by Peter Gerszten, MD, MPH, FACS
Associate Professor of Neurological Surgery

Pittsburgh, June 2, 2008 -- A significant proportion of patients cared for by members of the Spine Services Division of the Department of Neurological Surgery include older adult patients over the age of 60 years. Approximately 42% of older adults report having had at least one episode of low back pain during the past year, and an estimated 20% of these individuals have chronic low back pain (CLBP). Medicare spent nearly $1 billion for the treatment of low back pain for hospital-based outpatient costs during 2002 alone, a 387% increase compared to 1992.

The first line treatment of CLBP and symptomatic lumbar spinal stenosis includes physical therapy and non-opioid analgesics. Spinal injection procedures are also commonly performed, despite the absence of supportive efficacy data. When first line treatments fail, more aggressive treatments are sought such as opioid analgesics and/or spinal surgery. Risks associated with opioids may be life threatening, including hip fractures, delirium and obstipation. Surgery is commonly directed by the results of advanced imaging of the lumbar spine (e.g., magnetic resonance imaging) when spinal stenosis is documented.

Although osteoarthritis is typically generalized in older adults, CLBP associated with degenerative disease of the spine is often treated by specialists focused on spinal pathology alone. Hip osteoarthritis (OA) associated with compromised hip function may lead to altered spinal biomechanics and subsequent low back pain. Preliminary data from researchers at UPMC indicate that the prevalence of comorbid hip OA (limited motion and pain with passive movement, but hip pain less severe than low back pain) in older adults with a chief complaint of CLBP is on the order of one in five patients. Comorbid hip OA also strongly predicts poor outcomes in response to treatments directed toward the lumbar spine alone and may be key contributor to CLBP in older adults.

Over 50% of patients with radiographic evidence of hip OA are asymptomatic; thus no treatment is required. For patients with hip OA and hip pain, treatment is guided by evidence. Randomized controlled clinical trial data have demonstrated the efficacy of manual manipulation of the hip for reducing pain and improving function in patients with hip OA. An estimated 24% of patients ultimately undergo total hip replacement that is associated with pain elimination and improved function in 90% of cases.

The contribution of hip OA to CLBP is supported by the following more recent data:

1. total hip replacement surgery for patients with severe hip pain and advanced OA on x-ray reduces low back pain and improves overall spine function,
2. hip OA in older adults with a chief complaint of CLBP is a strong predictor of poor outcomes associated with non-surgical treatment of the low back, and
3. in patients with low back pain, diminished hip range of motion predicts poor outcomes following spinal manipulation.

The “Hip-Spine Syndrome” refers to symptoms that exist in the setting of concurrent degenerative pathology in both the hip and the spine. If hip OA causes CLBP, failure to appropriately examine and treat the hips in older adults with CLBP is a significant oversight. This oversight could lead to both unnecessary open surgical intervention as well as poorer outcomes after surgery. Despite the relationship between the hip and the lumbar spine, integrated treatment strategies across specialties that simultaneously take into account the hip and low back have often been lacking in the past.

In an effort to better understand the impact that hip problems have on the patients that are being evaluated and treated for spinal problems, members of the Spine Services Division of the Department of Neurological Surgery have teamed up with experts in hip osteoarthritis from a variety of disciplines across UPMC, including Debra K. Weiner, MD, from Geriatric Medicine, Michael Craig Munin, MD, from Physical Medicine and Rehabilitation, and Chester V. Oddis, MD, from Rheumatology.

For more information regarding this study, please contact the study’s nurse coordinator, Carol Kennedy, RN, at (412) 647-9786.