High Prevalence of Lumbosacral Pathology in Patients with Greater Trochanteric Pain Syndrome

Spine-Abductor Syndrome: Novel Associations Between Lumbar Spine Disease and Hip Gluteal Muscle Pathology

BACKGROUND

Risk factors for gluteal tears include age-related deterioration, female sex, and increased body mass index. As the literature that supports the sagittal relationship between the lumbar spine and the hip is increasing, there may be a parallel relationship between the perturbations in spinopelvic alignment caused by lumbar spine disease and gluteal muscle tears. Because no prior studies other than single-institution series have reported on this phenomenon, we investigated spine-abductor syndrome at the population level.

METHODS

This study utilized TriNetX, a federated research network that continuously aggregates deidentified electronic health record data from >92 million patients across the United States. The relative risks of gluteal tear encounter diagnoses and procedures were calculated for patients with and without the following characteristics: age ≥45 years, female sex, obesity, lumbar spine diagnoses, lumbar spine injections, and lumbar spine surgery. Utilizing the Cox proportional hazard model, we also analyzed gluteal tear-free survival over a period of ≥10 years in subgroups of patients who had been diagnosed with lumbar pathology, had been administered a lumbar injection, or had received lumbar surgery.

RESULTS

Of the 8,475,800 patients who had received lumbar spine diagnoses, undergone lumbar injections, and/or undergone lumbar surgeries, 458,311 patients (5.4%) had gluteal tears, representing a relative risk of 13.6 (95% confidence interval [CI]:13.6 to 13.6). After controlling for age, sex, and obesity, survival analysis showed markedly increased hazard ratios (HRs) for patients having a gluteal tear encounter diagnosis in the intervening 13 years (2010 to 2023) if they had had a previous lumbar spine pathology encounter diagnosis (HR: 4.8, 95% CI: 4.5 to 5.1), had undergone lumbar spine injections (HR: 7.7, 95% CI: 6.2 to 9.5), or had undergone lumbar spine surgery (HR: 6.6, 95% CI: 5.3 to 8.1) in 2010.

CONCLUSIONS

These findings suggest a strong association between lumbar spine pathology and abductor tears. Further biomechanical and neuroanatomic studies may elucidate the effects of lumbar spine disease in relation to gluteal tears. Additionally, there may be a need to optimize diagnostic protocols for lateral hip pain in patients with a history of lumbar spine disease.

LEVEL OF EVIDENCE

Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

High Rate of Concomitant Lumbo-Sacral Spine Pathology in the Setting of Hip Abductor Tendon Repair

BACKGROUND

Hip abductor deficiency is a common cause of lateral hip pain in middle-aged patients. Identifying upstream muscle denervation originating in the lumbo-sacral spine could potentially impact the management of patients who have abductor deficiency. The purpose of this study was to estimate the prevalence of lumbo-sacral pathology (L4 to S1) in patients undergoing hip abductor tendon repair.

METHODS

All cases of primary hip abductor repair performed at a tertiary care center between January 2010 and December 2021 were reviewed. Patients were classified into the following groups: A) confirmed L4 to S1 disease based on preoperative or perioperative L4 to S1 interventions (ie, surgery, epidural injections, and/or positive electromyography findings); B) radiographic evidence on lumbar spine magnetic resonance imaging demonstrating nerve compression at L4 to S1; and C) no evidence of L4 to S1 disease.

RESULTS

There were 131 cases of primary hip abductor repair that were included. Over 80% of patients were women, who had a mean age of 64 years (range, 20 to 85). There were thirteen patients (9.9%) who underwent concomitant total hip arthroplasty (THA). Of the included patients, 29% (n = 38) were categorized into group A, 12% (n = 16) into group B, and 59% (n = 77) into group C. Patients who had L4 to S1 pathology were older than patients who did not have L4 to S1 pathology (67 versus 61 years, P = .004). Of the patients undergoing concomitant THA and hip abductor repair, 54% demonstrated evidence of lumbo-sacral spine pathology.

CONCLUSIONS

Over 40% of patients undergoing isolated hip abductor tendon repair and >50% of patients undergoing concomitant hip abductor tendon repair and THA demonstrated evidence of L4 to S1 disease perioperatively. Patients demonstrating symptomatic hip abductor deficiency should be screened for concomitant lower lumbo-sacral spine pathology.

Hip-Spine Syndrome in the Nonarthritic Patient

Hip-spine syndrome refers to concurrent hip and spine pathology with overlapping symptoms. Most of the literature has studied it in relation to total hip arthroplasty literature and has been shown to increase dislocation risk. Lumbar spine and pelvic mobility have been studied less frequently in relation to nonarthritic pathologic hip states. Understanding the biomechanical relationship between the lumbar spine, pelvis, and hip can help elucidate how hip-spine syndrome affects the nonarthritic hip and how it impacts outcomes of hip arthroscopy. Changes in lumbar spine motion may be the reason certain predisposed patients develop symptomatic femoroacetabular impingement (FAI) or ischiofemoral impingement. Some athletes may be "hip users" with a low pelvic incidence, making them more reliant on hip motion due to less-intrinsic lumbopelvic motion. When these patients have FAI morphology, their increased reliance on hip motion makes them prone to experiencing femoroacetabular contact and concurrent symptoms. Other athletes may be "spine users," with larger pelvic incidence and more baseline lumbopelvic motion, making them less reliant on hip motion and therefore less prone to experiencing hip impingement even with hip FAI morphology. Hip-spine syndrome also appears to have an impact on patient selection, role of nonoperative treatment, and hip arthroscopy surgical outcomes. Identifying patients with concurrent pathology may allow surgeons to recommend targeted physical therapy or counsel patients better on their expectations after surgery.