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A case of low back pain and bilateral hip osteonecrosis

A case of low back pain and bilateral hip osteonecrosis A case of low back pain and bilateral hip osteonecrosis
A case of low back pain and bilateral hip osteonecrosis A case of low back pain and bilateral hip osteonecrosis

A 34-year-old man of Hispanic origin visited a clinic complaining of low back pain radiating into left anterolateral thigh that he was experiencing for four months. The severity of pain was varying and often worsened on walking and with rigorous activity. The patient also reported a new complaint of mild left anterior hip stiffness. There was no history of trauma or any accident. Intervertebral disc protrusions at the L4/5 and L5/S1 levels were observed in the lumbar spine MRI did at an outside institution. 

 

The most likely diagnosis of this presentation is

  • Low back pain/ hip pain
  • Osteoporosis
  • Osteonecrosis of the Hip
  • Hip fracture


Low back pain (LBP) is the most common ailment affecting work performances, well-being and overall quality of life. The pain may range from acute, or subacute to chronic and may be described as an aching, well defined, burning, stabbing, sharp, vague or dull. Infection, ankylosing spondylitis, tumour, fracture, inflammatory process, osteoporosis, and radicular syndrome are likely to be the factors causing back pain. Depression, ageing, occupational posture and obesity are the established risk factors. The current treatment regimen for LBP involves pain-relieving medicines, rehabilitation therapies and surgical approach as a last resort. The exact underlying cause of LBP is often challenging to identify, thereby making the diagnosis and treatment challenging.

 Nontraumatic osteonecrosis of the femoral head (ONFH) is caused by the degradation of bone cells resulting in subsequent osteoarthritis. It mainly affects elderly patients aged 30 to 40 years. Contributing causes of ONFH may include corticosteroids, alcohol abuse, history of trauma, hemoglobinopathy, Gaucher disease, coagulopathies, and other severe ailments. Osteonecrosis (ON) of the hip is characterized by the insufficient nutrient blood supply to the femoral head causing structural failure of the cortical surface. LBP can also result from concurrent conditions.

Moreover, patients with ON report concomitant pain in the low back, buttock, groin, thigh, and knee. Studies have reported the examples of LBP remotely generated from the hip osteoarthritis in patients who underwent total hip arthroplasty and experienced reduction in hip and LBP symptoms. Hip ailments as an underlying cause of LBP may be attributed to the functional interdependence of related regions and thus called as a hip-spine syndrome.

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Key take away

The patient presented with low back pain was diagnosed with bilateral idiopathic osteonecrosis of the femoral head, suggesting consideration of differential diagnosis. The patient recovered after THA of the left hip. 

Examination & lab investigations

On careful physical examination, thoracolumbar spine showed decreased range of motion. At the end range of flexion, increased spinal pain was noted. Lumbar spine movement was decreased, and the musculature was sensitive to touch at all points. No motor or sensory deformities were observed. Spinal instability was revealed from the prone instability test and Kemp’s test. Positive modified Thomas test revealed hip flexor hypertonicity. Based on this, the patient was diagnosed with dysfunction of lumbar segments, myofascial pain syndrome and dislocation of lumbar intervertebral discs without myelopathy. Accordingly, treatment was initiated. But due to continuous distress on the left side of the limp, the patient had to undergo re-examination. While evaluating the left hip, a positive C sign, in which the patient “cups” the anterior hip with their thumb and forefinger as to make the letter C, and considerable pain in the anterior hip during FABERE (Patrick’s), hip impingement, McCarthy and modified Thomas tests was observed. Left hip standard X-rays were carried out to eliminate hip impingement; showed signs of osteonecrosis, i.e. ill-defined sclerosis and collapse of the articular surface with the fragmentation of the femoral head. Bilateral hip MRI examination confirmed the osteonecrosis of the left femoral head. 

Management

Chiropractic treatments, including palliative care, manipulative therapies, and exercises, were employed to relieve the pain. Exercise programs that included McKenzie repetitive extension exercises and computerized traction/decompression therapy were given to the patient two times a week for three weeks. The patient experienced relief in low back pain. The patient was evaluated for the need for surgical intervention and was finally treated with bilateral total hip arthroplasty (THA).

Discussion

In the present case, a detailed diagnosis was not suggestive of a primary source of LBP originating from low back structures. Radiological studies also did not indicate underlying pathology in the lumbar spine. Assessment of the hip was mildly suggestive of several chronic ailments, including femoroacetabular impingement and osteoarthritis. Differentiating low back from hip pathology can be challenging due to overlapping pain referral patterns. It is difficult to distinguish pain originating from low back to pain originating from the hip in older patients due to degenerative changes. A brief assessment of a history and physical evaluation of the low back and hip regions may help in accurate and timely diagnosis.

 

The hip MRI confirmed ONFH in the patient under consideration. At preliminary diagnosis, ONFH can be bilateral in up to 60% of cases. The risk of further development of ONFH is very less if MRI of contralateral hip shows normal findings at preliminary diagnosis. The patient may show unilateral symptoms even in the presence of bilateral ONFH. The symptoms include significant hip pain, mild anterior hip stiffness, gait disturbances and limited range of motion.  

MRI should be considered as the most sensitive tool for detecting ONFH as standard X-rays depicts ONFH pathological signs (patchy sclerosis, fragmentation of femoral head) at a very late stage of the disease. At the early stage, ONFH can be treated by core decompression with implantation of a tantalum rod that provides structural support by acting as a buttress for the subchondral bone and encouraging bone ingrowth around the rod. However, sometimes patients operated on with decompression may experience more severe pain and restricted walking and had to undergo THA. Bone marrow mesenchymal stem cells (BMMSCs) have the potential of self-proliferation and multi-potential differentiation, therefore, can be induced to undergo osteogenesis. Thus, effective alternate therapy can be introduced.

Learning

While using MRI, the contralateral side not showing prominent symptoms should not be considered.

ONFH even the absence of risk factors should be suspected in older adults with significant hip pain or discomfort, not responding well to the treatment.

Differential diagnosis for the hip pain followed by diagnostic imaging could help in early recognition and timely treatment of the disease.

References

    1. Béatrice Duthey. Background Paper 6.24 Low back pain. Update on 2004 Background Paper WHO. March 2013.
    2. Lee GW, Park KS, Kim DY, et al. Results of Total Hip Arthroplasty after Core Decompression with Tantalum Rod for Osteonecrosis of the Femoral Head. Clin Orthop Surg. 2016 Mar;8(1):38-44.
    3. Minkalis AL, Vining RD. What is the pain source? A case report of a patient with low back pain and bilateral hip osteonecrosis. J Can Chiropr Assoc. 2015 Sep;59(3):300-10.
    4. Moore MR, Wilmarth MA, Corkery MB. Differentiating Hip Versus Back Pathology with a Patient Status Post LumbarLaminectomy and Fusion: A Case Study. Orthopaedic Practice. 2014 July; Vol. 26:3-14.
    5. Hernigou P, Trousselier M, Roubineau F,et al. Stem Cell Therapy for the Treatment of Hip Osteonecrosis: A 30-Year Review of Progress. Clin Orthop Surg. 2016 Mar;8(1):1-8.

Source:

J Chiropr Med. 2014 Sep; 13(3): 196–202.

Article:

Bilateral Idiopathic Osteonecrosis of the Femoral Head: A Case Report With an Emphasis on Differential Diagnosis, Imaging, and Treatment

Authors:

Patrick J. Battaglia et al.

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