What are the goals of surgery for Flatback Syndrome?

Flatback syndrome is a condition of spinal imbalance after spinal surgery which leads to symptoms such as pain, fatigue, a sensation of falling forward, and stooping at the end of the day. This condition is not uncommon after scoliosis correction using the Harrington rod and technique. The cause of this syndrome is related to the straightening of the scoliosis curve which by the same token straightens the normal lumbar lordosis necessary for good spinal balance. Most people can compensate for this surgically created imbalance for many years, however eventually it hurts more and more. Effective treatment of this condition requires a perfect realignment of the spine to restore the most ideal balance. It is also important in young adults with this problem, to preserve the last intervertebral discs at the bottom of the spine to preserve mobility.

Corrective surgery for flatback correction consist of Harrington rod removal, osteotomies of the fusion mass and replacement of instrumentation to maintain the corrected position of the spine until healing of the osteotomies. The new instrumentation is permanently left in place. This surgery is complex and requires significant expertise and experience. We have recently published a scientific paper in 'Spine' on Flatback (Vol 22, October 15 1997) and a simpler description of the same problem in 'Back Talk' (Vol.20 #1 Jan-Feb.1997).

If your questions are not answered here please feel free to contact us.

What does Flatback Syndrome mean?

The back (the spine) is a very complex structure. Each vertebra's anatomy is different to to participate in the global structure and function of the spine. Carrying and protecting nerve structures from the brain to the limbs, bearing the weight of the head and body and keeping stability while allowing smooth motion are all part of the demands placed upon the spinal column. The succession of four natural spine curves balancing each other in the sagittal plane permits meeting the above-mentioned challenges. When the natural curves are modified good balance and function is compromised. When anatomic changes cause the curves to become straightened leading to a pitched forward posture, pain, imbalance fatigue and dysfunction develop. This is called the "Flatback" and is most commonly related to spinal fusion performed for scoliosis surgery.

If your questions are not answered here please feel free to contact us.

Why does Flatback happen?

The process of aging modifies the lumbar natural lordosis into a loss of lordosis and ultimately slight kyphosis. This natural evolution with aging leads to some degree of Flatback. This natural Flatback is usually limited by ankylosis and is not always symptomatic. However, when surgical fusion is performed to treat spinal deformity such as scoliosis, and the balance in the sagittal plane is altered, a flatback may develop that can lead to symptoms.

If your questions are not answered here please feel free to contact us.

Why did the pain and stooping appears such a long time after my
first operation?

Assuming the first operation took place when you were an adolescent, you had the ability to accommodate with poor balance for a long period of time. The discs and ligamentous structures which were unevenly overloaded were healthy and resilient and it took time for those structures to "wear out" and degenerate. When these supportive structures of the spine begin to fail, the flatback syndrome develops. The symptoms of pain and progressive stooping can gradually worsen and a vicious cycle begins. This whole process may take 15 to 20 years or more to develop. Thus, if the first surgery was performed between the age of 12 to 15 years of age the symptoms of flatback usually do not surface until the late 30's. Flatback can develop more rapidly in patients operated as adults.

If your questions are not answered here please feel free to contact us.

My doctor said that my balance was bad, he also talked about
malalignment of my Spine. What does this mean?

Most likely, he is referring to your clinical and radiological evaluation, which may reveal a departure from the definition of good acceptable balance of a fused spine. In a standing position the head is above the pelvis and the gravity line (plumb line) dropped from the center of the head (odontoid process of C2) should fall between the two ankles passing by the middle of the sacrum.

The plumb line projects on a sagittal film from the odontoid process to mid distance between the sacral promontory and the projection of the femoral heads. If the evaluation showed the gravity line anteriorly displaced it means that the spine is out of balance as a result of malalignment. Other clues to flatback are a flexed position of the hips and sometimes a hyperextension of the upper back and neck.

If your questions are not answered here please feel free to contact us.

What is the best way to treat a severe Flatback?

When non-operative treatment does not offer relief then surgical realignment and refusing the spine in good balance may be the best surgical technique to offer. If this surgical protocol is applied early enough then discs under the misaligned fusion may still be salvaged.

If your questions are not answered here please feel free to contact us.

How does the surgeon know if the discs below my previous fusion
can be saved?

Disc evaluation may be performed in using discograms and MRI scans. In many patients it seems that even with signs of early degeneration, discs may continue to function well if good spinal alignment above them is achieved.

If your questions are not answered here please feel free to contact us.