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Flatback and Related Syndromes
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| Dr. Jean-Pierre C. Farcy being interviewed on FOX Health Report |
Flatback syndrome is a condition related to poor spinal alignment which
leads to symptoms such as back pain, bad posture with hips and
knees flexed while standing and a tendency to stoop forward at
the end of the day with increasing pain and fatigue in the back
and legs. This syndrome is mostly related to previous scoliosis
surgery and particularly the placement of Harrington rods extending
to the lumbar
spine.
It has become clear over the last decade that a direct relationship
exists between operations for scoliosis spinal fusion
with correction of the deformity by Harrington rod (and technique)
as an adolescent and the development of flatback as an adult.
In fact before the Harrington technique, which was developed in
the mid sixties, scoliosis was described as a deformity that affected
the spine as a rotational deformity evolving progressively into
a twisted shape similar to a spiral staircase. This abnormal deformation
of the spine leads to a rib cage deformity, which is apparent
on the patient as a hump when seen from the back.
Historically, with the development of Xray techniques, scoliosis
was evaluated on patients by obtaining chest films by postero-anterior
exposure. In the sixties it became routine to evaluate scoliosis
on a standing Xray with a similar exposure showing a projection
of the spine on antero-posterior films. We now know that this
radiographic technique does not provide sufficient information
on the complex shape of the spine. Spinal column evaluation must
be at least made on two films one antero-posterior and the other
lateral.
It is important to note that in a healthy spine there are several
normal curvatures of the spine seen from the side (sagittal view)
which are balanced such that the head remains centered over the
hips when standing. In scoliosis the local contour and balance
of the spine can be altered. In planning surgical treatment one
must carefully consider the effects on spinal balance to ensure
long-term success. As a result of the limited understanding of
scoliosis based on Xrays in the frontal
plane only, oversight of the sagittal plane may lead to treatment
of the frontal
plane curvature only. Many patients treated in the past had
a correction of their scoliosis which did not disturb the overall
balance of their spine. In some patients surgical treatment with
long fusions (and instrumentation in distraction) for scoliosis
correction, problems have developed with spinal imbalance and with
that a progressive development of a flatback (fig. 3,4 & 5).
Some degrees of spinal imbalance may be well tolerated by a patient.
This imbalance can be adjusted for by spinal segments which are
still mobile (not included in the fusion). However, when significant
malalignment has been created these mobile segment of the spine
will gradually 'wear out' with development of ligament and
disc
degeneration. As a result back pain, fatigue, and progressive
deterioration of endurance and posture can develop. Neck pain
may also be present due to the poor posture requiring additional
strain on the neck in order to maintain level vision. In severe
cases the entire upper spine may become deformed (swan neck deformity).
The treatment of flatback can be challenging. In mild cases of
malalignment the intitial treatment may focus on physical therapy
and functional rehabilitation of the back, buttock and leg muscles.
In moderate and severe cases, a non-operative approach may not
be sufficient. The treatment options may then include surgery
in order to obtain a correction of the spinal
alignment and a stable, well balanced spinal column. If there
are levels of the lumbar
spine that have not been fused in the intitial scoliosis surgery
but have become very degenerated, then surgery may include a fusion
of additional spinal levels in order to obtain balance and a solid,
painless spine. If it is not possible to obtain adequate spinal
re-alignment through fusing additional levels, then the previous
fusion may have to be cut (osteotomy)
in order to obtain correction through the old fusion. The surgery
in such a setting is very difficult, and only very experienced
teams should perform such operations. The risks can be significant
and the complication rates, even in the best of hands are not
low. With a good realignment of the spine, excellent results are
possible.
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