髋关节疾病合并腰椎退行性疾病(髋腰综合征)误诊误治的原因分析

Causes of misdiagnosis and mistreatment of lumbar degenerative diseases complicated with hip joint diseases (hip-spine syndrome)

目的总结33例髋关节疾病合并腰椎退行性疾病患者的临床特点,探讨将其误诊为腰椎退变性疾病的原因及对策。方法选取2013年4月至2020年8月诊断为腰椎退行性疾病而腰椎术后疗效不佳,随访中发现髋关节疾病需手术治疗患者33例,其中男18例,女15例,41~79岁,平均(51±12)岁。术前诊断:腰椎管狭窄症24例,腰椎间盘突出症9例。术前症状:腰部疼痛9例(27.3%),臀部疼痛11例(33.3%),大转子疼痛5例(15.2%),腹股沟疼痛2例(6.1%),大腿前/后方疼痛4例(12.1%),膝关节疼痛5例(15.2%),小腿疼痛3例(9.1%),间歇性跛行21例(63.6%)。术前查体:直腿抬高试验(+)7例,4字试验(-)19例、(+)5例,原始病历无记录9例。初次腰椎手术方式:腰椎椎板开窗、髓核摘除术6例,经皮内镜椎间孔入路髓核摘除术(PETD)2例,腰椎椎板切除、椎管减压术5例,后入路腰椎椎间融合术(Open-PLIF)19例,微创经椎间孔入路椎管减压、植骨融合内固定术(MIS-TLIF)1例。结果术后平均随访(3.4±1.3)年。术后3个月内发现症状缓解不佳,并明确髋关节疾病诊断患者21例,术后3个月至1年及1年以上明确诊断患者分别为10例和2例。髋关节疾病诊断:股骨头无菌性坏死16例(单侧14例,双侧2例),髋臼发育不良并骨性关节炎17例(单侧16例,双侧1例)。二次术前临床症状:腰部疼痛1例(3.0%),臀部不适/疼痛11例(33.3%),大转子疼痛5例(15.2%),腹股沟疼痛2例(6.1%),大腿前方/后方疼痛4例(12.1%),膝关节疼痛5例(15.2%),小腿疼痛3例(9.1%),跛行14例(42.4%)。查体:直腿抬高试验(+)1例,4字试验(-)4例、(+)23例、(±)6例。结论腰椎退行性疾病的影像学检查与症状、体征不符时应警惕髋关节疾病的可能。股骨头无菌性坏死和髋关节骨性关节炎的临床表现有时并不典型,可单纯表现为腰臀部疼痛不适,疼痛可放射至大腿前方或类似坐骨神经痛。髋腰综合征患者,直腿抬高试验及4字试验诊断特异性不高。仔细的术前查体及必要的影像学筛查可有效减少误诊误治。

Objective To summarize the clinical characteristics of hip joint diseases complicated with lumbar degenerative diseases,and to analyze the causes and countermeasures of misdiagnosing them as lumbar degenerative diseases.Methods Cases diagnosed as lumbar degenerative diseases who had poor therapeutic outcomes were collected during Apr.2013 and Aug.2020.During the follow-up,33 patients with hip disease requiring surgical treatment were involved,including 18 males and 15 females,aged from 41 to 79 years,with an average of(51±12)years.Preoperative diagnosis was lumbar spinal stenosis in 24 cases and lumbar disc herniation in 9 cases.Preoperative symptoms included low back pain in 9 cases(27.3%),hip pain in 11 cases(33.3%),greater trochanter pain in 5 cases(15.2%),groin pain in 2 cases(6.1%),anterior/posterior thigh pain in 4 cases(12.1%),knee pain in 5 cases(15.2%),lower leg pain in 3 cases(9.1%),and intermittent claudication in 21 cases(63.6%).Preoperative physical examination included straight-leg raising test(+)in 7 cases,Patrick sign(-)in 19 cases,Patrick sign(+)in 5 cases and no original medical records in 9 cases.Primary lumbar spine operation methods were lumbar lamina fenestration and discectomy in 6 cases,PETD in 2 cases,lumbar laminectomy and decompression in 5 cases,Open-PLIF in 19 cases and MIS-TLIF in 1 case.Results During the average follow-up of(3.4±1.3)years,21 cases had poor symptom relief and were confirmed 3 months after operation,10 cases were confirmed 3 months to 1 year after operation,and 2 cases were confirmed more than 1 year after operation.The re-diagnosis results included aseptic necrosis of femoral head in 16 cases(unilateral in 14 cases,bilateral in 2 cases),and acetabular dysplasia complicated with osteoarthritis in 17 cases(unilateral in 16 cases,bilateral in 1 case).Secondary preoperative clinical symptoms were low back pain in 1 case(3.0%),hip pain in 11 cases(33.3%),greater trochanter pain in 5 cases(15.2%),groin pain in 2 cases(6.1%),anterior/posterior thigh pain in 4 cases(12.1%),knee pain in 5 cases(15.2%),lower leg pain in 3 cases(9.1%),and limb in 14 cases(42.4%).Physical examination included straight leg lifting test(+)in 1 case,Patrick sign(-)in 4 cases,(+)in 23 cases and(±)in 6 cases.Conclusion When the imaging examination of lumbar degenerative diseases is inconsistent with the symptoms and signs,we should be alert to the possibility of hip joint diseases.The clinical manifestations of osteoarthritis of hip joint and idiopathic femoral head necrosis are sometimes atypical,which may simply manifests as pain and discomfort in waist and buttocks,and pain can radiate to the front of thigh or similar to sciatica.In patients with hip-spine syndrome,the diagnostic specificity of straight leg lifting test and Patrick sign is not high.Careful preoperative physical examination and necessary imaging screening can effectively reduce misdiagnosis and mistreatment.