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What Causes Hip Pain After Spinal Fusion

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What Is Lumbar Fusion

Spinal Fusion Hip Surgery

Lumbar fusion means that you take a part of the spine thats painful and bolt it together and add bone so it grows together and doesnt move . Commonly hardware is added to enhance the stability while the disc spaces and other areas grow bone. These days were also seeing doctors using recombinant growth factors like BMP to help bones fuse. For a common low back fusion x-ray, see the image here.

What Are We Seeing In This Image The Complexity Of The Hip Pelvic And Low Back Instability

To some surgeons, the back is the back and the hip is the hip. If the MRI shows disc degeneration, then there is justification for spinal surgery. If the MRI shows hip degeneration, then there is justification for hip replacement. This x-ray below belongs to Ross Hauser, MD. It is not one of his patients, it is actually HIS x-ray. Dr, Hausers years of ironman competitions and other hardcore competitions certainly took a toll. Look at what is going on here and the extent of pelvic, hip, and spine problems.

Dr. Hauser had this x-ray when he had acute pain in his left lower back and sciatic-like symptoms.

X-ray reveals:

  • A decrease in distance from the ischial tuberosity to the top of the iliac crest. The Ischial tuberosity, the bony prominences at the base of the pelvis, or commonly, the sit bones or the seat bones, are just that. The bones you sit on. This is a suspected pain origin when a patient complains of pain in the butt. That Dr. Hausers ischial tuberosity has moved closer to the top of his iliac crest signifies that he has pelvic tilt.
  • The lower back pain and sciatic-like symptoms were in part coming from pelvic distortions.

Injections May Help Identify The Pain Source In Hip

In a March 2020 study published in the surgical journal Orthopedics , doctors looked at the overlapping symptoms between hip and lumbar spine pathologies and the complication of diagnoses and treatments this problem causes. They suggest that diagnostic injections may help and write: in hip-spine syndrome when a pain source cannot be elucidated, an ultrasound- or fluoroscopic-guided intra-articular hip injection may be a powerful and reliable diagnostic tool.

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S Of The Hip Are They Worth It

Ross Hauser, MD discusses some very common MRI findings in asymptomatic patients and why MRI can lead to surgery even when that may not be the true pain-producing structure.

What are the types of imaging a person can be ordered when they have chronic pain? Are these tests accurate in helping him or her in treatment? Are these tests accurate?

A look at the imaging studies

Usually, a person with chronic hip pain will come into our office and they will have one, two, three, or all four of the following performed over a period of time.

How Does A Woman Go In For Spinal Fusion Surgery And Come Home With Pelvic Pain

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One answer is that the pelvic pain was there all along, it was mistaken for low back pain because an MRI gave evidence of degenerative disc disease and Sacroiliac joint dysfunction. The fact that the patients came home with pain is an indication that the surgery did not treat what was causing the pain.

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Patients Who Had Pain 7 11 Years After Spinal Fusion Had A 27% Reduction In Muscle Density

Doctors at Oslo University Hospital examined patients who had continued pain 7 to 11 years after spinal fusion. The purpose was to test their observations that reduced muscle strength and density observed at one year after lumbar fusion may deteriorate more in the long term. The results: 27% reduction in muscle density.

In earlier research from Norwegian researchers, patients with chronic low back pain who followed cognitive intervention and exercise programs improved signicantly in muscle strength compared with patients who underwent lumbar fusion. In the lumbar fusion group, muscle density decreased signicantly at L3L4 compared with the exercise group.

Types Of Sacroiliac Pain After Spinal Fusion

We have observed a full diversity of sacroiliac joint problems commencing postoperatively after spinal fusion, including all of the following diagnoses:

We have seen accelerated degeneration in the sacroiliac joint, in similar ways to the accelerated degeneration found surrounding the fusion in lumbar spondylodesis patients.

We have seen functional problems in the sacroiliac joint caused by ligamentous hypermobility and hypomobility problems which were not present prior to spinal fusion.

Unilateral sacroiliac pain is more common, but about 35% of symptomatic patients eventually develop pain in both SI joints following fusion. Hip joint degeneration is also commonly present and symptomatic, often requiring hip replacement surgery within several years time.

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There Is No Consensus On Which Pathological Condition Should Be Addressed First

An October 2021 paper from the Department of Orthopedics, the University of Colorado published in The Journal ofBone and Joint Surgery. American Volume, offered these learning points to doctors:

  • The proper diagnosis and treatment of patients with concurrent hip and spine pathological processes can be challenging because of the substantial overlap in symptomatology.
  • There is no consensus on which pathological condition should be addressed first.
  • A prior spinal fusion can increase the risk of hip replacement dislocation.
  • A proper understanding of sagittal balance and restoration of this balance is integral to improving patient outcomes following spinal surgery.

First, Danielle R. Steilen-Matias, MMS, PA-C explains the common problems we see in our patients.

Learning points summary:

In this next section, we will explore research leading up to clinical observations in helping patients with hip and low back pain problems.

So How Could My Hip Mri Be So Wrong Here Is A March 2019 Study

Why Does My Back Hurt After Lumbar Fusion?

In March 2019, in the surgeons journal Clinics in Orthopedic Surgery, surgeons and radiologists at the Chung-Ang University College of Medicine in Seoul, Korea shared these findings with the international medical community.

We are going to go back to talking about sensitivity and specificity .

In this research, the doctors and radiologists investigated the sensitivity, specificity, and accuracy of magnetic resonance imaging and computed tomography arthrography , on the basis of arthroscopic findings, to diagnose acetabular labral tears and chondral lesions.

  • They reviewed the results of MRI and subsequent CTA in 36 hips that underwent arthroscopic surgery
  • All patients had positive impingement test results and groin pain.

The sensitivity, specificity, and accuracy of computed tomography arthrography for detection of acetabular labral tears by two observers were 60%, 80%, and 64%, respectively, and 65%, 70%, and 69%, respectively.

  • In other words, 64% of the time or 69% of the time, the computed tomography arthrography and its interpretation correctly identified acetabular labral tears. How was this verified? By observation during arthroscopic surgery.
  • So it is possible that 31-36% of people had arthroscopic surgery to DISPROVE what the computed tomography arthrography suggested.

If you think that is bad. Here is the comparison to MRIs

What could the researchers conclude other than:

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The Study On Hip Replacement After Lumbar Fusion

The new study investigated the hypothesis that a dislocation of a hip replacement is more common when a patient has had a fusion of the lumbar spine. This was a very large-scale study using all of the patients in the Medicare database, covering an eight-year period, whod had lumbar fusions prior to a hip replacement. These subjects were compared to a control group of subjects whod had hip replacements but no spinal fusions. The results showed that subjects who had lumbar fusions prior to having a properly placed hip replacement had higher dislocation rates than hip-replacement subjects who did not have lumbar fusions. In addition, the more levels fused, the higher the dislocation rate, so patients with 37 fused levels fared worse than those with 12 fused levels.

The upshot? Who knew that the back impacted the hip? Oh wait, if youve been reading this blog, you knew. The funny thing is that by understanding that its all connected, you know more than most physicians who still look at the body as segmented parts. So go teach your doctor that your body is a whole machine, not just a hip, back, knee, or ankle!

Chris Centeno, MD

If you have questions or comments about this blog post, please email us at

Ischiofemoral Impingement Causing Lumbar Pathology

In a January 2017 paper entitled: The Hip-Spine Effect: A Biomechanical Study of Ischiofemoral Impingement Effect on Lumbar Facet Joints, Doctors at Baylor University and the University of Texas found a relation between ischiofemoral impingement and lumbar facet joint load during hip extension.

They suggested that limited terminal hip extension due to simulated ischiofemoral impingement significantly increases L3-4 and L4-5 lumbar facet joint load when compared with non-ischiofemoral impingement hips.

This study directly links ischiofemoral impingement to increased lumbar facet loads and supports the clinical findings of ischiofemoral impingement causes lumbar pathology. Assessing and treating hip disorders that limit extension could have benefits in patients with concomitant lower back symptoms.

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Why Do I Have Pain After Surgery

Surgery is seen as a threat to the body, no matter what kind of surgery. Undergoing surgery takes a significant toll on your overall health, and your muscle-joint interactions as well.

Threats like surgery or injury often cause your muscles to tighten, as an instinctive protective mechanism. During your recovery, your body is likely more stationary than usual as you heal. Your normal walking movements will be altered or assisted, and your muscles wont engage as readily or in the same fashion as usual, especially if you are experiencing pain. Add-in sleep challenges and increased pain, and its natural for your body to want to tighten the iliopsoas muscle and protect the pelvis.

You may have heard of the iliopsoas muscles under a different name: yourhip flexors. The iliopsoas muscle is made up of two muscles, the iliacus and the psoas, which work together to perform important movements like walking, sitting, and standing.

The iliacus crosses over your hip joint and attaches to the pelvis, whereas the psoas crosses both the hip joint and pelvis to the spine. If these muscles tighten, they can pull the region off balance by creating a tilt or twist, which can affect your whole lower body and cause lower back and hip pain.

But if you had a knee or foot surgerywhy are you experiencing lower back and hip pain instead of knee or foot pain? Lets take a look at how it all connects.

Strength Training For Lower Back And Hip Pain

Hip Pain After Spinal Fusion  The Hip Flexor

A big part of targeted physical therapy is balancing and strengthening your muscles to recover from or prevent future injury. Something you must remember when you exercise in any capacity is that you need equal strength in all of your muscles.

For instance, if you only exercise your front abdominal muscles and neglect your back core muscles, you are far more likely to injure your back or start to develop back pain from a consistent pull from the front of your abdomen.

The same is true for your legs and hips. Finding ways to work all of your muscles to build strength equally can help your body maintain alignment and balance and prevent lower back and hip pain.

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Whats The Difference Between These Imaging Techniques

Perhaps the question is not what is the difference in the techniques, but rather what is the difference in how helpful these images can be.

The x-ray shows:

For the most part, the initial imaging examination will be an X-ray. An X-ray will be most effective in showing degenerative bony abnormalities and loss of joint space, signifying cartilage loss. In degenerative hip disease, it is usually the X-ray that convinces someone with hip pain that they have advancing hip osteoarthritis, bone death or avascular necrosis, bone spurs, and loss of cartilage.

The CT scan shows:

CT or CAT scans are looking for soft tissue damage that the x-rays do not see. This would be muscle, ligaments, and tendons. Because of the complexity of the hip, this imaging test is usually not favored for hip pain patients as images are poorly defined.

The MRI shows:

For some people, the end-all of all end-alls is the MRI image. It is extraordinarily difficult for people to believe that their MRI is not telling the correct story of their hip pain. The research questioning MRI accuracy will be shown below.

An MRI is looking for things the X-ray and the CT scan cannot show. This would be soft tissue damage, fluid buildup, or hidden swelling. The MRI may also reveal bone deformities that the X-ray did not show.

Ultrasound

Why Is There Typically Hip Pain After Back Surgery

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Scar Tissue And Pain After Back Surgery

The formation of scar tissue near the nerve root is a common occurrence after back surgeryso common, in fact, it is so common that it often occurs for patients with successful surgical outcomes as well as for patients with continued or recurrent leg pain and back pain. For this reason, the importance of scar tissue as a potential cause of postoperative paincommonly called failed back surgery syndromeis controversial.

Scar tissue formation is part of the normal healing process after a spine surgery. While scar tissue can be a cause of back pain or leg pain, in and of itself the scar tissue is rarely painful since the tissue contains no nerve endings. Scar tissue is generally thought to be the potential cause of the patient’s pain if it binds the lumbar nerve root with fibrous adhesions.

The Confusion About Hip

High Rate of SI Joint Dysfunction after Lumbar Fusion

Doctors at the University Hospitals Cleveland Medical Center wrote in the September 2017 edition of Orthopaedics and Traumatology, Surgery and Research:

  • Researchers have recently proposed the concept of hip-spine syndrome, however, there exists limited evidence available to differentiate whether these accompanying or associated hip and spine pain and inflammation are due to anatomic/structural causes, or systemic/metabolic effects.
  • In other words, the confusion of the hip spine is significant and can lead to poor surgical choices. Not only is hip-spine syndrome a diagnosis for suggesting that the patients pain needs to be thought of as possibly coming from the hip, from the spine, and from both, but in addition, a problem of factors that may include systemic/metabolic factors, such asinflammation from obesity or autoimmune problems and disease. PLEASE NOTE: Again we are being issued warnings of the possibility of continued pain after a complicated surgery was possibly performed on the wrong area.

Here are more factors the doctors discussed:

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Severe Leg Pain After Spinal Fusion

In summary, these are all these things that can go wrong in a fusion operation. These are also all the reasons why people can end up with not only back pain but also leg pain following the operation.

The problem with a fusion operation is that theres no going back from it.

Once youve fused a joint and done a diskectomy thats it.

If the surgery fails, all you can do is try to do the fusion again. This means the surgeon goes in and scrapes more bone from somewhere in the body to fill the spacer cage.

Its a very difficult thing to fix, especially when you get a pseudoarthrosis. The chances of a second bone graft taking are not that good once the area is already inflamed.

If the surgery does fail, people often end up with worse pain than before. These are some of the people Ive seen in my chronic pain clinic. The tragedy is that while some of them did need a fusion, many of them may not have needed the operation at all.

Once its done, though, theyre stuck with it. This is why I see a spinal fusion as a last resort, and only to be undertaken when all other paths have been tried.

The Incidence Of New Onset Sacroiliac Joint Pain Following Lumbar Fusion

Yu Chao Lee, Robert Lee, Clare Harman

Spinal Surgery Unit, Royal National Orthopaedic Hospital, Stanmore, UK

Contributions: Conception and design: YC Lee, R Lee Administrative support: All authors Provision of study materials or patients: R Lee, C Harman Collection and assembly of data: All authors Data analysis and interpretation: YC Lee, R Lee Manuscript writing: All authors Final approval of manuscript: All authors.

Correspondence to:

Background: The sacroiliac joint can be a new source of pain following lumbar fusion. The aim of this study was to identify the incidence of and predisposing factors for new onset SIJ pain following successful lumbar fusion.

Methods: We review our series of 317 patients who underwent spinal fusion in the past 5 years to identify patients who developed new onset SIJ pain. All patients had a minimum 12 months follow up. Diagnostic criteria for SIJ pain were: New onset pain localised to lower lumbar region and buttocks, 2 positive provocative tests of SIJ and pain relief of > 70% achieved from SIJ block.

New onset SIJ pain can arise following spinal fusion. We have not found a higher frequency of SIJ pain in patients with fusion extending to sacrum or longer spinal construct.

Keywords: Sacroiliac joint pain spinal fusion lumbar fusion

Submitted May 14, 2019. Accepted for publication Jul 24, 2019.

doi: 10.21037/jss.2019.09.05

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