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vol. 47
Original paper

The influence of lumbar degenerative disc disease with disc herniation on the range of movements in the hip joints

Robert Gasik
Tadeusz Styczyński

Reumatologia 2009; 47, 4: 223–229
Online publish date: 2009/10/19
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Multidimentional functional interdependences between hip joints and lumbar spine are well recognised. Pathological relationships develop in disorders involving one of the above mentioned structures. In literature there are reports on disfunctional relations between hip joints and lumbar spine concerning its mobility, lordosis angle and scoliosis level [1-5]. Other types of connection between lumbar degenerative disc disease (DDD) with disc herniation and concomitant neurological deficits are: microcirculatory disregulation within bony parts of the hip and the lower extremity, pareses and increased muscle fatigability [6-13].
The above mentioned relations could adversely influence the function of hip joints, but they are only a part of complicated issue of mutual interrelations between spinal column and hip joints in pathological states [14-17]. The study was to assess the influence of lumbar DDD with disc herniation and hips muscles pareses on the range of passive and active movements and structural changes in the hip joint.

Material and methods
One hundred and sixty randomly assigned patients, including 84 women, and 76 men aged 25-77 years (mean age 47 years) suffering from lumbar DDD with disc herniation and with radicular pain were qualified to the study and examined. In every case the diagnosis was confirmed with MRI scan of the spine.
Eight people were excluded from the study group because of injury of the hip joint region, hemiparesis in sequence of stroke, diabetic polyneuropathy, organic scoliosis and high grade gonarthrosis impairing walking. Duration of symptoms from their first manifestation was 1-550 months (mean 149.23 months).
Lumbar DDD with disc herniation at L3 -L4 level was present in 2 persons (1.31%), at L4-L5 level in 54 persons (35.6%), at L5-S1 level in 51 persons (33.6%), at L4-L5 and L5-S1 levels in 31 persons (20.3%), at L3-L4 and L4-L5 levels in 11 persons (7.22%) and at the three spine levels in 3 persons (1.97%). No statistically significant difference between numbers of patients with right and left-sided radicular pain syndrome was observed.

Research methods were divided into the following categories:

1. Clinical examination
Medical history taken from patients included especially profession character and other factors which could influence hip joints function. Physical examina-tion included neurological assessment and segmental orthopaedic assessment.
Neurological examination was focused on deficit symptoms including sphincter symptoms, sensation impairments, deep reflexes, lower extremities muscle tone, thigh and shank circumferences as well as muscle strength of lower limbs [18]. Orthopaedic examination included Patrick, Thomas and Gensler signs, measurements of relative and absolute lengths of lower extremities, and physiological spinal curvatures. Functional state of sacroiliac joints was assessed with tests described by Lewit, Ostgaard and Buckup [19, 20].

2. Assessment of active and passive range of movements in the hip joints
Measurements were performed with hand goniometer in lying position, except for rotation measurement which was carried out in sitting position [18-20]. During measurements pelvis was stabilised with belts with special attention paid to avoid pelvic movements. To assess abduction and adduction the examined limb was lifted on hangers. In order to avoid inaccurate results multiple measurments were carried out and mean value from three tests was taken. Measurement result was accepted on account that the procedure did not provoke pain.
In the first ten patients measurements were repeated on the other day – repetability of measurments was confirmed.

3. Measurement of hip muscle strength
Measurements were performed with HMF 1 measuring station manufactured by JBA Staniak (Fig. 1). The station was equipped with electronic dynamometers synchronised with computer software. During the measurment patient was in sitting position on a chair which enabled stabilisation of pelvis and spine to avoid measurement errors. All measurements were performed with maintenance of constant distance between joint (movement axis) and the site of dynamometric assessment.
In the first 10 patients the measurements were repeated the next day and repeatability of results was confirmed.

4. Radiological examinations
Radiological imaging of pelvis and spine was performed to identify the cause of pain syndrome. Assessments included bilateral wideness measurements of superior, inferior and medial articular clefts of the hip joint, circumferential and marginal osteophytosis, subchondral sclerotisation as well as geodes of head and acetabulum of the hip joint. The assessments were carried out in a manner similar as in the studies of other authors [21]. During measurement, the patients were asked to stand in the same distance at the X-ray cassette, to position the hips paralell to the film, and to extend the knee to its maximum. Examination involved also sacroiliac joints.

5. Statistical analyses
Statistical analyses were performed in medical statistics laboratory with the use of SAS software (version 8). Statistical tests included T-Student test, Wilcoxon test, Kruskal-Wallis test, Duncan test and (ANOVA) analysis of variance when the distribution of the groups were normal. Statistical level of significance was p < 0,05.

Results were classified into subgroups where correlations were calculated. The main subject of the study was the assessment of difference between the range of movements and radiologic picture of the hip joints on the side of radicular syndrome and on the opposite side. To evaluate the influence of radicular syndrome duration on the range of movements and radiologic picture of the hip joints patients with disease duration of less than 10 years and more than 10 years were compared (Table I).

1. Assessment of the range of movements in the hip joints on the side of radicular syndrome and on the opposite side Decrease in range of passive and active extension as well as passive hip abduction were observed on the painful side (Table II, III).

2. Assessment of the range of movements in the hip joints in patients with disease duration of less than 10 years and more than 10 years
There were statistically significant differences between active abduction on the painful and on the painless side between patients with disease duration of more than 10 years and less than 10 years, which were 4.9º and 2, respectively. The range of movements was always lower on the side of radicular syndrome (Table IV).

3. Radiologic changes within hip joints on the side of radicular syndrome and on the opposite side
Analysis of the whole study group revealed the presence of osteophytes on the side of radicular syndrome in 37% of patients. Mean length of the osteophytes measured on radiologic slides was 4.9 mm. On the opposite side osteophytes localised on the superior edge of the iliac acetabulum were found in 23% of patients, and their mean length was 2.6 mm. Difference between osteophyte lengths on the symptomatic and asymptomatic side was statistically significant (p < 0.01) (Fig. 2a, b).
Osteophytes localised on the superior edge of the iliac acetabulum on symptomatic side were more frequent in patients with longer duration of the disease. In the group of patients suffering from the disease for less than 10 years osteophytes localised on the side of radicular syndrome were present in 26% of persons, and in the second group in 51% of persons. The difference was statistically significant (p < 0.02).

4. Hip muscle pareses
Pareses of hip joint muscles compatible with radical innervation were observed in studied patients. The most common type of paresis was associated with hip abductors. Muscle strength of hip joint abductors was 126.5 N at the side of radicular syndrome and 151 N at the opposite side. Statistically significant bilateral differences in strength of hip abductors was observed in 69.3% of patients.

Analysis of results and discussion
The results revealed decrease in the range of passive and active extension on the side of radicular syndrome. Decrease in abduction on the painful side was limited to passive movements. I did not find any paper unequivocally describing these phenomena. There are authors, who seek causes of hip movements impairment in changes which involve sacroiliac joints [7].
The study revealed no statistically significant differences between pain or radiologically assessed structural changes in sacroiliac joints and the range of movements in hip joints. This inspired us to search for other causes responsible for described impairments of hip mobility.
Domination and subsequent contracture of muscles uninvolved by pareses, additional, long-lasting compulsory hip flexion in patients with sciatic neuralgia could impair the range of extension or abduction.
Indirect proof of the above described is the decrease in strength of hip abductors in examined patients demonstrated by measurements with use of HMF 1 electronic chair dynamometer.
This type of pareses was consistent with damage to the radices in course of lumbar DDD with disc herniation. Muscular pareses and/or local trophic changes resulting from impairment of neurogenic control over microcirculation could be responsible for changes in soft tissues sourrounding joints (muscles, ligaments and articular capsule), which manifest through decreased range of movement in hip joints, especially, that muscle groups innervated from those levels often play antagonistic roles (extensors-flexors, adductors-abductors) [8, 9, 12]. Besides factors resulting from pathology of periarticular tissues, there are factors that lead to decrease in range of movements resulting from degenarative changes of bony articular structures [9]. Our study revealed discrete osteoarthrotic changes of hip joints on the side of radicular syndrome, especially more frequent (statistically significant) occurrence of osteophytes localised at the edge of the iliac acetabulum affected by radicular syndrome. This fact may indicate greater importance of ligaments in articular stabilisation in patients with pareses. Osteophytes localised at the superior edge of the iliac acetabulum develop at the site of attachment of iliac joint capsule. Abductors pareses may be responsible for stretching of the capsule due to pelvic drop as in the mechanism underlying the Trendelenburg sign. This may affect iliac abduction range in terminal phase of the movement.
An interesting finding is correlation between disease duration and the decrease in range of movements concerning active and passive hip abduction on the side of radicular syndrome.
Gradual development of functional impairments, e.g.: decrease in range of hip movements on the side of radicular syndrome seems to be natural element of disease progression or persistence of its consequences [2, 11]. Described changes were reflected in physical examination of patients. On the side of radicular syndrome Patrick sign was observed in 37% of patients (5.5% on the opposite side). Longer duration of disease predisposed to the presence of Patrick sign on the side of radicular syndrome (46.2% in patients with longer disease duration, and 35% in patients with shorter disease duration).
The results indicate negative influence of lumbar DDD with disc herniation on cooperation of biomechanical chain elements, leading to disorders most clearly visible on the side of radicular syndrome [2]. Davis, Farfan and other authors think, that all collective movements of spine, hips and sacroiliac joints have their specific ranges and that the movements develop in physiological sequence [22, 23]. Describing those phenomena, Cailliet introduced even a term for interrelations between spinal and pelvic movements called “lumbar-pelvic rhythm” [24]. On the other side many authors point at disruption of those biomechanical relations in patients with lumbar spine pain syndrome [25, 26].

Lumbar DDD with disc herniation causes decrease in range of hip joint movements.
Decrease in range of hip joint movements is always present on the side of radicular pain syndrome, and increases with duration of the syndrome, which demonstrates pathogenic influence of lumbar DDD with disc herniation on hip joints function.
Changes in the course of disc herniation may influence the rate of iliac osteoarthrosis development. The conclusion requires further investigation.

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Copyright: © 2009 Narodowy Instytut Geriatrii, Reumatologii i Rehabilitacji w Warszawie. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International (CC BY-NC-SA 4.0) License (http://creativecommons.org/licenses/by-nc-sa/4.0/), allowing third parties to copy and redistribute the material in any medium or format and to remix, transform, and build upon the material, provided the original work is properly cited and states its license.

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