Lumbar vs Hip Pathology
Lumbar versus Hip Pathology
“If what you are doing is working, keep doing it. If what you are doing is not working, stop doing it.” I remember this quote from one of my PA school professors and it has always stuck with me. In preparing this case study, these words of wisdom keep popping up in my mind. The patient involved in this case study spent 4 years looking for help from many providers in several fields. It’s important to remember that people will sometimes present in atypical ways for common problems. It’s also important to remember that it can be difficult to change a patient’s mind once they are convinced they know what the cause of their pain is. Also, hindsight is often 20/20.
The patient is a 42 year old male (5’ 10”, 286lbs) who originally presented to a Walk In Orthopedic Clinic four years ago at the age of 38. He complained of a 5 month history of low back pain and right sided buttock pain that radiated to his posterior mid-thigh. He reported a gradual, insidious onset. He had previous chiropractic treatment without relief. He had tried OTC Ibuprofen 800mg tid-qid with minimal benefit. Sitting helped relieve most of his symptoms. Pain was exacerbated with work (Laborer), walking, and carrying relatively light loads (10-20lbs). Pain at night was worsened with side lying, improved in supine. He denied lower extremity weakness but felt that he was having a harder time doing his job and was too tired to play with his young children. He denied fever or recent illness. Patient had no complaints of knee, hip, or groin pain. He did not have any numbness or paresthesia. As well, he had no history of steroid use or ETOH abuse.
Physical exam revealed a morbidly obese (BMI 41), otherwise healthy male in no acute distress. Vital signs were unremarkable. He had a slow, asymmetrical gait with mild antalgia, favoring his right leg. No obvious atrophy in the lower extremities was noted, though body habitus made this difficult. There was no asymmetry in the lower extremities, nor his back. Palpation was nontender in the knees, greater trochanters, and there was only mild discomfort in the right lower lumbar region and right buttock. Range of motion was reported as normal in the knees and hips. Trunk ROM was not documented. Strength was 5/5 in the LE’s though the examiner stated the patient had severe pain attempting a Straight Leg Raise on the right. FABER maneuver was positive bilaterally for unspecified pain. DTR’s were equal, symmetrical, and brisk. Sensation was WNL.
Lumbar x-rays were ordered and read preliminarily by the treating provider and were felt to be normal. X-ray over reading in this clinic was done by Radiology. No lumbar pathology was identified.
With only the preliminary X-ray read, the patient was started on a 10 day Prednisone Taper starting at 60mg. The patient was instructed to follow up in 14 days and if no improvement was noted, an MRI of the Lumbar spine would be ordered. The patient called back in 3 days to request the MRI. A lumbar MRI was scheduled the following day.
The Lumbar MRI showed L3-4 and L4-5 Left sided disc herniations contacting the L3 and L4 nerve roots without significant compression. A Lumbar Epidural Steroid Injection was ordered that provided only 2 or 3 days relief. A referral was made for Neurosurgery evaluation. His first Neurosurgeon felt that his symptoms, physical exam, and MRI were not consistent in a manner that would be helped by surgical intervention. Symptoms were on the right side though the disc herniations were on the left. Physical Therapy was offered and after only a few sessions, was discontinued by the patient. The patient requested a second opinion from a different Neurosurgeon in the area and was given the same recommendation of conservative care. The patient did not follow up with his initial provider after the first Neurosurgery consultation but had requested the second opinion over the phone with a message. Over the next 2 years, the patient subsequently found third and fourth opinions, independently, out of state. He received another LESI and was offered L3-4, L4-5 Discectomies on the left. He continued to complain of severe low back pain and right sided buttock pain but was now having left buttock pain as well. He underwent L3-4 fusion approximately a year after the discectomies and returned home. He was unable to work and could only walk short distances. He was seen by his Family Practice provider and started on Cymbalta 60mg qd for depression and Norco 5/325 tid for worsening pain.
INITIAL LUMBAR AP XRAY.
Note that the superior aspect of the femoral heads are visible. Narrowing of the hip joint space is seen bilaterally.
POST L3-4 FUSION
Two years after his spine fusion and 4 years after his initial presentation to the Walk In Clinic, his PCP ordered a Pelvic CT scan to see if something else was causing his pain. He was only ambulating in his home with the use of furniture and ,on occasion, a front wheeled walker. His depression was significantly worse and he hadn’t been able to work for the past 2½ years. He was referred to Orthopedic Surgery for evaluation and plain X-rays were ordered. Severe bilateral AVN was noted with collapse of the femoral heads.
BILATERAL AVN OF THE HIPS
His physical exam showed almost no internal or external rotation of the hips due to pain. He had a 5 degree flexion contracture of both hips and 20 degrees of Abduction. Loud crepitus was noted with any attempts to perform ROM. He was unable to flex his hips against gravity due to pain. He required extensive effort to stand up from the wheelchair and was not able to take steps in the exam room due to pain. The patient was offered, and underwent, bilateral staged Total Hip Arthroplasty 6 weeks apart. He was started in Physical therapy 2 weeks after his second THA using a single point cane, reporting 1/10 pain with activity.
In hindsight, this was a series of unfortunate events. First, the patient was certain he had done something to his back. Afterall, it was his back, right buttock and posterior thigh that hurt! His initial presentation was equivocal as his only significant finding was a positive bilateral FABER’s and severe pain with performing a SLR on the right. Secondly, when reviewing his initial lumbar films, the AP x-ray showed evidence of early femoral head AVN. The first two neurosurgeons were correct in that his left sided disc herniations and clinical findings didn’t suggest a lumbar etiology for his symptoms. The patient did not feel the need to follow up with the initial provider but instead felt he needed to find someone to operate on his back, which unfortunately, he eventually did. All of the treatments directed at his lumbar spine and his MRI were unsuccessful yet with each new provider, no one recognized the failures and tried to treat lumbar pathology that, very possibly, wasn’t pathologic at all. Follow up evaluation to discuss the MRI results may have resulted in correctly identifying the hip pathology through reexamination, reviewing the initial AP lumbar film and ordering an AP pelvis x-ray.