Missed Hips, Missed Opportunities: Specialty-Driven Differences in Evaluating Hip– Spine Syndrome

Missed Hips, Missed Opportunities: Specialty-Driven Differences in Evaluating Hip– Spine Syndrome | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Missed Hips, Missed Opportunities: Specialty-Driven Differences in Evaluating Hip– Spine Syndrome Chao-Chien Chang, Feng-Chih Kuo, Fu-Shine Yang, Cheh-Yung Chang, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7771457/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 10 Jan, 2026 Read the published version in BMC Musculoskeletal Disorders → Version 1 posted 11 You are reading this latest preprint version Abstract Background Hip-spine syndrome (HSS) poses a diagnostic challenge because lumbar degenerative disease, sacro-iliac joint dysfunction, and hip osteoarthritis often produce overlapping symptoms. Earlier work suggested that orthopaedic surgeons order hip imaging and identify hip pathology more consistently than neurosurgeons when treating patients who eventually require both lumbar and hip operations. Whether this observation holds in a tertiary-care electronic medical-record (EMR) setting remains unknown. Methods We queried the Chang Gung Research Database (CGRD), the largest multi-institutional EMR repository in Taiwan, for patients aged 50–85 years who underwent both hip arthroplasty and lumbar surgery within the same 12-month period between 2001 and 2024. Cohorts were categorised as hip-then-spine (HS, n = 58), spine-then-hip (SH, n = 223), or simultaneous procedures (Both, n = 2). SH patients were stratified by the specialty of the spine surgeon: orthopaedic (OS, n = 104) versus neurosurgical (NS, n = 111). Primary outcomes were (1) pre-operative ordering of combined spine + pelvis/hip radiography and (2) documentation of hip pathology before spine surgery. Group differences were analysed with χ² or Student’s t tests (α = 0.05). Results In the SH cohort, combined spine-and-hip imaging was obtained significantly more often by OS than by NS (73.1% vs 51.4%; p < 0.001). Hip osteoarthritis or osteonecrosis was recorded pre-operatively in 26.9% of OS cases versus 21.6% of NS cases, a non-significant difference attributable to limited sample size. The SH:HS ratio showed approximately 4 : 1, indicating that spine surgery typically precedes hip arthroplasty in routine practice. Conclusions Within a tertiary-care EMR database, orthopaedic surgeons were more likely than neurosurgeons to order comprehensive spinopelvic imaging, thereby enhancing detection of hip pathology in HSS. These cross-database findings underscore the importance of routine hip assessment before lumbar surgery and support efforts to harmonise diagnostic protocols across specialties. Hip-spine syndrome (HSS) tertiary-care database orthopedic surgeon neurosurgeon Figures Figure 1 Background Lumbar spinal stenosis-related referred pain, sacroiliac joint (SIJ) pathology, and degenerative hip osteoarthritis frequently present with overlapping clinical manifestations. Accurate differentiation relies on careful history taking, focused physical and neurologic examinations, and selective local anesthetic blocks [ 1 ]. According to the literature, 12.5–17.5% of patients with low-back pain that radiates caudally are found to have concurrent spine and hip disease or a combination of spine pathology and SIJ dysfunction, whereas the simultaneous presence of spine, SIJ, and hip disorders is observed in fewer than 2% of cases. [ 2 ] Hip-spine syndrome was first described by Offierski and Macnab in 1983 [ 3 ]. Hip–spine syndrome can be stratified into four categories on the basis of the interaction between hip and spinal pathology: simple, mixed, complex, and misdiagnosed. The simple type denotes degeneration confined to either the hip or the spine, with no clinically meaningful involvement of the other region. The mixed type encompasses cases in which degenerative changes are present in both the hip and the spine, and each lesion reciprocally aggravates the other. In the complex type, pathologies in both regions progress in concert, producing a combined biomechanical and symptomatic burden that surpasses the contribution of either lesion alone. Finally, the misdiagnosed type refers to situations in which pathology at one site is overlooked, leading to an incorrect treatment strategy that fails to address the true source of the patient’s symptoms. The optimal order of surgical intervention in hip–spine syndrome remains unsettled. [ 4 ] Certain studies have linked performing spinal fusion first with a higher incidence of subsequent hip dislocation, whereas some experts contend that addressing the spine first may lower the risk of neural injury.[ 5 ] At present, a definitive consensus has yet to be established.[ 6 ] [ 7 ] Accurate diagnosis is paramount; consequently, pre-operative imaging must be sufficiently comprehensive to encompass both the spine and the hip if the likelihood of correct diagnostic attribution is to be maximized. [ 8 ] [ 9 ] Prior investigations involving patients with concomitant spinal and hip pathology have compared the performance of orthopaedic and neurosurgical specialists, attributing observed differences chiefly to variations in residency training. Neurosurgeons typically gain more intensive exposure to spinal procedures, whereas orthopaedic surgeons are trained across the full spectrum of spinal as well as appendicular musculoskeletal surgery. [ 10 ] In the present investigation, we aimed to interrogate Taiwan’s Chang Gung Research Database (CGRD) to determine whether its tertiary-medical-center setting, finer subspecialty delineation, and richly detailed electronic medical records yield distinctive insights. Specifically, we compared orthopaedic and neurosurgical practitioners to ascertain which specialty more consistently orders comprehensive spine–hip imaging and achieves a more thorough and accurate pre-operative diagnosis. Methods Data source The Chang Gung Research Database (CGRD) is the greatest multi-institutional electronic medical records (EMR) database in Taiwan. It was derived from medical records of Chang Gung Memorial Hospital (CGMH) which is also the largest hospital system alliance in Taiwan. 15-year longitudinal data could be aggregated in detailed standardization format. Not only secondary data from billing order or charge codes, the CGRD has a more comprehensive dataset with original data, which may be better than national database like the Taiwan National Health Insurance Research Database (NHIRD). Compared with the NHIRD and medical-center cohorts in Taiwan, patients captured in the CGRD typically present with higher Charlson Comorbidity Index scores and a greater prevalence of select comorbidities, suggesting that the CGRD is particularly well suited for research on populations with more severe and complex diseases.[ 11 ] This study was approved by the Research Ethics Committee of Chang Gung Medical Foundation Institutional Review Board (no. 201801118B0) Study population : First, we applied predefined diagnostic codes to identify all patients who had concurrent diagnoses of both spinal disorders and hip-joint diseases in CGRD. Next, we identified specific procedure codes, including total hip arthroplasty (64162B), partial hip arthroplasty (64170B), fusion surgery (83043B, 83044B, 83045B, or 83046B), laminectomy (83002C or 83003C), or lumbar discectomy (83024C). We extracted data on patients aged 50–85 who had undergone both hip and spine surgeries within the same 12-month period (total: 463). For the spine cohort, we limited inclusion to degenerative lumbosacral disorders, explicitly excluding vertebral fractures (ICD-9-CM: 805* or 806*), cervical spine conditions (ICD-9 CM: 723*), neoplasms, and infectious diseases. For the hip cohort, we likewise excluded any cases involving fractures. We collected all the remaining patients’ demographic data, including surgeon specialty, the timing and items of radiographic examination and discharge diagnoses. We subsequently stratified the cohort into three groups according to the timing and sequence of their hip and spine surgeries: (1) underwent hip and spine surgery at the same admission (Both), (2) hip surgery prior to spine surgery (HS), and (3) spine surgery prior to hip surgery (SH). Patients in the SH (spine surgery prior to hip surgery) group were further subdivided into (1) spine surgery performed by an orthopedic surgeon (OS) or (2) spine surgery performed by a neurosurgeon (NS). Statistics Descriptive statistics of the Both, HS, and SH groups were performed, including age, sex, the items and timing of image, Charlson Comorbidity Index (CCI), and specialty of the surgeon. Differences between the OS and NS groups were assessed using independent Student’s t-test for continuous variables and Chi-Square test for nominal variables. Significance was defined as p < 0.05 in two-tailed testing. Results From the CGRD, we initially identified 463 patients aged 55–85 who underwent both spine-related surgery and hip arthroplasty within the same 12-month window. After applying the Figure 1 exclusion criteria (eliminating 180 cases), 283 patients remained for analysis. Among these patients, 2 were included in Both group (hip and spine procedures during the same admission), 58 were categorized in HS group ( hip surgery performed before spine surgery), and 223 were included in SH group (spine surgery performed before hip surgery). All hip operations were carried out by orthopaedic surgeons. Spine procedures were further stratified by surgical specialty into orthopaedic surgeon (OS) and neurosurgical surgeon (NS) subgroups. Comprehensive demographic characteristics, length of stay, interval between the two operations, and Charlson Comorbidity Index scores are summarized in Table 1 . The specialty distribution of surgeons across the study cohorts is illustrated in Table 2 . Within the SH group, 45.29 % of spine operations were performed by orthopaedic surgeons, whereas 49.33 % were carried out by neurosurgeons. Overall, only about 15–20 % of patients had consulted both orthopaedics and neurosurgery in the preoperative period. The preoperative imaging patterns across the three cohorts are detailed in Table 3 . In the both-group, every patient underwent both spinal radiography and a KUB study. Among the HS group, roughly 40 % had a spine X-ray prior to surgery, whereas this proportion rose to 80.27 % in the SH group. Conversely, pelvic radiography was far more common in the HS cohort—performed in 81.03 % of patients—while only 21.08 % of those in the SH group received the same examination. The distribution of diagnoses recorded before surgery and at discharge are presented in Table 4 . In the HS group, 63.79 % of patients already carried a spine-disease diagnosis preoperatively, while hip osteoarthritis and hip osteonecrosis were documented in 75.86 % and 51.72 % of cases, respectively. By contrast, the SH group showed a markedly higher preoperative prevalence of spine-related diagnoses at 98.21 %, whereas hip osteoarthritis and avascular necrosis of the femoral head were noted in only 17.94 % and 9.42 % of patients. At discharge, hip-related diagnoses in the SH cohort remained uncommon, with the combined frequency of hip osteoarthritis and osteonecrosis amounting to roughly 15 %. Table 5 shows distinct imaging habits between the two surgical specialties. In the OS group, 79.81 % of patients received spine radiograph before surgery, yet as many as 73.08 % underwent a combined study that included a spine X-ray plus either a KUB or pelvic radiograph. By contrast, in the NS group, 81.68 % had a spine X-ray, whereas just 51.35 % obtained both spine and hip films. Overall, orthopaedic surgeons ordered combined spine-and-hip imaging more frequently, whereas neurosurgeons more often relied on spine radiographs alone—an inter-group difference that reached statistical significance. The pattern persists in Table 6 : patients in the OS group had higher pre-operative rates of both spine-related and hip-related diagnoses than those in the NS group, although the differences did not achieve statistical significance. Discussion Hip-spine disorders demand keen diagnostic acumen: a meticulous history, thorough physical examination, and judicious interpretation of imaging each contribute to a more reliable diagnosis. Our group previously examined hip-spine syndrome with Taiwan’s National Health Insurance Research Database (NHIRD) and published those findings; the present study tackles the same theme using the Chang Gung Research Database (CGRD) to provide a cross-database perspective.[ 12 ] Covering electronic medical records from multiple Chang Gung campuses between 2001 and 2024, the CGRD offers richer clinical detail, albeit with a smaller underlying population than the NHIRD. Patients drawn from this tertiary-care system show slightly longer median hospital stays and wider intervals between operations, underscoring the greater case complexity typical of level-III medical centers. [ 11 ] Because the CGMH network is built around such centers, the CGRD arguably captures practice patterns that best represent subspecialized care in Taiwanese medical-center settings. [ 13 ] Orthopedic surgeons in the CGRD cohort ordered hip-related radiographs far more frequently than their neurosurgical counterparts (p < 0.001), thereby increasing the likelihood that hip lesions would be detected in patients they managed. This divergence almost certainly reflects the specialties’ different training emphases: neurosurgeons focus primarily on central nervous system disorders, whereas orthopedic surgeons are more versed in limb skeletal, joint, and tendon pathology. In the NHIRD analysis, the pre-operative detection rate of hip osteoarthritis was higher when spine surgery was performed by orthopaedic surgeons—a trend mirrored in the CGRD cohort, although the smaller CGRD sample meant the difference did not reach statistical significance. One plausible explanation is the tertiary-referral nature of the Chang Gung health-care system: many patients may have undergone initial hip assessments at primary or secondary facilities before being referred for definitive care, so those earlier diagnoses were not captured in the CGRD’s electronic records. Consequently, the apparent lack of a statistically significant difference in hip diagnostic rates may reflect under-documentation of hip pathology that had already been recognized outside the CGRD network. Across both the NHIRD and CGRD datasets, the SH-to-HS ratio consistently falls between 3 : 1 and 4 : 1, highlighting that clinicians most often treat spinal pathology before addressing the hip. Cases in the Both group are too few to support meaningful inference. In practice, the optimal order of intervention when spine and hip disease coexist remains controversial; the critical task is to identify the dominant pain generator, because operating on one site can either relieve—or, in some instances, exacerbate—symptoms arising from the other [ 14 ]. Numerous studies address surgical sequencing in hip–spine syndrome—i.e., spine-first versus hip-first—as well as the associated radiographic (spinopelvic) parameters. In contrast, the present study focuses on whether the preoperative imaging portfolio is sufficient to ensure the accuracy and completeness of the preoperative diagnosis. Among patients who underwent both lumbar spine surgery and total hip arthroplasty within a single year, the vast majority of hip pathologies were not identified prior to spine surgery, primarily due to inadequate imaging of the hip/pelvis. As a result, many patients experienced suboptimal symptom relief after spine procedures, necessitating further evaluation during which the hip lesion was ultimately recognized; subsequent hip surgery then produced meaningful clinical improvement. We also found that imaging-ordering practices vary by specialty training. Notably, the magnitude of specialty-related differences within this tertiary-care hospital system was smaller than that observed in the nationwide database, suggesting reduced inter-specialty variability in tertiary-center practice. Several limitations merit mention. Although the CGRD is the largest single-system database in Taiwan, it still represents only a segment of the national population when compared with the NHIRD. Because the CGRD captures care delivered mainly at tertiary medical centers, many patients arrive after comprehensive work-ups in primary or secondary facilities, a referral pattern that may introduce diagnostic bias even as it reflects real-world practice. In addition, the diagnostic codes entered in electronic records can vary with each attending physician’s habits or administrative needs, potentially influencing case ascertainment. That said, the CGRD’s granular documentation allows for extensive cross-checking, which helps to minimize—but not completely eliminate—these sources of bias. Conclusions This study aimed to delineate how orthopaedic surgeons and neurosurgeons differ in diagnosing hip–spine syndrome, using the completeness of pre-operative imaging and the pattern of diagnostic codes as proxies for diagnostic accuracy and, ultimately, for enhancing treatment success. Consistent with our previous analysis of the NHIRD and the present investigation of the CGRD, the findings indicate that orthopaedic surgeons are more likely than neurosurgeons to order comprehensive imaging and to arrive at accurate diagnoses of hip pathology. Importantly, spine surgeons should explicitly consider the possibility of concomitant hip pathology before proceeding and ensure a sufficiently comprehensive preoperative work-up—including targeted pelvis/hip imaging—to support accurate diagnosis and surgical planning. Abbreviations Hip–spine syndrome (HSS) electronic medical-record (EMR) Chang Gung Research Database (CGRD) sacroiliac joint (SIJ) Taiwan National Health Insurance Research Database (NHIRD) Charlson Comorbidity Index (CCI) Declarations Ethics approval and consent to participate: The need for informed consent was waived by the Ethics Committee/Institutional Review Board of the Institutional Review Board of Chang Gung Medical Foundation has approved this study (IRB No. 201801118B0). This study was conducted in accordance with the Declaration of Helsinki and its later amendments. Consent for publication: Not applicable. Clinical trial number: Not applicable. Availability of data and materials: The datasets used and/or analyzed during the current study are available from the corresponding author and first author on reasonable request. Competing interests: There is no financial nor non-financial interests that are directly or indirectly related to the work submitted for publication. Funding: There is no funding support in this study. Authors’ contributions: Chao-Chien Chang: writing-Original Draft & Editing Feng-Chih Kuo: methodology; data analysis Fu-Shine Yang: resources; methodology Cheh-Yung Chang: resources Chieh-Cheng Hsu: resources; Investigation Meng-Ling Lu: resources; methodology Re-Wen Wu: resources; Investigation Tsung-Cheng Yin (corresponding author): Conceptualization; methodology; review Acknowledgements: Not applicable References Sembrano JN, Polly DW, Jr.: How often is low back pain not coming from the back? Spine (Phila Pa 1976) 2009, 34 (1):E27-32. Shemshaki H, Nourian SM, Fereidan-Esfahani M, Mokhtari M, Etemadifar MR: What is the source of low back pain? J Craniovertebr Junction Spine 2013, 4 (1):21-24. Offierski CM, MacNab I: Hip-spine syndrome . Spine (Phila Pa 1976) 1983, 8 (3):316-321. Huppert A, Ambrosio L, Nwosu K, Pico A, Russo F, Vadala G, Papalia R, Denaro V: Previous lumbar spine fusion increases the risk of dislocation following total hip arthroplasty in patients with hip-spine syndrome: a systematic review and meta-analysis . BMC Musculoskelet Disord 2024, 25 (1):732. Buckland AJ, Puvanesarajah V, Vigdorchik J, Schwarzkopf R, Jain A, Klineberg EO, Hart RA, Callaghan JJ, Hassanzadeh H: Dislocation of a primary total hip arthroplasty is more common in patients with a lumbar spinal fusion . Bone Joint J 2017, 99-B (5):585-591. Diebo BG, Beyer GA, Grieco PW, Liu S, Day LM, Abraham R, Naziri Q, Passias PG, Maheshwari AV, Paulino CB: Complications in Patients Undergoing Spinal Fusion After THA . Clin Orthop Relat Res 2018, 476 (2):412-417. Grammatopoulos G, Dhaliwal K, Pradhan R, Parker SJM, Lynch K, Marshall R, Andrade ATJ: Does lumbar arthrodesis compromise outcome of total hip arthroplasty? Hip Int 2019, 29 (5):496-503. Sing DC, Barry JJ, Aguilar TU, Theologis AA, Patterson JT, Tay BK, Vail TP, Hansen EN: Prior Lumbar Spinal Arthrodesis Increases Risk of Prosthetic-Related Complication in Total Hip Arthroplasty . J Arthroplasty 2016, 31 (9 Suppl):227-232 e221. Rodkey DL, Lundy AE, Tracey RW, Helgeson MD: Hip-Spine Syndrome: Which Surgery First? Clin Spine Surg 2022, 35 (1):1-3. Pham MH, Jakoi AM, Wali AR, Lenke LG: Trends in Spine Surgery Training During Neurological and Orthopaedic Surgery Residency: A 10-Year Analysis of ACGME Case Log Data . J Bone Joint Surg Am 2019, 101 (22):e122. Shao SC, Chan YY, Kao Yang YH, Lin SJ, Hung MJ, Chien RN, Lai CC, Lai EC: The Chang Gung Research Database-A multi-institutional electronic medical records database for real-world epidemiological studies in Taiwan . Pharmacoepidemiol Drug Saf 2019, 28 (5):593-600. Yin TC, Wegner AM, Lu ML, Yang YH, Wang YC, Kung WM, Lo WC: Do Orthopedic Surgeons or Neurosurgeons Detect More Hip Disorders in Patients with Hip-Spine Syndrome? A Nationwide Database Study . Brain Sci 2021, 11 (4). Buckland AJ, Miyamoto R, Patel RD, Slover J, Razi AE: Differentiating Hip Pathology From Lumbar Spine Pathology: Key Points of Evaluation and Management . J Am Acad Orthop Surg 2017, 25 (2):e23-e34. Chavarria JC, Douleh DG, York PJ: The Hip-Spine Challenge . J Bone Joint Surg Am 2021, 103 (19):1852-1860. Tables Table 1. Demographics, length of stay, and Charlson Comorbidity Index (CCI) for each group. Characteristics Hip and Spine Surgery in the Same Admission (Both) (n=2) Hip Before Spine Surgery (HS) (n=58) Spine Before Hip Surgery (SH) (n=223) Age 58.50 (4.95) 65.26 (7.31) 68.84 (8.75) 1st hospital stays 36.0 (41.01) 5.43 (2.11) 8.66 (6.50) 1st + 2nd hospital stays 36.0 (41.01) 15.98 (9.30) 15.10 (9.23) Duration between admissions - 195.71 (96.32) 149.15 (93.88) CCI at 1st admission 0.50 (0.71) 0.40 (0.67) 0.43 (0.88) CCI at 2nd admission - 0.74 (1.83) 0.53 (1.16) n % n % n % Female 0 0 34 58.6 158 70.9 Male 2 100 24 41.4 65 29.1 Table 2. Comparison of the numbers of surgeries performed by orthopedic surgeons and neurosurgeons. Hip and Spine Surgery in the Same Admission (Both) (n=2) Hip Before Spine Surgery (HS) (n=58) Spine Before Hip Surgery (SH) (n=223) n % n % n % First surgery by orthopedic surgeon 2 100 58 100.00 104 46.64 First surgery by neurosurgeon 0 0 0 0.00 111 49.78 Second surgery by orthopedic surgeon - - 36 62.07 203 91.03 Second surgery by neurosurgeon - - 15 25.86 0 0.00 Orthopedic clinic visit before first surgery (<6 months) 2 100 58 100.00 146 65.47 Neurosurgery clinic visit before first surgery (<6 months) 1 50 9 15.52 121 54.26 Orthopedic and neurosurgery clinic visits before first surgery 1 50 9 15.52 44 19.73 Table 3 . Comparison of preoperatively arranged imaging studies in each group. Characteristics Hip and Spine Surgery in the Same Admission (Both) (n=2) Hip Before Spine Surgery (HS) (n=58) Spine Before Hip Surgery (SH) (n=223) n % n % n % Had spinal AP and spine lateral X-rays before first surgery 2 100 23 39.66 179 80.27 Had KUB X-ray before first surgery 2 100 30 51.72 139 62.33 Had pelvic X-ray before first surgery 0 0 47 81.03 47 21.08 Table 4. Comparison of the diagnoses of spine or hip disorders in each group. Characteristics Hip and Spine Surgery in the Same Admission (Both) (n=2) Hip Before Spine Surgery (HS) (n=58) Spine Before Hip Surgery (SH) (n=223) n % n % n % Had spinal disease-related diagnosis before surgery 2 100 37 63.79 219 98.21 Had hip osteoarthritis diagnosis before surgery 0 0 44 75.86 40 17.94 Had hip osteonecrosis diagnosis before surgery 1 50 30 51.72 21 9.42 Had spine-related-diagnosis at first discharge 2 100 8 13.79 195 87.44 Had hip-related diagnosis at first discharge (osteoarthritis) 0 0 39 67.24 21 9.42 Had hip-related diagnosis at first discharge (osteonecrosis) 1 50 26 44.83 11 4.93 Table 5 . Comparison of preoperative imaging studies. Spine Surgery Was Performed by OS (n = 104) Spine Surgery Was Performed by NS (n = 111) p-Value Preoperative spinal X-ray <6 months 83 (79.81) 94 (81.68) p <0.001 Preoperative spine X-ray + KUB or pelvic X-ray <6 months 76 (73.08) 57 (51.35) p <0.001 Table 6 . Comparison of preoperative imaging studies. Spine Surgery Was Performed by OS (n = 104) Spine Surgery Was Performed by NS (n = 111) p-Value Spine-related diagnosis before surgery 104 (100) 108 (97.30) 0.022 Hip-related diagnosis before surgery 28 (26.92) 24 (21.62) 0.186 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 10 Jan, 2026 Read the published version in BMC Musculoskeletal Disorders → Version 1 posted Editorial decision: Revision requested 28 Oct, 2025 Reviews received at journal 16 Oct, 2025 Reviewers agreed at journal 16 Oct, 2025 Reviews received at journal 16 Oct, 2025 Reviewers agreed at journal 16 Oct, 2025 Reviewers agreed at journal 16 Oct, 2025 Reviewers invited by journal 16 Oct, 2025 Editor invited by journal 15 Oct, 2025 Editor assigned by journal 15 Oct, 2025 Submission checks completed at journal 14 Oct, 2025 First submitted to journal 14 Oct, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Yin","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA80lEQVRIiWNgGAWjYPCCA0DM2MDwAUixsRNQy4OshXEGSAsz8VoYGJjBPEJa7PkPH3v4peaOnLlEcttjm1/b5PmYGRg/fMzBY4tEWrqxzLFnxpYzEtuNc/tuG7YxMzBLztyGTwuPmbRkw+HEDTcS26Rze24zArWwMfPi08J/BqylHqzFsue2PWEtDDlmkh8bDicYgLQw/LidSFjLjbQ0aYZjhw03nHnYJtnbcDu5jZmxGa9f2PsPH5P8UXNY3uB4+jOJH39u285vbz744SMeLSAAiQ6BBGBstoFYwGRACDD+AJH8B4DEH4KKR8EoGAWjYAQCAOIpUe2wxwqHAAAAAElFTkSuQmCC","orcid":"","institution":"Kaohsiung Chang Gung Memorial Hospital, Chang Gung University","correspondingAuthor":true,"prefix":"","firstName":"Tsung-Cheng","middleName":"","lastName":"Yin","suffix":""}],"badges":[],"createdAt":"2025-10-03 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12:17:43","extension":"png","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":61048,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7771457/v1/a7acb11d948a4726a7285682.png"},{"id":94763115,"identity":"ead273c2-05a1-4d23-9a6f-cef9e11f78eb","added_by":"auto","created_at":"2025-10-30 12:17:43","extension":"xml","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":76038,"visible":true,"origin":"","legend":"","description":"","filename":"809a2981c4504b7c9825cb76a766f4111structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7771457/v1/a3ce366e14324806c69d0318.xml"},{"id":94824707,"identity":"49c20960-ae89-433c-b733-7b51be84d6dc","added_by":"auto","created_at":"2025-10-31 06:49:14","extension":"html","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":84612,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7771457/v1/af2a740728f63283cbde5504.html"},{"id":94763109,"identity":"60fba197-89a2-435c-8f34-4daa9f336569","added_by":"auto","created_at":"2025-10-30 12:17:43","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":283803,"visible":true,"origin":"","legend":"\u003cp\u003eA total of 463 patients who underwent both spine and hip surgery within a single 12-month interval were retrieved from the CGRD (Chang Gung Research Database). After excluding 180 cases involving trauma, neoplasm, infection, or procedure-related complications, the remaining patients were allocated to three groups according to surgical sequence. Within the spine-then-hip (SH) group, cases were further stratified by the specialty of the spine surgeon—orthopaedic surgery (OS), neurosurgery (NS), or other subspecialties.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7771457/v1/0a8ed852a0b2e6fdd2a0b290.png"},{"id":100070636,"identity":"d7f5852a-d0e1-4410-8a4b-3f60c1820cc3","added_by":"auto","created_at":"2026-01-12 16:18:11","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1666476,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7771457/v1/2171ab09-a3f0-46dd-a8d3-a7100b7c5bfd.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Missed Hips, Missed Opportunities: Specialty-Driven Differences in Evaluating Hip– Spine Syndrome","fulltext":[{"header":"Background","content":"\u003cp\u003eLumbar spinal stenosis-related referred pain, sacroiliac joint (SIJ) pathology, and degenerative hip osteoarthritis frequently present with overlapping clinical manifestations. Accurate differentiation relies on careful history taking, focused physical and neurologic examinations, and selective local anesthetic blocks [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. According to the literature, 12.5\u0026ndash;17.5% of patients with low-back pain that radiates caudally are found to have concurrent spine and hip disease or a combination of spine pathology and SIJ dysfunction, whereas the simultaneous presence of spine, SIJ, and hip disorders is observed in fewer than 2% of cases. [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eHip-spine syndrome was first described by Offierski and Macnab in 1983 [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Hip\u0026ndash;spine syndrome can be stratified into four categories on the basis of the interaction between hip and spinal pathology: simple, mixed, complex, and misdiagnosed. The \u003cem\u003esimple\u003c/em\u003e type denotes degeneration confined to either the hip or the spine, with no clinically meaningful involvement of the other region. The \u003cem\u003emixed\u003c/em\u003e type encompasses cases in which degenerative changes are present in both the hip and the spine, and each lesion reciprocally aggravates the other. In the \u003cem\u003ecomplex\u003c/em\u003e type, pathologies in both regions progress in concert, producing a combined biomechanical and symptomatic burden that surpasses the contribution of either lesion alone. Finally, the \u003cem\u003emisdiagnosed\u003c/em\u003e type refers to situations in which pathology at one site is overlooked, leading to an incorrect treatment strategy that fails to address the true source of the patient\u0026rsquo;s symptoms.\u003c/p\u003e\u003cp\u003eThe optimal order of surgical intervention in hip\u0026ndash;spine syndrome remains unsettled. [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] Certain studies have linked performing spinal fusion first with a higher incidence of subsequent hip dislocation, whereas some experts contend that addressing the spine first may lower the risk of neural injury.[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] At present, a definitive consensus has yet to be established.[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eAccurate diagnosis is paramount; consequently, pre-operative imaging must be sufficiently comprehensive to encompass both the spine and the hip if the likelihood of correct diagnostic attribution is to be maximized. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] Prior investigations involving patients with concomitant spinal and hip pathology have compared the performance of orthopaedic and neurosurgical specialists, attributing observed differences chiefly to variations in residency training. Neurosurgeons typically gain more intensive exposure to spinal procedures, whereas orthopaedic surgeons are trained across the full spectrum of spinal as well as appendicular musculoskeletal surgery. [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eIn the present investigation, we aimed to interrogate Taiwan\u0026rsquo;s Chang Gung Research Database (CGRD) to determine whether its tertiary-medical-center setting, finer subspecialty delineation, and richly detailed electronic medical records yield distinctive insights. Specifically, we compared orthopaedic and neurosurgical practitioners to ascertain which specialty more consistently orders comprehensive spine\u0026ndash;hip imaging and achieves a more thorough and accurate pre-operative diagnosis.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eData source\u003c/strong\u003e\u003cp\u003eThe Chang Gung Research Database (CGRD) is the greatest multi-institutional electronic medical records (EMR) database in Taiwan. It was derived from medical records of Chang Gung Memorial Hospital (CGMH) which is also the largest hospital system alliance in Taiwan. 15-year longitudinal data could be aggregated in detailed standardization format. Not only secondary data from billing order or charge codes, the CGRD has a more comprehensive dataset with original data, which may be better than national database like the Taiwan National Health Insurance Research Database (NHIRD). Compared with the NHIRD and medical-center cohorts in Taiwan, patients captured in the CGRD typically present with higher Charlson Comorbidity Index scores and a greater prevalence of select comorbidities, suggesting that the CGRD is particularly well suited for research on populations with more severe and complex diseases.[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] This study was approved by the Research Ethics Committee of Chang Gung Medical Foundation Institutional Review Board (no. 201801118B0)\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eStudy population\u003c/b\u003e: First, we applied predefined diagnostic codes to identify all patients who had concurrent diagnoses of both spinal disorders and hip-joint diseases in CGRD. Next, we identified specific procedure codes, including total hip arthroplasty (64162B), partial hip arthroplasty (64170B), fusion surgery (83043B, 83044B, 83045B, or 83046B), laminectomy (83002C or 83003C), or lumbar discectomy (83024C). We extracted data on patients aged 50\u0026ndash;85 who had undergone both hip and spine surgeries within the same 12-month period (total: 463).\u003c/p\u003e\u003cp\u003eFor the spine cohort, we limited inclusion to degenerative lumbosacral disorders, explicitly excluding vertebral fractures (ICD-9-CM: 805* or 806*), cervical spine conditions (ICD-9 CM: 723*), neoplasms, and infectious diseases. For the hip cohort, we likewise excluded any cases involving fractures.\u003c/p\u003e\u003cp\u003eWe collected all the remaining patients\u0026rsquo; demographic data, including surgeon specialty, the timing and items of radiographic examination and discharge diagnoses. We subsequently stratified the cohort into three groups according to the timing and sequence of their hip and spine surgeries: (1) underwent hip and spine surgery at the same admission (Both), (2) hip surgery prior to spine surgery (HS), and (3) spine surgery prior to hip surgery (SH). Patients in the SH (spine surgery prior to hip surgery) group were further subdivided into (1) spine surgery performed by an orthopedic surgeon (OS) or (2) spine surgery performed by a neurosurgeon (NS).\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eStatistics\u003c/strong\u003e\u003cp\u003eDescriptive statistics of the Both, HS, and SH groups were performed, including age, sex, the items and timing of image, Charlson Comorbidity Index (CCI), and specialty of the surgeon. Differences between the OS and NS groups were assessed using independent Student\u0026rsquo;s t-test for continuous variables and Chi-Square test for nominal variables. Significance was defined as p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 in two-tailed testing.\u003c/p\u003e\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eFrom the CGRD, we initially identified 463 patients aged 55\u0026ndash;85 who underwent both spine-related surgery and hip arthroplasty within the same 12-month window. After applying the Figure 1 exclusion criteria (eliminating 180 cases), 283 patients remained for analysis. Among these patients, 2 were included in Both group (hip and spine procedures during the same admission), 58 were categorized in HS group\u003cstrong\u003e\u0026nbsp;(\u003c/strong\u003ehip surgery performed before spine surgery), and 223 were included in SH group (spine surgery performed before hip surgery).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll hip operations were carried out by orthopaedic surgeons. Spine procedures were further stratified by surgical specialty into orthopaedic surgeon (OS) and neurosurgical surgeon (NS) subgroups. Comprehensive demographic characteristics, length of stay, interval between the two operations, and Charlson Comorbidity Index scores are summarized in \u003cstrong\u003eTable 1\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003eThe specialty distribution of surgeons across the study cohorts is illustrated in \u003cstrong\u003eTable 2\u003c/strong\u003e. Within the SH group, 45.29 % of spine operations were performed by orthopaedic surgeons, whereas 49.33 % were carried out by neurosurgeons. Overall, only about 15\u0026ndash;20 % of patients had consulted both orthopaedics and neurosurgery in the preoperative period. The preoperative imaging patterns across the three cohorts are detailed in \u003cstrong\u003eTable 3\u003c/strong\u003e. In the both-group, every patient underwent both spinal radiography and a KUB study. Among the HS group, roughly 40 % had a spine X-ray prior to surgery, whereas this proportion rose to 80.27 % in the SH group. Conversely, pelvic radiography was far more common in the HS cohort\u0026mdash;performed in 81.03 % of patients\u0026mdash;while only 21.08 % of those in the SH group received the same examination.\u003c/p\u003e\n\u003cp\u003eThe distribution of diagnoses recorded before surgery and at discharge are presented in \u003cstrong\u003eTable 4\u003c/strong\u003e. In the HS group, 63.79 % of patients already carried a spine-disease diagnosis preoperatively, while hip osteoarthritis and hip osteonecrosis were documented in 75.86 % and 51.72 % of cases, respectively. By contrast, the SH group showed a markedly higher preoperative prevalence of spine-related diagnoses at 98.21 %, whereas hip osteoarthritis and avascular necrosis of the femoral head were noted in only 17.94 % and 9.42 % of patients. At discharge, hip-related diagnoses in the SH cohort remained uncommon, with the combined frequency of hip osteoarthritis and osteonecrosis amounting to roughly 15 %.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5\u003c/strong\u003e shows distinct imaging habits between the two surgical specialties. In the OS group, 79.81 % of patients received spine radiograph before surgery, yet as many as 73.08 % underwent a combined study that included a spine X-ray plus either a KUB or pelvic radiograph. By contrast, in the NS group, 81.68 % had a spine X-ray, whereas just 51.35 % obtained both spine and hip films. Overall, orthopaedic surgeons ordered combined spine-and-hip imaging more frequently, whereas neurosurgeons more often relied on spine radiographs alone\u0026mdash;an inter-group difference that reached statistical significance. The pattern persists in \u003cstrong\u003eTable 6\u003c/strong\u003e: patients in the OS group had higher pre-operative rates of both spine-related and hip-related diagnoses than those in the NS group, although the differences did not achieve statistical significance.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eHip-spine disorders demand keen diagnostic acumen: a meticulous history, thorough physical examination, and judicious interpretation of imaging each contribute to a more reliable diagnosis. Our group previously examined hip-spine syndrome with Taiwan\u0026rsquo;s National Health Insurance Research Database (NHIRD) and published those findings; the present study tackles the same theme using the Chang Gung Research Database (CGRD) to provide a cross-database perspective.[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] Covering electronic medical records from multiple Chang Gung campuses between 2001 and 2024, the CGRD offers richer clinical detail, albeit with a smaller underlying population than the NHIRD. Patients drawn from this tertiary-care system show slightly longer median hospital stays and wider intervals between operations, underscoring the greater case complexity typical of level-III medical centers. [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] Because the CGMH network is built around such centers, the CGRD arguably captures practice patterns that best represent subspecialized care in Taiwanese medical-center settings. [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eOrthopedic surgeons in the CGRD cohort ordered hip-related radiographs far more frequently than their neurosurgical counterparts (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), thereby increasing the likelihood that hip lesions would be detected in patients they managed. This divergence almost certainly reflects the specialties\u0026rsquo; different training emphases: neurosurgeons focus primarily on central nervous system disorders, whereas orthopedic surgeons are more versed in limb skeletal, joint, and tendon pathology.\u003c/p\u003e\u003cp\u003eIn the NHIRD analysis, the pre-operative detection rate of hip osteoarthritis was higher when spine surgery was performed by orthopaedic surgeons\u0026mdash;a trend mirrored in the CGRD cohort, although the smaller CGRD sample meant the difference did not reach statistical significance. One plausible explanation is the tertiary-referral nature of the Chang Gung health-care system: many patients may have undergone initial hip assessments at primary or secondary facilities before being referred for definitive care, so those earlier diagnoses were not captured in the CGRD\u0026rsquo;s electronic records. Consequently, the apparent lack of a statistically significant difference in hip diagnostic rates may reflect under-documentation of hip pathology that had already been recognized outside the CGRD network.\u003c/p\u003e\u003cp\u003eAcross both the NHIRD and CGRD datasets, the SH-to-HS ratio consistently falls between 3 : 1 and 4 : 1, highlighting that clinicians most often treat spinal pathology before addressing the hip. Cases in the Both group are too few to support meaningful inference. In practice, the optimal order of intervention when spine and hip disease coexist remains controversial; the critical task is to identify the dominant pain generator, because operating on one site can either relieve\u0026mdash;or, in some instances, exacerbate\u0026mdash;symptoms arising from the other [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eNumerous studies address surgical sequencing in hip\u0026ndash;spine syndrome\u0026mdash;i.e., spine-first versus hip-first\u0026mdash;as well as the associated radiographic (spinopelvic) parameters. In contrast, the present study focuses on whether the preoperative imaging portfolio is sufficient to ensure the accuracy and completeness of the preoperative diagnosis. Among patients who underwent both lumbar spine surgery and total hip arthroplasty within a single year, the vast majority of hip pathologies were not identified prior to spine surgery, primarily due to inadequate imaging of the hip/pelvis. As a result, many patients experienced suboptimal symptom relief after spine procedures, necessitating further evaluation during which the hip lesion was ultimately recognized; subsequent hip surgery then produced meaningful clinical improvement. We also found that imaging-ordering practices vary by specialty training. Notably, the magnitude of specialty-related differences within this tertiary-care hospital system was smaller than that observed in the nationwide database, suggesting reduced inter-specialty variability in tertiary-center practice.\u003c/p\u003e\u003cp\u003eSeveral limitations merit mention. Although the CGRD is the largest single-system database in Taiwan, it still represents only a segment of the national population when compared with the NHIRD. Because the CGRD captures care delivered mainly at tertiary medical centers, many patients arrive after comprehensive work-ups in primary or secondary facilities, a referral pattern that may introduce diagnostic bias even as it reflects real-world practice. In addition, the diagnostic codes entered in electronic records can vary with each attending physician\u0026rsquo;s habits or administrative needs, potentially influencing case ascertainment. That said, the CGRD\u0026rsquo;s granular documentation allows for extensive cross-checking, which helps to minimize\u0026mdash;but not completely eliminate\u0026mdash;these sources of bias.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study aimed to delineate how orthopaedic surgeons and neurosurgeons differ in diagnosing hip\u0026ndash;spine syndrome, using the completeness of pre-operative imaging and the pattern of diagnostic codes as proxies for diagnostic accuracy and, ultimately, for enhancing treatment success. Consistent with our previous analysis of the NHIRD and the present investigation of the CGRD, the findings indicate that orthopaedic surgeons are more likely than neurosurgeons to order comprehensive imaging and to arrive at accurate diagnoses of hip pathology. Importantly, spine surgeons should explicitly consider the possibility of concomitant hip pathology before proceeding and ensure a sufficiently comprehensive preoperative work-up\u0026mdash;including targeted pelvis/hip imaging\u0026mdash;to support accurate diagnosis and surgical planning.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eHip\u0026ndash;spine syndrome (HSS)\u003c/p\u003e\n\u003cp\u003eelectronic medical-record (EMR)\u003c/p\u003e\n\u003cp\u003eChang Gung Research Database (CGRD)\u003c/p\u003e\n\u003cp\u003esacroiliac joint (SIJ)\u003c/p\u003e\n\u003cp\u003eTaiwan National Health Insurance Research Database (NHIRD)\u003c/p\u003e\n\u003cp\u003eCharlson Comorbidity Index (CCI)\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/strong\u003eThe need for informed consent was waived by the Ethics Committee/Institutional Review Board of the Institutional Review Board of Chang Gung Medical Foundation has approved this study (IRB No. 201801118B0). This study was conducted in accordance with the Declaration of Helsinki and its later amendments.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number:\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u0026nbsp;\u003c/strong\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author and first author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e There is no financial nor non-financial interests that are directly or indirectly related to the work submitted for publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eThere is no funding support in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eChao-Chien Chang: writing-Original Draft \u0026amp; Editing\u003c/p\u003e\n\u003cp\u003eFeng-Chih Kuo: methodology; data analysis\u003c/p\u003e\n\u003cp\u003eFu-Shine Yang: resources; methodology\u003c/p\u003e\n\u003cp\u003eCheh-Yung Chang: resources\u003c/p\u003e\n\u003cp\u003eChieh-Cheng Hsu: resources; Investigation\u003c/p\u003e\n\u003cp\u003eMeng-Ling Lu: resources; methodology\u003c/p\u003e\n\u003cp\u003eRe-Wen Wu: resources; Investigation\u003c/p\u003e\n\u003cp\u003eTsung-Cheng Yin (corresponding author): Conceptualization; methodology; review\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;Acknowledgements:\u0026nbsp;\u003c/strong\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSembrano JN, Polly DW, Jr.: \u003cstrong\u003eHow often is low back pain not coming from the back?\u003c/strong\u003e \u003cem\u003eSpine (Phila Pa 1976) \u003c/em\u003e2009, \u003cstrong\u003e34\u003c/strong\u003e(1):E27-32.\u003c/li\u003e\n\u003cli\u003eShemshaki H, Nourian SM, Fereidan-Esfahani M, Mokhtari M, Etemadifar MR: \u003cstrong\u003eWhat is the source of low back pain?\u003c/strong\u003e \u003cem\u003eJ Craniovertebr Junction Spine \u003c/em\u003e2013, \u003cstrong\u003e4\u003c/strong\u003e(1):21-24.\u003c/li\u003e\n\u003cli\u003eOffierski CM, MacNab I: \u003cstrong\u003eHip-spine syndrome\u003c/strong\u003e. \u003cem\u003eSpine (Phila Pa 1976) \u003c/em\u003e1983, \u003cstrong\u003e8\u003c/strong\u003e(3):316-321.\u003c/li\u003e\n\u003cli\u003eHuppert A, Ambrosio L, Nwosu K, Pico A, Russo F, Vadala G, Papalia R, Denaro V: \u003cstrong\u003ePrevious lumbar spine fusion increases the risk of dislocation following total hip arthroplasty in patients with hip-spine syndrome: a systematic review and meta-analysis\u003c/strong\u003e. \u003cem\u003eBMC Musculoskelet Disord \u003c/em\u003e2024, \u003cstrong\u003e25\u003c/strong\u003e(1):732.\u003c/li\u003e\n\u003cli\u003eBuckland AJ, Puvanesarajah V, Vigdorchik J, Schwarzkopf R, Jain A, Klineberg EO, Hart RA, Callaghan JJ, Hassanzadeh H: \u003cstrong\u003eDislocation of a primary total hip arthroplasty is more common in patients with a lumbar spinal fusion\u003c/strong\u003e. \u003cem\u003eBone Joint J \u003c/em\u003e2017, \u003cstrong\u003e99-B\u003c/strong\u003e(5):585-591.\u003c/li\u003e\n\u003cli\u003eDiebo BG, Beyer GA, Grieco PW, Liu S, Day LM, Abraham R, Naziri Q, Passias PG, Maheshwari AV, Paulino CB: \u003cstrong\u003eComplications in Patients Undergoing Spinal Fusion After THA\u003c/strong\u003e. \u003cem\u003eClin Orthop Relat Res \u003c/em\u003e2018, \u003cstrong\u003e476\u003c/strong\u003e(2):412-417.\u003c/li\u003e\n\u003cli\u003eGrammatopoulos G, Dhaliwal K, Pradhan R, Parker SJM, Lynch K, Marshall R, Andrade ATJ: \u003cstrong\u003eDoes lumbar arthrodesis compromise outcome of total hip arthroplasty?\u003c/strong\u003e \u003cem\u003eHip Int \u003c/em\u003e2019, \u003cstrong\u003e29\u003c/strong\u003e(5):496-503.\u003c/li\u003e\n\u003cli\u003eSing DC, Barry JJ, Aguilar TU, Theologis AA, Patterson JT, Tay BK, Vail TP, Hansen EN: \u003cstrong\u003ePrior Lumbar Spinal Arthrodesis Increases Risk of Prosthetic-Related Complication in Total Hip Arthroplasty\u003c/strong\u003e. \u003cem\u003eJ Arthroplasty \u003c/em\u003e2016, \u003cstrong\u003e31\u003c/strong\u003e(9 Suppl):227-232 e221.\u003c/li\u003e\n\u003cli\u003eRodkey DL, Lundy AE, Tracey RW, Helgeson MD: \u003cstrong\u003eHip-Spine Syndrome: Which Surgery First?\u003c/strong\u003e \u003cem\u003eClin Spine Surg \u003c/em\u003e2022, \u003cstrong\u003e35\u003c/strong\u003e(1):1-3.\u003c/li\u003e\n\u003cli\u003ePham MH, Jakoi AM, Wali AR, Lenke LG: \u003cstrong\u003eTrends in Spine Surgery Training During Neurological and Orthopaedic Surgery Residency: A 10-Year Analysis of ACGME Case Log Data\u003c/strong\u003e. \u003cem\u003eJ Bone Joint Surg Am \u003c/em\u003e2019, \u003cstrong\u003e101\u003c/strong\u003e(22):e122.\u003c/li\u003e\n\u003cli\u003eShao SC, Chan YY, Kao Yang YH, Lin SJ, Hung MJ, Chien RN, Lai CC, Lai EC: \u003cstrong\u003eThe Chang Gung Research Database-A multi-institutional electronic medical records database for real-world epidemiological studies in Taiwan\u003c/strong\u003e. \u003cem\u003ePharmacoepidemiol Drug Saf \u003c/em\u003e2019, \u003cstrong\u003e28\u003c/strong\u003e(5):593-600.\u003c/li\u003e\n\u003cli\u003eYin TC, Wegner AM, Lu ML, Yang YH, Wang YC, Kung WM, Lo WC: \u003cstrong\u003eDo Orthopedic Surgeons or Neurosurgeons Detect More Hip Disorders in Patients with Hip-Spine Syndrome? A Nationwide Database Study\u003c/strong\u003e. \u003cem\u003eBrain Sci \u003c/em\u003e2021, \u003cstrong\u003e11\u003c/strong\u003e(4).\u003c/li\u003e\n\u003cli\u003eBuckland AJ, Miyamoto R, Patel RD, Slover J, Razi AE: \u003cstrong\u003eDifferentiating Hip Pathology From Lumbar Spine Pathology: Key Points of Evaluation and Management\u003c/strong\u003e. \u003cem\u003eJ Am Acad Orthop Surg \u003c/em\u003e2017, \u003cstrong\u003e25\u003c/strong\u003e(2):e23-e34.\u003c/li\u003e\n\u003cli\u003eChavarria JC, Douleh DG, York PJ: \u003cstrong\u003eThe Hip-Spine Challenge\u003c/strong\u003e. \u003cem\u003eJ Bone Joint Surg Am \u003c/em\u003e2021, \u003cstrong\u003e103\u003c/strong\u003e(19):1852-1860.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"841\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" style=\"width: 841px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 1.\u003c/strong\u003e Demographics, length of stay, and Charlson Comorbidity Index (CCI) for each group.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 205px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 230px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHip and Spine Surgery in\u0026nbsp;\u003cbr\u003e\u0026nbsp;the Same Admission\u0026nbsp;\u003cbr\u003e\u0026nbsp;(Both) (n=2)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHip Before Spine Surgery\u003cbr\u003e\u0026nbsp;(HS) (n=58)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSpine Before Hip Surgery\u003cbr\u003e\u0026nbsp;(SH) (n=223)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 205px;\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 230px;\"\u003e\n \u003cp\u003e58.50 (4.95)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 208px;\"\u003e\n \u003cp\u003e65.26 (7.31)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 198px;\"\u003e\n \u003cp\u003e68.84 (8.75)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 205px;\"\u003e\n \u003cp\u003e1st hospital stays\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 230px;\"\u003e\n \u003cp\u003e36.0 (41.01)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 208px;\"\u003e\n \u003cp\u003e5.43 (2.11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 198px;\"\u003e\n \u003cp\u003e8.66 (6.50)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 205px;\"\u003e\n \u003cp\u003e1st + 2nd hospital stays\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 230px;\"\u003e\n \u003cp\u003e36.0 (41.01)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 208px;\"\u003e\n \u003cp\u003e15.98 (9.30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 198px;\"\u003e\n \u003cp\u003e15.10 (9.23)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 205px;\"\u003e\n \u003cp\u003eDuration between admissions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 230px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 208px;\"\u003e\n \u003cp\u003e195.71 (96.32)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 198px;\"\u003e\n \u003cp\u003e149.15 (93.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 205px;\"\u003e\n \u003cp\u003eCCI at 1st admission\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 230px;\"\u003e\n \u003cp\u003e0.50 (0.71)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 208px;\"\u003e\n \u003cp\u003e0.40 (0.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 198px;\"\u003e\n \u003cp\u003e0.43 (0.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 205px;\"\u003e\n \u003cp\u003eCCI at 2nd admission\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 230px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 208px;\"\u003e\n \u003cp\u003e0.74 (1.83)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 198px;\"\u003e\n \u003cp\u003e0.53 (1.16)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 205px;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 129px;\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 205px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 129px;\"\u003e\n \u003cp\u003e58.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e158\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e70.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 205px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 129px;\"\u003e\n \u003cp\u003e41.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e29.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"871\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" style=\"width: 870px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 2.\u0026nbsp;\u003c/strong\u003eComparison of the numbers of surgeries performed by orthopedic surgeons and neurosurgeons.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 407px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e \u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHip and Spine Surgery in\u0026nbsp;\u003cbr\u003e\u0026nbsp;the Same Admission\u0026nbsp;\u003cbr\u003e\u0026nbsp;(Both) (n=2)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 133px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHip Before Spine Surgery\u003cbr\u003e\u0026nbsp;(HS) (n=58)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 133px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSpine Before Hip Surgery\u003cbr\u003e\u0026nbsp;(SH) (n=223)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 407px;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 103px;\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 68px;\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 407px;\"\u003e\n \u003cp\u003eFirst surgery by orthopedic surgeon\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 103px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e100.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e104\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 68px;\"\u003e\n \u003cp\u003e46.64\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 407px;\"\u003e\n \u003cp\u003eFirst surgery by neurosurgeon\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 103px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e111\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 68px;\"\u003e\n \u003cp\u003e49.78\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 407px;\"\u003e\n \u003cp\u003eSecond surgery by orthopedic surgeon\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 103px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e62.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e203\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 68px;\"\u003e\n \u003cp\u003e91.03\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 407px;\"\u003e\n \u003cp\u003eSecond surgery by neurosurgeon\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 103px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e25.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 68px;\"\u003e\n \u003cp\u003e0.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 407px;\"\u003e\n \u003cp\u003eOrthopedic clinic visit before first surgery (\u0026lt;6 months)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 103px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e100.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e146\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 68px;\"\u003e\n \u003cp\u003e65.47\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 407px;\"\u003e\n \u003cp\u003eNeurosurgery clinic visit before first surgery (\u0026lt;6 months)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 103px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e15.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e121\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 68px;\"\u003e\n \u003cp\u003e54.26\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 407px;\"\u003e\n \u003cp\u003eOrthopedic and neurosurgery clinic visits before first surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 103px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\n \u003cp\u003e15.52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\n \u003cp\u003e44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 68px;\"\u003e\n \u003cp\u003e19.73\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 407px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 103px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 65px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 67px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 1px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"851\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" style=\"width: 851px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 3\u003c/strong\u003e. Comparison of preoperatively arranged imaging studies in each group.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 253px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHip and Spine Surgery in\u0026nbsp;\u003cbr\u003e\u0026nbsp;the Same Admission\u0026nbsp;\u003cbr\u003e\u0026nbsp;(Both) (n=2)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 201px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHip Before Spine Surgery\u003cbr\u003e\u0026nbsp;(HS) (n=58)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSpine Before Hip Surgery\u003cbr\u003e\u0026nbsp;(SH) (n=223)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 253px;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 106px;\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 119px;\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 253px;\"\u003e\n \u003cp\u003eHad spinal AP and spine lateral\u003cbr\u003e\u0026nbsp;X-rays before first surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 106px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e39.66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e179\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 119px;\"\u003e\n \u003cp\u003e80.27\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 253px;\"\u003e\n \u003cp\u003eHad KUB X-ray before first surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 106px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e51.72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e139\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 119px;\"\u003e\n \u003cp\u003e62.33\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 253px;\"\u003e\n \u003cp\u003eHad pelvic X-ray before first surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 106px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 92px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 68px;\"\u003e\n \u003cp\u003e47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp\u003e81.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 119px;\"\u003e\n \u003cp\u003e21.08\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"869\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" style=\"width: 869px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 4.\u0026nbsp;\u003c/strong\u003eComparison of the diagnoses of spine or hip disorders in each group.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 345px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 198px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHip and Spine Surgery in\u0026nbsp;\u003cbr\u003e\u0026nbsp;the Same Admission\u0026nbsp;\u003cbr\u003e\u0026nbsp;(Both) (n=2)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 166px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHip Before Spine Surgery\u003cbr\u003e\u0026nbsp;(HS) (n=58)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 161px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSpine Before Hip Surgery\u003cbr\u003e\u0026nbsp;(SH) (n=223)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 345px;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003en\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 345px;\"\u003e\n \u003cp\u003eHad spinal disease-related diagnosis before surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e63.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e219\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e98.21\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 345px;\"\u003e\n \u003cp\u003eHad hip osteoarthritis diagnosis before surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e75.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e17.94\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 345px;\"\u003e\n \u003cp\u003eHad hip osteonecrosis diagnosis before surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e51.72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e9.42\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 345px;\"\u003e\n \u003cp\u003eHad spine-related-diagnosis at first discharge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e13.79\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e195\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e87.44\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 345px;\"\u003e\n \u003cp\u003eHad hip-related diagnosis at first discharge\u003cbr\u003e\u0026nbsp;(osteoarthritis)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e67.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e9.42\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 345px;\"\u003e\n \u003cp\u003eHad hip-related diagnosis at first discharge\u003cbr\u003e\u0026nbsp;(osteonecrosis)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 99px;\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e44.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 79px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 81px;\"\u003e\n \u003cp\u003e4.93\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"870\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" style=\"width: 870px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 5\u003c/strong\u003e. Comparison of preoperative imaging studies.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 397px;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSpine Surgery Was Performed by OS (n = 104)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSpine Surgery Was Performed by NS (n = 111)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-Value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 397px;\"\u003e\n \u003cp\u003ePreoperative spinal X-ray \u0026lt;6 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003e83 (79.81)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 208px;\"\u003e\n \u003cp\u003e94 (81.68)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003ep \u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 397px;\"\u003e\n \u003cp\u003ePreoperative spine X-ray + KUB or pelvic X-ray \u0026lt;6 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 189px;\"\u003e\n \u003cp\u003e76 (73.08)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 208px;\"\u003e\n \u003cp\u003e57 (51.35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003ep \u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"862\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\" style=\"width: 862px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 6\u003c/strong\u003e. Comparison of preoperative imaging studies.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 1px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 293px;\"\u003e\n \u003cp\u003e \u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 227px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSpine Surgery Was Performed by OS (n = 104)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 217px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSpine Surgery Was Performed\u003cbr\u003e\u0026nbsp;by NS (n = 111)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 125px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-Value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 293px;\"\u003e\n \u003cp\u003eSpine-related diagnosis before surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 227px;\"\u003e\n \u003cp\u003e104 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 217px;\"\u003e\n \u003cp\u003e108 (97.30)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 125px;\"\u003e\n \u003cp\u003e0.022\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 293px;\"\u003e\n \u003cp\u003eHip-related diagnosis before surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 227px;\"\u003e\n \u003cp\u003e28 (26.92)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 217px;\"\u003e\n \u003cp\u003e24 (21.62)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 125px;\"\u003e\n \u003cp\u003e0.186\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 293px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 227px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 217px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 125px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd style=\"width: 1px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Hip-spine syndrome (HSS), tertiary-care database, orthopedic surgeon, neurosurgeon","lastPublishedDoi":"10.21203/rs.3.rs-7771457/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7771457/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eHip-spine syndrome (HSS) poses a diagnostic challenge because lumbar degenerative disease, sacro-iliac joint dysfunction, and hip osteoarthritis often produce overlapping symptoms. Earlier work suggested that orthopaedic surgeons order hip imaging and identify hip pathology more consistently than neurosurgeons when treating patients who eventually require both lumbar and hip operations. Whether this observation holds in a tertiary-care electronic medical-record (EMR) setting remains unknown.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eWe queried the Chang Gung Research Database (CGRD), the largest multi-institutional EMR repository in Taiwan, for patients aged 50\u0026ndash;85 years who underwent both hip arthroplasty and lumbar surgery within the same 12-month period between 2001 and 2024. Cohorts were categorised as hip-then-spine (HS, n\u0026thinsp;=\u0026thinsp;58), spine-then-hip (SH, n\u0026thinsp;=\u0026thinsp;223), or simultaneous procedures (Both, n\u0026thinsp;=\u0026thinsp;2). SH patients were stratified by the specialty of the spine surgeon: orthopaedic (OS, n\u0026thinsp;=\u0026thinsp;104) versus neurosurgical (NS, n\u0026thinsp;=\u0026thinsp;111). Primary outcomes were (1) pre-operative ordering of combined spine\u0026thinsp;+\u0026thinsp;pelvis/hip radiography and (2) documentation of hip pathology before spine surgery. Group differences were analysed with χ\u0026sup2; or Student\u0026rsquo;s t tests (α\u0026thinsp;=\u0026thinsp;0.05).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eIn the SH cohort, combined spine-and-hip imaging was obtained significantly more often by OS than by NS (73.1% vs 51.4%; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Hip osteoarthritis or osteonecrosis was recorded pre-operatively in 26.9% of OS cases versus 21.6% of NS cases, a non-significant difference attributable to limited sample size. The SH:HS ratio showed approximately 4 : 1, indicating that spine surgery typically precedes hip arthroplasty in routine practice.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eWithin a tertiary-care EMR database, orthopaedic surgeons were more likely than neurosurgeons to order comprehensive spinopelvic imaging, thereby enhancing detection of hip pathology in HSS. These cross-database findings underscore the importance of routine hip assessment before lumbar surgery and support efforts to harmonise diagnostic protocols across specialties.\u003c/p\u003e","manuscriptTitle":"Missed Hips, Missed Opportunities: Specialty-Driven Differences in Evaluating Hip– Spine Syndrome","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-30 12:17:38","doi":"10.21203/rs.3.rs-7771457/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-28T10:32:25+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-16T19:47:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"200562202442086952148200143158874258537","date":"2025-10-16T19:35:50+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-16T15:52:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"266412379611879260095544211743146041832","date":"2025-10-16T15:13:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"2416685335451389869962973261885867253","date":"2025-10-16T14:51:04+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-16T13:48:25+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-10-15T08:08:01+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-15T08:05:01+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-14T07:07:44+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Musculoskeletal Disorders","date":"2025-10-14T07:05:12+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a38b9dd8-fd2f-496f-b95d-5155e38524be","owner":[],"postedDate":"October 30th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-01-12T16:13:58+00:00","versionOfRecord":{"articleIdentity":"rs-7771457","link":"https://doi.org/10.1186/s12891-025-09479-x","journal":{"identity":"bmc-musculoskeletal-disorders","isVorOnly":false,"title":"BMC Musculoskeletal Disorders"},"publishedOn":"2026-01-10 15:57:32","publishedOnDateReadable":"January 10th, 2026"},"versionCreatedAt":"2025-10-30 12:17:38","video":"","vorDoi":"10.1186/s12891-025-09479-x","vorDoiUrl":"https://doi.org/10.1186/s12891-025-09479-x","workflowStages":[]},"version":"v1","identity":"rs-7771457","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7771457","identity":"rs-7771457","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}