examined 45 consecutive patients with pain after total knee replacement. Of the 45 patients, one-third, 15 patients had degenerative hip and lumbar spine disease. Nine patients had unexplained pain.

The study concluded: “Patients may still be undergoing knee arthroplasty for degenerative lumbar spine and hip osteoarthritis. We suggest heightened awareness at pre- and post-operative assessment and thorough history and examination with the use of diagnostic injections to identify the cause of pain if there is doubt.”

Our treatment options – treating the hip and spine and treating them at the same time

We offer stem cell therapy and Platelet Rich Plasma Therapy

Darrow Stem Cell Institute research article published in the Biomedical Journal of Scientific & Technical Research (BJSTR), July 2018. This article presents highlighted portions of that research.

You can read about 4 patient’s cases studies here:

Study’s findings: This is the first reported study treating low back with bone marrow aspirate (BMC) stem cell injections to the ligaments, fascia, and muscles surrounding the lumbar spine. It is promising that at one-year follow-up, 100% of patients in this study experienced a decrease in resting and active pain in addition to performing daily activities with less difficulty.

• All four patients experienced sustained or increased improvement at annual follow-up compared to short-term follow-up.
• On average, patients reported:
  • 80% decrease in resting pain,
  • 78% decrease in active pain,
  • and a 41% increase in functionality score.
• Additionally, patients reported a mean 80% total overall improvement following
  treatment.
• The two patients who considered surgery prior to BMC treatment no longer felt the need for it.
• These results provide evidence that appropriately chosen patients (not all patients) with low back pain may find relief with BMC injections.

Can Stem Cell Therapy be effective in treating hip osteoarthritis and in helping you avoid a hip replacement surgery?

The research in support of stem cell therapy for hip osteoarthritis and “bone on bone.”

• In recent research doctors at Toronto Western Hospital suggested that stem cells injected into the joint can initiate the healing environment in a degenerated hip including the regrowth of bone in cases of osteocronosis (bone death).(12)
• Doctors at the Mayo Clinic write that in pre-clinical studies the use of stem cells uniformly demonstrates improvements in osteogenesis (bone growth) and angiogenesis (blood vessel formation). In clinical studies, groups treated with stem cells show significant improvements in patient reported outcomes.) (13)
• Researchers in France led by Philippe Hernigou of the Department of Orthopaedic Surgery, University Paris East shows that despite advanced hip disease, bone marrow derived stem cell therapy can repair bone damage in hip osteonecrosis for the long-term. In one study, the researchers treated 189 hips in 116 patients with bone marrow concentrate and had a follow-up of 5 to 10 years. Satisfactory results were achieved in the majority of patients according to improvement of the (pain) hip score, radiographic assessment and the avoidance of hip replacement.(14)
• Doctors in Argentina and Seton Hall University in New Jersey combined to suggest that in their research in patients receiving bone marrow aspirate intra-articular injections for the treatment of early knee or hip osteoarthritis were found to be safe and demonstrated satisfactory results in 63.2% of patients. It should be pointed out that this was a single injection treatment. (15)

Here are four patient cases we published in Clinical medicine insights. Case reports.

In research from our Stem Cell Institute, we suggested that the use of mesenchymal (connective tissue) stem cells from bone marrow concentrate improved quality of life for patients with hip osteoarthritis. Based on these results we were able to demonstrate that receiving multiple bone marrow concentrate stem cell injections within a short time period may provide an effective hip cartilage repair.

You can read the research and the patient case studies we presented here: Can Stem Cell Therapy help you avoid a hip replacement surgery?

The treatment in this study is explained in the video above.

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Marc Darrow MD JD

With over 25 years experience in regenerative medicine techniques and the treatment of thousands of patients, Dr. Darrow is considered a leading pioneer in the non-surgical treatment of degenerative Musculoskeletal Disorders and sports related injuries. He is one of the busiest Regenerative Medicine doctors in the world. Dr. Darrow has co-authored and continues to co-author leading edge medical research including research on bone marrow derived stem cells. He also comments and writes on research surrounding the treatment of chronic tendon injury, ankle and foot pain, elbow, hand and finger pain.

References:

1 Prather H, Cheng A, May KS, Maheshwari V, VanDillen L. Association of Hip Radiograph Findings with Pain and Function in Patients Presenting with Low Back Pain. PM&R. 2017 Jun 16.
2. Prather H, Cheng A, May KS, Maheshwari V, VanDillen L. Hip and Lumbar Spine Physical Examination Findings in People Presenting With Low Back Pain With or Without Lower Extremity Pain. J Orthop Sports Phys Ther. 2017 Feb 3:1-36. doi: 10.2519/jospt.2017.6567.

3 Devin CJ, McCullough KA, Morris BJ, Yates AJ, Kang JD. Hip-spine syndrome. JAAOS-Journal of the American Academy of Orthopaedic Surgeons. 2012 Jul 1;20(7):434-42.
4. Liu N, Goodman SB, Lachiewicz PF, Wood KB. Hip or spine surgery first?: a survey of treatment order for patients with concurrent degenerative hip and spinal disorders. Bone Joint J. 2019 Jun;101-B(6_Supple_B):37-44. doi: 10.1302/0301-620X.101B6.BJJ-2018-1073.R1. PubMed PMID: 31146559; PubMed Central PMCID: PMC6568023.
5. Kovacs FM, Arana E. Degenerative disease of the lumbar spine. Radiologia. 2016 Apr;58 Suppl 1:26-34. doi: 10.1016/j.rx.2015.12.004. Epub 2016 Feb 10
6 Mosley GE, Evashwick‐Rogler TW, Lai A, Iatridis JC. Looking beyond the intervertebral disc: the need for behavioral assays in models of discogenic pain. Annals of the New York Academy of Sciences. 2017 Aug 10.
7 Franz EW, Bentley JN, Yee PP, Chang KW, Kendall-Thomas J, Park P, Yang LJ. Patient misconceptions concerning lumbar spondylosis diagnosis and treatment. J Neurosurg Spine. 2015 May;22(5):496-502. doi: 10.3171/2014.10.SPINE14537. Epub 2015 Feb 27.
8, Steffens D, Hancock MJ, Maher CG, Williams C, Jensen TS, Latimer J. Does magnetic resonance imaging predict future low back pain? A systematic review. Eur J Pain. 2013 Nov 26. doi: 10.1002/j.1532-2149.2013.00427.x. [Epub ahead of print]
9. Balagué F, Dudler J. [Imaging in low back pain: limits and reflexions]. Rev Med Suisse. 2013 Jun 26;9(392):1351-2, 1354-6, 1358-9
10. Nakamura J, Oinuma K, Ohtori S, et al. Distribution of hip pain in osteoarthritis patients secondary to developmental dysplasia of the hip. Mod Rheumatol. 2012 Apr 11
11. Al-Hadithy N, Rozati H, Sewell MD, Dodds AL, Brooks P, Chatoo M. Causes of a painful total knee arthroplasty. Are patients still receiving total knee arthroplasty for extrinsic pathologies? Int Orthop. 2012 Jan 11.
12 Lau RL, Perruccio AV, Evans HM, Mahomed SR, Mahomed NN, Gandhi R. Stem cell therapy for the treatment of early stage avascular necrosis of the femoral head: a systematic review. BMC Musculoskelet Disord. 2014 May 16;15:156. doi: 10.1186/1471-2474-15-156.
13 Houdek MT, Wyles CC, Martin JR, Sierra RJ. Stem cell treatment for avascular necrosis of the femoral head: current perspectives. Stem Cells Cloning. 2014 Apr 9;7:65-70. eCollection 2014.
14 Hernigou P, Beaujean F. Treatment of osteonecrosis with autologous bone marrow grafting. Clinical Orthopaedics and Related Research®. 2002 Dec 1;405:14-23.
15 Rodriguez-Fontan F, Piuzzi NS, Kraeutler MJ, Pascual-Garrido C. Early Clinical Outcomes of Intraarticular Injections of Bone Marrow Aspirate Concentrate for the Treatment of Early Osteoarthritis of the Hip and Knee: A Cohort Study. PM&R. 2018 May 29. 2935