Flat Back Syndrome

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).

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.


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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