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).
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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.
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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.
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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.
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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.
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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.
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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.
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to contact
us.
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