In recent years the spine and orthopaedic community has begun to understand the interrelatedness of spinal and hip disease. The importance of understanding this relationship has been underscored by the fact that many patients experience both, and unfortunately may experience debilitating hip pathology as well as lumbar spine disease requiring decompression of neural structures and potentially fusion for instability. One important remaining question for the patient experiencing both hip and spine pathology and considering surgery for both is – should the hip or spine be addressed first?
In a new study, Yang et al. analyzed greater than 85,000 patient records spanning 10 years and compared four groups of hip-spine patients:
- Patients undergoing total hip replacement (THR) without spine pathology.
- Patients with previous spinal fusions >2 years old that then underwent THR.
- Patients with both hip and spine pathology that underwent THR then lumbar spine fusion (LSF) or
- Patients with both hip and spine pathology that underwent LSF then THR.
Previous reports have proposed that LSF should occur before THR in the setting of dual pathology as this then allows your total joint surgeon to place the “cup” part of the THR in a more favorable position to avoid dislocation. This new research supports this proposition by demonstrating that those who underwent THA before LSF had the highest rates of dislocation or requiring another surgery. These same patients however also had higher rates of other complications including infections as well as higher opioid used post-operatively, suggesting that the question of which order to undergo hip and spine surgery may be related to more than just the position of the THR cup.
When it comes to the ordering of surgery in patients with dual hip and spine disease, usually one pathology demands attention first due to seriousness of the disease or the area of worst symptoms. If this is the case then focus on that! Nonetheless, for those patients who truly have both to roughly the same degree, proceeding with spine surgery first seems reasonable based on these new findings. Further studies will be needed to more closely understand these intricate relationships and underlying mechanisms.