Differential diagnosis of spinal pathology Hip pathology
Unambiguous differential diagnosis between spinal and joint pathology is impossible as long as two opposing explanatory models are used.
Yin et al. (2021): Using data from the Taiwanese National Health Insurance Research Database (NHIRD), the extent to which differential diagnosis between hip and lumbar spine pathology was performed by hip and spine surgeons was investigated.
A total of 1824 patients underwent hip and lumbar spine surgery: 103 (5.6%) underwent hip and back surgery virtually simultaneously, 431 (23.5%) underwent hip surgery first and back surgery within one year, and as a striking result, 1290 (71%) patients received a new hip within one year of lumbar spine surgery.
Apparently, the diagnosis of hip pathology as the main cause of pain and dysfunction is missed more often by neurosurgeons than by orthopaedic surgeons in many cases (71 %), even in advanced osteoarthritis. Obviously, the focus is too one-sided on the spine, so that hip pathology is not recognised or recognised much too late.
The question now arises as to how many patients who only present with clinical symptoms of hip pathology are not diagnosed as such.
Liu et al. (2019): Stanford University researchers surveyed 110 surgeons, all members of the Hip Society or the Scoliosis Research Society, about their preferred surgical sequence and their rationale for five fictitious patients with clinical symptoms of both hip and lumbar spine OA, divided into five scenarios:
1) Lumbar canal stenosis with neurological claudication: 59% of hip surgeons (HC) and 49% of spine surgeons (WC) choose hip surgery first,
2) Degenerative spondylolisthesis of the lumbar spine with leg pain: 73 % HC and 70 % WC choose hip surgery first.
3) Lumbar disc herniation with leg weakness: 47 % HC and 19 % WC choose hip surgery first.
4) Lumbar scoliosis with back pain: 47% HC and 78% WC choose hip surgery first.
5) Thoracolumbar disc herniation with myelopathy: 10% HC and 0% WC choose hip surgery first.
For scenarios 3 and 4, the question "hip or spine surgery first" remains controversial even for experienced surgeons. The type of neurological symptoms (nociceptive/neuropathic) may influence surgeons' decision-making, the researchers say.