Questions About Flatback Deformity

  1. What is Flatback Syndrome?

    The spine has a normal natural arch (called lordosis) in the low back that allows us to stand straight. When we lose this arch, the lumbar spine becomes flat, hence the term “Flatback”. Flatback syndrome is most commonly caused by previous fusion surgery that did not take into account this natural arch, rendering the lumbar spine flat. An example is Harrington instrumentation that was done for scoliosis many years ago. However, many patients who have had fusion for degeneration many years ago can also develop flatback syndrome if the instrumentation did not recreate the natural lumbar lordosis.

  2. What are the goals of surgery for Flatback Syndrome?

    Patients with Flatback syndrome have spinal imbalance which leads to a sensation of falling forward, and stooping forward as patient stands and walks. Stooping forward leads to significant pain and fatigue and is a very disabling problem. The goal of treatment is to recreate the natural arch in the low back so that the patient can stand straight and no longer stoop forward. The surgery involves removing all previous instrumentation (Harrington rods for example), performing osteotomies (which means breaking the joints in the spine) and placing new instrumentation to maintain the corrected position of the spine. It is a complex operation that requires significant expertise and experience.

  3. My surgery was done when I was a teenager, why am I having problems now?

    Harrington instrumentation was done for adolescents with scoliosis throughout the 1960s, 70s and 80s. Many patients with Harrington rods developed flatback right after surgery. But because they were young, they were able to compensate for this flatback deformity. The discs and ligaments that were unevenly overloaded as a result of the fusion were able to withstand the forces placed on them for many years. Eventually, as the spine ages, these structures gradually degenerate and “wear out”. When the patient is no longer able to compensate for the flatback, symptoms of pain and progressive stooping forward gradually develop. This process takes 2-3 decades, or longer, to unfold. Thus, if the Harrington fusion was done when the patient was a teenager, typically that patient does well throughout their 20s (healthy discs and young age able to compensate), and it is not until late 30’s and 40’s when they develop symptoms.

  4. What type of surgery is done for flatback syndrome?

    There are several options for treating flatback, and the details depend on many patient factors. In all cases, the surgery is very extensive and requires significant surgeon experience and training. In many cases the surgery can be done from the back of the spine (called posterior fusion), involving osteotomies. Osteotomies involve breaking the vertebrae and joints in the spine to allow correction of the deformity. In some patients, it is preferable to approach the spine from the front (anterior) and back. This is commonly called a “front-back fusion”, or “360 degree fusion”.

    In some patients, especially those who have had extensive fusions done in the past, the surgery may need to be staged. This means that the surgery is divided into 2 stages, performed on different days. For example, if the surgeon anticipates that the surgery will take 9 hours to complete, this can be done in 2 surgeries, each lasting about 4.5 hours.

  5. What is the recovery like after surgery for flatback syndrome?

    Patients are usually in the hospital for several days, at least 5-7 days, sometimes longer. It takes several weeks to recover from this extensive operation, and much of this depends on the type of surgery that is done and the patient’s age. Physical therapy is a critical part of the recovery process.