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Flatback Syndrome

WHAT IS FLATBACK SYNDROME:
Flatback Syndrome is a postural defect that results from a reduction in the patient's lordosis, or backwaist curve, that leans the person forward in a malaligned position. Also called Flatback Deformity, the condition is a deformity of the spine in the Sagittal Plane in which the vertebral disks at the person's backwaist are pushed outward. This reduces the backwaist curve so that it appears "flat" or flatter than it was originally. This abnormal posture causes a myriad of predictable symptoms which are extremely painful and disabling, along with psychological symptoms that come with knowing one's body is deformed.

CAUSES OF FLATBACK SYNDROME:
Flatback Syndrome has muliple causes, but it is usually a direct consequence of spinal fusions performed for scoliosis. It has become clear over the last decade that a direct relationship exists between operations for scoliosis (specifically spinal fusion with correction of the curvature by Harrington rod technique) as an adolescent in the 1960s, 1970s, and 1980s and the development of Flatback as an adult. The most common cause of Flatback Syndrome in a scoliosis patient, thus, is from the accumulated distraction forces of a Harrington Rod Spinal Hardware System implanted in the 1960s, 1970s and possibly 1980s. This spinal hardware, which is now considered faulty and no longer being used, has been found over time to force an outward shift of disks below the fusion. Flatback Syndrome can thus occur decades after an adolescent or young adult has had a spinal fusion and is least expecting further scoliosis problems.

Flatback Syndrome may also be congenital or a component of Adult Degenerative Scoliosis, which is primarily a result of aging disks. In rare cases it can also be caused by poorly-done surgery on non-scoliosis-related disk disorders such as herniations, with treatment consisting of spinal fusions limited to two or three vertebrae. This article addresses Flatback Deformity which comes specifically as a consequence of Spinal Fusion for Scoliosis, although patients with the condition caused by other factors may also find much of its information useful.

Flatback syndrome can also occur immediately after spinal fusion surgery if the surgeon reduces the patient's degrees of lordosis to amounts which are intolerable for the patient's to adjust. This is called Iatrogenic Flatback, or that which is caused by poor techniques used in the medical intervention itself. In the late 1980s, new spinal instrumentation was developed that made it possible for the first time for surgeons to perform 3-D corrections of the spine, allowing the alignment of scoliotic spines into a more normal configuration in all three planes. In attempting such complicated manipulations, however, spinal surgeons retained an emphasis on straightening the spine up the middle of the back and did not fully appreciate the importance of maintaining balance in the Sagittal Plane. Thus, the patient's lordosis (or back waist curve) was often reduced to a degree that met the surgeon's standard for "average," but did not maintain the curve to which the patient's body had adapted throughout his/her life up to that time. This lack of understanding of the importance of maintaining the patient's original lordosis curves produced most of the Flatback Syndrome cases that were induced immediately after surgery (iatrogenic cases) in the 1980s.

While most spinal surgeons today are aware of the extreme consequences of reducing the backwaist curve during spinal fusions, they are apparently still not totally able to prevent Flatback Syndrome. Part of the reason for this failure is that correction of a scoliotic spine that is malaligned in two or three different planes is tricky, and correction consists of making compromises in order to get the best overall results. Flatback Syndrome is particularly problematic for patients who enter surgery with hyperlordosis, or a degree of lordosis that is considered too high to be within the normal range. Flatback occurs most often today in fusion extensions from the thoracic spine through the lumbar region to the sacrum, in which a surgeon reduces the patient's lordosis (back waist curve) too much with no "free" or unfused disks left to compensate for the change.

In older scoliosis fusions, Flatback Syndrome can gradually occur from other fusion-related causes such as failing instrumentation, pseudoarthrosis (inability of the spine to solidly fuse at various locations), or collapse of the anterior portion of the disks in a posterior-only fusion.

Differences Between Flatback Syndrome in the Harrington Rod Patient and Iatrogenically (Surgically-Caused) Flatback Syndrome:

HARRINGTON ROD - INDUCED FLATBACK:

  1. Occurs gradually over time, allowing the body to adapt gradually to many of the changes in lordosis until a critical point is reached where there are no more ways for the body to compensate for the steadily reducing curve at the backwaist.
  2. Because of the gradual change in lordosis, symptoms may not be noticed for 10-20 years.
  3. When at the 10-20 year point, patients realize they have become noticeably deformed, with obvious leaning-forward postures that prevent them from even raising their heads to look straight, making the condition easy for doctors to diagnose.

IATROGENICALLY (SURGICALLY-INDUCED) FLATBACK:

  1. Occurs immediately on the operating table so that patients usually feel unbalanced right away while noticing that they also look different and discover they can't fit into previously-worn clothes--yet they are unable to determine exactly what is "wrong."
  2. Since this form of Flatback occurs all at once, the body cannot adjust to the huge sudden change of lordosis reduction, and symptoms begin occurring in 1-3 years rather than 10-20.
  3. Since most cases of Iatrogenically-Induced Flatback are caused in scoliosis patients who originally had hyperlordosis (see section below on Hyperlordosis in the Spinal Fusion Patient), their new backwaist curves are NOT flat, but are just reduced to an extent that their bodies cannot tolerate; therefore they do not present as particularly deformed. (Compensatory knee bending and neck craning, unconsciously performed by the patient, may indeed make such victims look nearly normal, even to the trained eye.)
  4. Because these Flatback patients do not appear deformed to most doctors--even to scoliosis experts, who associate Flatback Syndrome with the "key" sign of completely flat backwaists--these patients often spend many devastating years going from doctor to doctor until they are able to obtain correct Flatback diagnoses; in the meantime, these patients are often identified mistakenly as psychiatric cases, leading to treatment with inappropriate medications and therapies, accompanied by intense frustration. (This is why scoliosis patients are advised to ALWAYS gather and retain their x-rays, because Iatrogenic Flatback can only be 100% confirmed by spinal surgeons who can compare patients' before and after x-rays to see their changed lordosis curvatures.) 5. Because patients with Iatrogenically-Induced Flatback cases do not appear as "deformed," there is a tendency on the part of doctors--even scoliosis experts--to advise against corrective surgery even though their physical symptoms, pain, and disabling aspects are just as severe as those Flatback patients who "look" worse; therefore, their access to appropriate osteotomies can be impeded.

WHICH DOCTORS TREAT FLATBACK SYNDROME:
Scoliosis Research Society (SRS) Dr. Michael LaGrone of Amarillo, Texas (Baptist St. Anthony Hospital) is one of a handful of spinal surgeons in the United States recognized as a Flatback Syndrome expert. In the late 1990s, he authored an extensive document called "Spinal Surgeon Seminar: Flatback Syndrome" for the spinal surgeon community. The article guides SRS spinal surgeons in both preventing Flatback Syndrome during spinal fusion surgeries of scoliosis patients and correcting Flatback Syndrome after if has occurred by using various operating techniques. (Patients can obtain this document at a medical library, often located in large city hospitals or medical schools, that is open to the public. Call first to inquire.)

Although many spinal surgeons can perform the osteotomy operations to correct Flatback, a Scoliosis patient with a Spinal Fusion needing such surgery should ONLY go to a surgeon recognized as a scoliosis expert who can perform full scoliosis correction surgeries (formerly known as "salvage" surgeries and more recently, as scoliosis "revision" surgeries). That is because a patient with Flatback Deformity must be fully assessed as to whether any other work should be done to correct the old spinal fusion at the same time. At the same time, spinal hardware may have to be removed; pseudoarthroses remended; and curvatures reoriented in order to obtain a good overall result. The surgeons who specialize in corrective surgeries for previously spinally fused patients are NOT the same ones who do original spinal fusions on adolescents with scoliosis. These scoliosis correction surgeons must have a great deal more expertise and many more years of experience in order to successfully operate on spines that have already been functionally reduced by previous operations.

A scoliosis patient considering having a "failed" spinal fusion for scoliosis redone or one who needs surgical correction for Flatback Syndrome would be well advised to choose a surgeon from the list of members in the Scoliosis Research Society. Doctors here are orthopedists trained specially as spinal surgeons who have been further prepared to do the complex spinal manipulations required for spinal fusions for scoliosis. The SRS site publishes a list of its scoliosis spinal surgeons by state and country. Keep in mind that most surgeons on the list limit themselves to first-time scoliosis fusions and are NOT specially trained to take failed spinal fusion patients and properly correct them. The Flatback Deformity patient should ask all SRS doctors s/he visits how many correction surgeries they do a year on adults who have already been surgically treated for scoliosis, in addition to how many osteotomies they have done to correct Flatback Deformity. They will find that spinal surgeons who are recognized as experts in scoliosis correction tend to be located in a finite number of large cities; these doctors dedicate themselves to doing at least 50 to 100 of these specialty surgeries a year in order to keep technique levels high. That is because there is definitely an "art" to getting the best possble results with the least amount of risk and experience is the greatest factor in ensuring success. Doctors consulted by these patients should also be able to assure them that they are familiar with Dr. LaGrone's very important document, "Spinal Surgeon Seminar: Flatback Syndrome" and fully adhere to its principles.

Patients should ask to see before-and-after pictures of the doctors' former patients, which are freely offered by most top surgeons, and can ask to be referred to some patients they can call. Keep in mind that even the best doctors do not have a 100% success rate, so you should also expect to hear about cases that did not turn out well--if your doctor is being honest with you. Ask surgeons for details on their surgical results including complications, which occur in the area of 15% for even the best of surgeons. Expect to hear frank and forthright descriptions. The most common complications of this type of surgery are pseudoarthroses, or areas of the spinal bone that do not fully fuse (creating a nonunion), followed by transient and sometimes permanent nerve damage, and infection. There are many other possible complications, from temporary bladder dysfuction to paralysis (which is exceedingly rare today), but they are too numerous to mention here. Be aware that some of these complications may require followup surgeries to resolve.

It is VITAL for the patient who suspects s/he may have Flatback Syndrome to obtain second and third opinions from top spinal surgeons and to ask direct questions about their often differing assessments and recommendations. Flatback Syndrome is treated in great numbers in the U.S. today by only by a dozen or two SRS surgeons scattered across the country. This is because spinal surgeons do not train extensively in this aspect of spinal surgery, as they expect the need for Flatback Syndrome corrections to greatly diminish after the troublesome first generation Harrington Rod failures are treated. Also, better overall surgical techniques and less problematic hardware are hoped to create many fewer cases. Besides Dr. LaGrone, who practices at Baptist St. Anthony Hospital in Amarillo, TX, Flatback Syndrome/failed spinal fusion specialists are primarily located in the large cities and major hospitals of Boston, New York City, Baltimore, St. Louis, Minnesota, and San Francisco. Unfortunately, there are no doctors in the South who do these surgeries successfully in great numbers, so southerners must be prepared to travel.

Patients in the United States needing scoliosis correction surgery of any kind should call the National Scoliosis Foundation in Massachusetts at 1-800-673-6922 and ask specifically for all information they can mail on treatment for failed fusions in adults. NSF can also furnish a list of SRS doctors in their regions in addition to advice on finding a specific surgeon with experience in correcting fusions that have failed in adults. DO NOT go to a scoliosis surgeon whose major practice is original spinal fusions for adolescents. If s/he still cannot find an appropriate physician, a patient can start by calling 1-806-354-2529 to speak to Dr. LaGrone. He is the only doctor of this specialty known to conduct phone consults with a patient's mailed x-rays before the patient has to commit to long distance travel to find out if s/he can or should be helped.

SYMPTOMS OF FLATBACK SYNDROME:
Flatback syndrome exacerbates the complications of a spinal fusion by adding severe postural problems to which the body cannot usually adapt. The patient presents with leaning forward posture that comes from the patient unconsciously hyperextending the knees and hips in efforts to stand up straighter and not look hunchbacked. Over time, this posture can result in degeneration of the chronically pressured and inflamed knees, an abnormal walking gait, and permanent damage with severe pain to the hips and sacro-iliac joints. In order to see straight ahead, the patient must also hyperextend the neck, which can lead to collapse and herniation of the cervical neck disks as well as malalignment of the jaw with TM (temporomandibular) Disorder. Thoracic outlet syndrome can accompany this surgically-created condition because the leaning-over posture restricts the thoracic opening for the nerves running down into the hands and arms, causing "dead arm." Severe fatigue and pain of the back muscles is common so that a person cannot remain upright for long periods of time. In addition, the malaligned posture of Flatback Syndrome pushes internal organs and structures into abnormal positions, and can, for example, even alter the vaginal opening of female patients so that there is (often unrecognized) reduction of sexual pleasure.

Because severe Flatback Syndrome virtually never occurs in the natural world and results primarily as a consequence of spinal fusions, this deformity is universally unknown outside the spinal surgery community. It may also not still be fully appreciated even by all spinal doctors who are not scoliosis-centered. Thus, patients who are 5, 10, 20, or even 30 years post-fusion for scoliosis may seek treatment from medical specialists who do not recognize this condition, as they visit orthopedists for what they think are unrelated knee problems, pinched nerves in the neck, or other diverse symptoms. In addition, since spinal surgeons are loathe to diagnose Flatback Syndrome (since it is a consequence mainly of either old substandard hardware used in spinal fusions or poor surgical technique), patients who see spinal experts who recognize the deformity might not be told in definite terms that they have it. Many patients thus do not realize that they have Flatback Syndrome until it has caused permanent damage to multiple joints, muscles, and nerves. This is unfortunate, because the condition can be almost completely reversed with few, if any, lingering aftereffects if diagnosed and surgically corrected within about two years after symptoms start. The end result of Flatback Syndrome is often worse than the initial disability (the curved spine of scoliosis) that was to have been corrected. Increasing damage to the legs, hips, arms, hands, back, and neck from Flatback Syndrome can, over time, render many people permanently disabled.

The more unusual man who ends up with Flatback Syndrome from a former scoliosis fusion (more unusual because men are afflicted with severe scoliosis requiring some kind of surgery in a 1:10 ratio as compared with women in the first place) is often told that the spinal surgeon will attempt to restrict his corrective operation to a posterior-only approach, regardless of what other imbalances or complications he has. That is because an anterior approach in men can result in impotence in rare cases, primarily because of the location of the nerve to the prostate. Sexual impairment in women from this type of surgery has not been reported in the literature and is more doubtful because of the location of women's nerves to the genitals, but it also has not been researched in any serious fashion.

Ironically, Flatback Syndrome is not always easy for a spinal surgeon to diagnose, especially since it can occur slowly over a great length of time and not be visually apparent if only comparing from year to year. Also contributing to the difficulty of diagnosis is the fact that the doctor to whom the patient goes for consultation is only very rarely the initial surgeon who did the original spinal fusion; patients may have moved to a different area of the country and/or may find that the doctors who operated on them when they were teenagers or young adults are retired by the time the symptoms of Flatback begin. Also, since there is such a tremendous variability in what is considered "normal" for backwaist curves, spinal surgeons can often not make a definitive diagnose unless they have access to the patients' x-rays of their original backwaist curves from 20 years previous. (This is one very important reason that scoliosis patients should keep x-rays from all stages of their treatments over their lifetimes.)

PSYCHOLOGICAL CONSEQUENCES OF FLATBACK SYNDROME:
Because patients with Flatback Syndrome often see themselves as "deformed," neither standing nor walking in a normal way, they often suffer a tremendous loss of self-esteem and consequent psychological damage. If Flatback Syndrome is sudden, such patients suddenly find that none of the clothes they own fit any longer because their backwaists are so much larger and they look hunchbacked. Discarding their old clothes and buying new garments to accomodate their distorted posture can be devastating to them. It is also difficult for Flatback Syndrome patients to have a disabling disorder that absolutely none of their acquaintances--or even their own family doctors acknowledges or understands.

When the severe, unrelenting, and disabling pain of years of ever-increasing symptoms of Flatback Syndrome is added to these failed spinal fusion patients' lives, they often require the ancillary services of pain control teams in addition to psychiatrist or psychological counsellors, physical therapists, and other health professionals. Long term Flatback Syndrome patients find they can only get relief from nonsteroidal anti-inflammatory drugs (NSAIDs) for a limited period of time, and must resort to using narcotic pain medications to be able to function even minimally. There is widespread anecdotal evidence that they self dose by combining their medications with alcohol to be able to stem off the severe pain. Many Flatback Patients require prescriptions of antidepressants in order to stem destructive personal thinking and ameliorate suicidal thoughts. Individual and group pain control counselling sessions may also be indicated, particularly in regards to the anger and loss of control these patients commonly feel due to an unexpected new deformity developing after a previous deformity was supposedly corrected.

Complicating the matter is the fact that virtually all Flatback Syndrome patients have already gone through at least one major spinal surgery, and they are well aware of the seriousness of undergoing another one at an older age. Besides the dangers that are associated with any spinal surgery, they know firsthand how difficult and invasive their previous surgeries were. They also have memories of the forbiddingly high pain levels and lengthy recovery times of up to a year or more through which they suffered. They learn, too, that each succeeding spinal operation has less and less of a success rate. These factors make Flatback Syndrome patients extremely reluctant to undergo salvage surgeries--conversely the only choice for some relief that is open to them. This thinking may result in these patients putting corrective action off until they are physically and psychologically damaged to intolerable levels. Many patients present to spinal surgeons as having "no life" left and feeling they must either get surgically corrected or give up on living. (This is one of Dr. John Kostuik's key measures on judging how bad the Flatback Syndrome symptoms of his patients are.)

PSYCHOLOGICAL CONSEQUENCES OF FLATBACK SYNDROME:
The only permanent treatment for Flatback Syndrome is surgical correction. Patients cannot be made to stand straighter through exercises, physical therapy, a brace, or any other less invasive means. The deformity can be disguised to some degree by judicious choice of clothing and maladaptive adjustments to posture (which is generally not advisable).

Some patients elect to try to ameliorate the individual symptoms of Flatback Syndrome's (thoracic outlet syndrome, cervical disk herniation, etc.) with physical therapy or less extensive symptom-specific surgeries rather than go through the spinal surgery salvage procedure to correct the cause of Flatback Syndrome. This approach can sometimes work in cases in which the lordosis reduction was not very large, particularly in a younger patient, but it will not stop the degeneration in an adult Flatback Syndrome patient with more severe reduction of lordosis. Patients should note that Flatback Syndrome at its worst does not cause paralysis.

In any case, it is vital for every Flatback Syndrome patient, as well as for all adult scoliosis patients with intact spinal fusions, to try to maintain maximum possible flexibility and strength. Part of the reason for this is that long-term spinal fusion patients have already lost natural flexibility of the back after muscles around the fused column are no longer used normally and thus atrophy. Those with aging spinal fusions often find these inactivated muscles, and particularly those which connect to them, knot up and gradually harden into rock-like masses, further restricting associated joints and causing extra pain. A regular exercise program designed for the spinal fusion patient can be very helpful, with swimming, stretching, and other low-impact activities highly recommended. However, many such people may find that eventually they need individual physical therapy to reloosen and try to relearn to activate these little-used muscles and connecting tissues (which is sometimes not possible). Severely restricting activity in response to pain caused by muscle and joint tightness can often thus be the worst thing the spinal fusion patient can do, only leading to further disability and increased pain. However, it must be noted that the Flatback Patient must assiduously avoid exercise that may further damage joints adversely affected by this postural deformity.

Current philosophy is to reoperate on the malaligned spine as soon as Flatback Syndrome is detected rather than to wait until symptoms and irreversible physical and psychological damage occurs. Unfortunately, by the time many typical Flatback Syndrome patients get to the few top spinal doctors who can diagnose and reverse their conditions, they have commonly already lost their jobs, discarded normal social activities, and and may even have lost abilities to drive, to stand or walk unaided for any distance, to use their hands and arms for specific purposes, or to even hold their heads up to look at television.

GOAL OF SURGERY FOR FLATBACK SYNDROME:
The main goal of salvage surgery to correct Flatback Syndrome is to center the head directly over the sacrum in the Sagittal Plane (side view), realigning the spine properly by reintroducing a greater level of lordosis at the back waist so that the patient can stand upright properly. However, often the correction cannot restore the exact posture the patient had previously because the osteotomy (bone wedge removals) performed on the spine at waist level often results in pushing the chest and abdomen forward into a somewhat abnormal position. Patients thus sometimes complain about having what looks like a "pot belly," something they never had before. Overcorrection of the flatback, which surgeons try assiduously to avoid, exacerbates this postural problem and may cause overstretching of the spinal cord with consequent neuropathy (painful and permanent nerve damage) in the limbs.

Unfortunately, patients presenting with Flatback Syndrome often have additional problems with their original spinal fusions, such as weak or nonhealed areas that need to be re-fused. Thus, patients may find that a full "revision" operation may be necessary beyond the osteotomy to correct Flatback. This would involve installing new rod/screw hardware with another bone graft as part of a full Anterior/Posterior (A/P) spinal fusion. See "Related Medical Problems that Might Require Treatment" below for more information.

DETERMINING DEGREES OF LORDOSIS RESTORATION:
Determining the exact level of lordosis to restore to a Flatback Syndrome patient is an art as well as a science. The surgeon may first take the present level of the Flatback Syndrome patient's lordosis degrees and subtract that number from original lordosis degrees as evidenced by the patient's old x-rays prior to initial spinal surgery. If old x-rays are available, it is not unusual to find differences of 10, 20, or even 30 degrees or more of lordosis in symptomatic Flatback Syndrome patients. Note, however, that a person with scoliosis may also have developed abnormal lordosis curves prior to his or her spinal fusion, so that the surgeon may not want to fully restore the old back waist curve if to do so would put it into the hyperlordosis range (see below). Lordosis varies from about 28 to 65 degrees in the normal, healthy population, so the acceptable range is very large and individually different for each person. Therefore, doctors cannot just shoot for an "average" number of lordosis degrees and get it right.

The surgeon may also not want to reduplicate the old backwaist curve if the scoliosis patient has been in Flatback Syndrome failure for many years, because the adult body often cannot successfully adapt to very large and sudden changes in posture even if they are corrective only. Indeed, a radical restoration of lordosis can unduly strain nearby muscles, connective tissue, and the spinal cord/nervous system as a whole. Such an approach may also put too much pressure on the patient's remaining free vertebrae by trying to force an unachievable readjustment to new positioning. It is not unheard of for a long-term Flatback Syndrome patient to develop new problems, such as herniated cervical disks, after having had salvage surgery to restore lordosis and proper upright posture. Also, nerves and muscles--in their new positions--can be quite painful for months and months after the corrective surgery, and patients must be particularly careful not to overdo physical therapy, which can damage these vulnerable areas. Walking for ever-increasing distances and, eventually, aerobic capacity is the first recommended activity starting about month or two after surgery, with use of a recumbent bike second. (A recumbent bike takes all pressure off the back.) Specific strength building exercises should come only after muscle pain has calmed down and nerve pain is at a minimal level.

If original x-rays are not available, or if the Flatback Syndrome patient had an abnormal lordosis curve before original spinal fusion surgery, the surgeon uses an objective measure to pin down the desired degrees of lordosis restoration. A plumb line is hung from the C7 (neck) vertebrae on a side view x-ray of the straight-standing Flatback Syndrome patient to see where it falls in relation to the sacrum. The surgeon can extrapolate how many degrees of lordosis restoration are necessary to get the plumb line to fall directly over the sacrum again.

Doctors are often reluctant to restore too much lordosis in adult patients who have had Flatback Syndrome for many years, not only because it may necessitate a much more complex surgery, but also because they want their patients to be able to adapt successfully to the change. Therefore, doctors often stay on the side of cautiousness and aim for a lower level of restoration. Studies in the late 1980s have shown that nearly half of the scoliosis patients who had salvage surgery for Flatback Syndrome still felt they were leaning forward somewhat even though their overall posture and symptoms were improved. (Ironically, these reports have led to surgeons leaning patients back too much in the 1990s with the new knowledge that it is better to over- than under-correct.) Therefore, sometimes the surgeon uses a combination of old x-rays and the plumb line method to hit upon a more advisable lordosis restoration figure. He or she will then revise the determined amount according to how long the patient has been in Flatback Syndrome failure and how much flexibility (and thus adaptive ability) remains in the unfused portions of the remaining spine.

HYPERLORDOSIS IN THE SPINAL FUSION PATIENT:
Scoliosis patients who present with hyperlordosis prior to spinal fusion surgery are a special problem to spinal surgeons, who have not yet developed foolproof systems as to how to plan for successful spinal corrections for them in all three planes. Part of the reason for this is thºat scoliosis patients with hyperlordosis are often balanced with a compensatory curve in the thoracic spine called kyphosis, or sway back. This is seen in the illustration at the right as a giant sideways S-curve that keeps the head of the lordosis patient properly balanced over his/her hips. Alteration of the lordosis without a consequent balancing of the swayback portion of the spine in the thoracic region can create some of the worst of the Flatback cases. Hyperlordosis patients today have anecdotally been found to have surgically-created Flatback Syndrome in higher proportions following spinal fusions than others in a more normal sagittal range because of the extreme complexities of their original curves. This is because while surgeons are very good at straightening their side-to-side scoliotic curves in the coronal plane (the main goal of scoliosis surgery), they find it difficult not to also reduce the extreme curve at their backwaists in the sagittal plane. Meanwhile, hyperlordotic patients' bodies, which have already compensated for their extreme backwaist curves with kyphotic curves or other mechanisms, cannot usually adapt to the more "normal" levels of hyperlordosis created in the surgery. Thus, a patient with a hyperlordosis of 65 or 70 degrees can have his/her lordosis reduced to a still high 45 or 50 degrees and develop Flatback Syndrome. (See "Determining Degrees of Lordosis Restoration" above.) Salvage surgery for a Flatback Syndrome patient who formerly had hyperlordosis can be problematic, and the spinal surgeon community has not cumulated enough data to set general definitive standards for correction.

SURGERY FOR FLATBACK SYNDROME:
The osteotomy (bone wedge removal) technique is most often used to correct Flatback Syndrome in patients who are already solidly fused at the backwaist/lumbar level. Depending on the procedure used, surgery can often be accomplished with one osteotomy wedge in a posterior-only procedure with pedicle screws and new rods supporting the realignment. (If old spinal instrumentation hardware is present, it will have to first be removed, possibly in a two-staged operation.) To restore more than 20 or 30 degrees of lordosis and create a more natural appearance, spinal surgeons often have to do a series of osteotomies with an anterior/posterior approach consisting of two 10-15" incisions with new instrumentation of rods and pedicle screws to clamp together the cut vertebra(e) and support the realignment. However, the common method is to put all the correction into only one bone wedge removal at one level, as this cuts down substantial surgical risk to the patient.

Patients with pre-existing fusions only in the thoracic (upper) spine may have their realignment of the anterior of the spine at the backwaist accomplished with a newer configuration which consists of interthreaded cages that are positioned and then packed with bone graft and supported by posterior instrumentation. Either technique is extremely complex and risky, and should only be done by experienced spinal experts who perform spinal "revision" surgery on adults on a regular basis. Note that most SRS doctors who do original spinal fusions on adolescents and young adults are usually NOT widely experienced with these corrective techniques. Because osteotomies on the posterior part of the spine result in spinal shortening, danger to overstretching nerves and other tissues is lessened, unlike similar surgery for kyphosis.

Flatback Syndrome patients are wise to obtain the opinions of at least two or three experienced spinal surgeons before deciding whether to have corrective surgery, even though some surgeons express disdain if they find out. Patients should be prepared to find that salvage surgery plans from different doctors will vary, sometimes remarkably, and that the initial result of such consultations can be very confusing. The best way in which to select a surgeon (once you are assured you are dealing with experienced, respected spinal surgeon revisionists) is to arm oneself with information and ask any and all questions that are of concern about their surgical plans. It is important for the Flatback Syndrome patient to have the ultimate in trust for his/her surgeon pre-surgery in order to pave the way for a positive result. See the third paragraph "Symptoms of Flatback Syndrome" above for names of some of the doctors who do this operation frequently.

Note that all patients having surgery for Flatback Syndrome will normally asked to donate 4 to 8 pints of blood prior to the procedure because the cutting of bone during the osteotomies typically causes heavy blood loss. Plan to space out the fresh donations as much as possible (usually a 6-week maximum) and freeze some units (6-month maximum), if necessary. It is better if the patient can get close family members with the same blood type to donate for them. This is because donating too much blood just before the scheduled operation can weaken the patient--especially the small, slim woman with less blood volume to begin with. Thus, even though some doctors will ask for a pint of blood each week for 4 weeks just prior to surgery, the patient must decide whether s/he feels he or she can comply or whether this will put him or her in a more risky state. Usually doctors will prescribe special iron tablets to boost hemoglobin counts before donations are made. Patients can also ask for the supplement "Procrit" which is a blood builder which can lessen the need for additional transfusions. Often doctors will also advise scoliosis patients with the typical slim "dancer-type" bodies to gain weight before surgery because weight drop can be as much as 10 to 20 pounds post-surgery. Patients with mitral valve prolapse (MVP), another common problem of people with scoliosis, will often be given antibiotics to prevent heart valve infection during surgery, although most doctors prescribe antibiotics prophylacticly for all of their spinal surgery patients, especially to prevent skin infections in the lengthy surgical openings.

Most patients having a corrective spinal surgery for Flatback Syndrome can plan on a hospital stay of 5 to 7 days, with that extended to 10 or 14 days for more extensive operations, if all goes well. If there are complications, expect the hospital stay to be longer. Some patients go into a rehabilitation facility for several weeks after the hospital if they are not yet ready to go home because they still need assistive care. This is particularly true for patients who do not have someone at home to care for them 24 hours a day, or are having surgery at a hospital some distance from home and having to fly back. Patients who fly home after this extensive operation are strongly advised to buy first class seats on an airline--despite possible money woes--so that they can stretch out with more room in relatively comfortable seats. They also should ask their physicians to provide them with particularly powerful painkillers to take during the trip, which can be physically stressful.

See information about complications in the latter half of the section above called "Which Doctors Treat Flatback Syndrome?"

RELATED MEDICAL PROBLEMS THAT MIGHT REQUIRE TREATMENT:
Patients who have had Flatback Syndrome for many years should not be surprised if their MRIs, bone scans, diagnostic sacro-iliac injections, CT-scans, discograms, and other tests indicate that associated damage in areas related to the spinal fusion also necessitates surgical correction. Many Flatback Patients have pseudoarthroses (nonhealing points where the bone did not fully fuse in previous fusions) that may cause pain and allow the curvature to start increasing again. These areas will have to be refused and possibly realigned, usually with new bone graft and new spinal instrumentation systems. Note that most doctors now use rib bone for grafting purposes, as bone from this site is thought to be more expendable bone than that from the hips, which were often used for grafts in past years. (Most doctors require the patient donate his/her own bone, as the rate of successful healing is at least 10% better than that of donated bone; however, if your circumstances are such that you fear additional complications from an autologous graft, you should ask your doctor about the option of using donated material.) Those afflicted with an inflexible "swan" neck as a result of long-term Flatback Syndrome may need to consider having it surgically corrected, possibly at the same time as the osteotomy procedure. A patient with a side-to-side lumbar curve causing uneven hips may need a biplanar osteotomy--a side wedge that takes more out of the higher hip side--in order to bring the hips into alignment. This correction is particularly important for patients having knee, hip, and leg symptoms primarily on the higher hip side.

In addition, older patients having correction for Flatback Syndrome often must have their fusions extended further into the lumbar vertebrae or even to the sacrum at the same time (see x-ray below). The reason this is often necessary is because the weight of the fused spine with bone graft and hardware over 20 or 30 years puts an out-of-proportion-sized pressure on the free (nonfused) lumbar and cervical vertebrae both above and below the fusion. Over time, this causes degeneration, collapse, herniation, and instability of the free disks decades earlier than that which occurs within the general population, with consequent sciatia and other painful nerve-related disorders. Symptoms are similar to those of older Adults with Degenerative Scoliosis. Unfortunately, research has consistently shown that for each lumbar vertebra that is fused, the scoliosis patient should expect 20% more chronic pain for the rest of his/her life. If all lumbar vertebrae are fused to the sacrum, the patient has a fairly predictable chance of developing unresolvable chronic back or hip pain. So the fusion extension to the sacrum should not be decided upon lightly.

Patients who have already had spinal fusions that extend into their lumbar vertebrae or to the sacrum may also have degeneration of their sacro-iliac joints, which are severely strained by lumbar fusions and some spinal instrumentation systems in addition to the leaning-forward posture. Therefore, their doctors might propose fusing the sacro-iliac joints to relieve hip and leg pain at the same time that the osteotomies are performed. (The diagnostic test for whether S-I fusion is predicted to be effective is the patient's immediate and long-term response to injections of anaesthetics and sometimes steriods directly into the joints by an experienced orthopedic radiologist or spinal surgeon.) If both sacro-iliac joints are fused and packed with the patient's own bone, s/hewill ordinarily be on complete bedrest for two to three months while the bone solidifies. Usually a patient having only one S-I joint fused is allowed up on crutches a week or so after surgery with no weight allowed on the fused side. Spinal surgeons usually will not fuse the S-I joints at the same time as performing other spinal surgical procedures because it is too difficult for such a patient to use crutches and/or recover from both S-I fusions at the same time as recovering from the spinal operation. Some spinal surgeons are against fusing the S-I joints at all since it is a controversial procedure. Thus, fusion of the s-i joints is rarely done.

Spinal fusion patients at any time can develop loss of bowel and bladder control as more and more nerves are affected in the degeneration process of the vertebrae. Some patients demonstrate partial damage to these nerves by getting frequent urinary tract infections, sometimes from the bladder retaining urine after the patients voids as completely as possible. These patients may be particularly sensitive to nerve medications such as Elavil, Neurotonin, and Flexeril that can further exacerbate urinary retention in a vulnerable person. Even though spinal surgeons have been as yet unable to specifically pinpoint why this happens and what in particular can be done to rectify the situation, they have found that salvage surgery to reposition the spine into a more normal alignment can sometimes spontaneously correct some of these problems. It should also be noted that temporary loss of bladder control is not uncommon after spinal fusion surgery, particularly in the adult female patient. This may mean the patient needs to be cathetorized for several weeks following surgery while the bladder nerves recover from the "shock."

It is widely documented that female adolescents develop idiopathic scoliosis (scoliosis of unknown origin) that necessitates surgical treatment 8 to 10 times more frequently than young men, but thus far little is known as to why this is true. Little if any research is currently directly focussed on this issue although a limited number of genetics studies are now under way. Anecdotal evidence lends credence to the notion that many women with scoliosis and subsequent spinal fusions have life-long hormonal problems that show up frequently as irregularities in their menstrual cycles, such as Disfunctional Uterine Bleeding. Remarkably, fertility and reproduction are apparently unaffected. However, before such a woman has spinal salvage surgery, her doctor may recommend that she has her gynecological problems brought under control. Unfortunately, hormone therapy, as the first line of treatment, anecdotally often fails in women with scoliosis, with the speculation that their imbalances are due to more fine-tuned forces that do not respond normally to the simple estrogen/progesterone regiments. Older women, therefore, may be advised to have ablations of the uterus (burnings of the uterus lining) or even hysterectomies, if indicated. It is completely unknown as to whether women with spinal fusions for scoliosis benefit more than other women by being on Hormone Replacement Therapy to maintain bone strength during the menopausal years, but it is thought to be valuable to prevent osteoporosis in this vulnerable population. Adult men with scoliosis should also be tested for osteoporosis, and appropriate non-hormonal medications prescribed, if indicated.

Many scoliosis/spinal fusion patients also anecdotally report greater incidences of digestive problems than the general population, ranging from gastric reflux to irritable bowel syndrome, though there is no explanation of this phenomenon in the literature. However, digestive ills can make recovery from spinal surgery even more difficult, especially in regards to the strong constipating-producing pain medications that are prescribed for some time both before and after the procedure. Usually patients are induced to have their first bowel movements after surgery before they are dismissed from the hospital, because assistance of drugs or other medical means is often necessary to achieve results. Patients may be on strong pain medications such as morphine, oxycontin, or methadone for weeks, months, or even a year or more, and it is extremely important to avoid blockages and risk of rupture of the colon that these drugs can provoke. Older patients, in particular, take much longer to heal and recover and should expect the entire recuperation to take 12 months or more.

FLATBACK SURGERY SUCCESS RATES:
The proper correction of Flatback Syndrome often necessitates an extension of the spinal fusion into the lumbar vertebrae to the sacrum. While often the cosmetic result of the osteotomies is fairly good, patients must keep in mind that there are no guarantees regarding reversal of damage from joints, muscles, or nerves that occurred while the body was in the malaligned "flatback" posture position. Results depend primarily on how long the patient was in Flatback before corrective surgery, with two years or less being ideal.

Despite the grueling surgical salvage procedure and the lengthy recovery time, most Flatback Syndrome patients are never-the-less happy that they ultimately made the decision to have corrective surgery. Since actual bone fusion of the osteotomy(ies) or interthreaded cages takes nearly a year for adults, full body recovery averages one to two years, depending on the extent of surgery, postural adjustment, and strength-building required. Only after nerve damage has quieted down should patients' total bodies should be assessed for weaknesses, and specific exercises for strengthening must be overseen by physical therapists familiar with spinally-fused patients. If anterior surgery involving the lungs with a chest tube was also done, patients must have pulmonary therapy to regain the 30 to 40% loss in lung capacity that usually occurs right after surgery so that it does not become permanent. Satisfaction and recovery appears to directly correlate with age of patient, length of time s/he has been in Flatback Syndrome failure, whether the patient has to have a fusion extension or another corrective procedure at the same time, and the degree of disability experienced prior to surgery. A positive attitude is regarded as a key factor. A younger patient who has not been experiencing Flatback Syndrome symptoms for long and who does not have related spinal problems that need correction has a much easier time, of course, with good chance for a very positive result.

Patients who undergo the corrective spinal fusion procedure must fully acknowledge to themselves that they will be experiencing the most intensely involved surgery in the world, with many risks and extremely difficult recoveries. Therefore, proper psychological and physical preparation preceding these operations are a must. First, the patient must be able to accept the fact that no spinal surgery for scoliosis is ever going to be "perfect" in its results because medical science has not yet developed methods of restoring the spine to a perfectly normal position in the 3-D plane. This is especially true of adults who present with more rigid spines and histories of prior spinal operations. Sometimes, particularly in salvage surgeries, it is a matter of reducing the damaging rotational forces from the joints, where it can cause extreme disability, and putting the remainder in less damaging places, such as the trunk. Sometimes, after a biplanar osteotomy is done, the patient may be prescribed a shoe lift on one side that will help put the person in better side-to-side alignment than the surgery was able to accomplish. The main goal for most Flatback Syndrome patients is pain reduction and restoration of abilities to live their lives "normally" again.

Not only must patients recover from the extensive surgeries ranging from 4 to 12 hours, sometimes staged in two different procedures a week apart, and consisting of up to 40 or more inches of scars and blood needs averaging 4-6 units, but also they must anticipate very demanding recoveries. (By the way, if your doctor wants to schedule the two operations several days or a week apart, make sure there is a good medical indicator for two-staging your surgery. Unfortunately, in this era of managed care, some physicians feel forced to do the procedures on two different days solely for additional insurance money they will then get, despite the negative psychological implications for the patient.) After surgery, the bedrest that is required can become extremely boring and stressful (TV can get dull very quickly), and the patient should be prepared with activities with low physical demands that are interesting to him or her. The bracing that is often done for several months afterward for adult patients requires much maintenance and attention, too. With many of their soft tissues surgically reoriented through bone shifts into different postural positions, the entire body goes through months of often agonizing muscle spasms and nerve pain responding to these changes. In addition, the brain must adjust to new body positioning that is very challenging. With more fragile bones and muscle atrophy that is difficult to restore, adult patients must expect to struggle with exercises geared to stretch and strengthen themselves only when nerve pain and muscle spasms have quieted down. Such exercises afterward can indeed be difficult and discouraging because of slow progress and the experience of many patients of repeatedly going one step backward before going two steps forward. Aerobic activities must be integrated into a physical therapy program to help restore proper lung function and capacity. (Many scoliosis patients are anecdotally found not to be able to breathe in a natural way making full use of the diaphragm, and although exercises to change this can be tried, they are often unsuccessful.)

It is unknown how many of Flatback Syndrome patients who had been significantly disabled before salvage surgery were later able to resume lives that included returning to work and going back to other activities and social commitments that were earlier halted. Spinal surgeons generally caution Flatback Syndrome patients who have deteriorated to the point of having to stop working for several years to be realistic in expecting that, though their posture and pain levels will improve, they will possibly remain in a condition too fragile in which to return to all levels of activity or to gainful employment.

This physician-reviewed article was written in layman's language to provide a comprehensive, patient-oriented article on the basics of Flatback Syndrome, where few resources are available. Information was gathered from interviews with prominent Scoliosis Research Society surgeons, Medline medical journal studies (particularly from "Spine," the journal of spinal surgeons), orthopedic and spinal textbooks, and from various Flatback Syndrome patients who have experienced the symptoms, and have gone through the diagnosis and corrective surgery for the condition. Note that the material presented here is general in character and does not cover specific individual circumstances that may alter opinions doctors may render. No Flatback Syndrome patient should thus regard this resource as medical advice. The key to appropriate trement for Flatback Syndrome is in selecting a top notch spinal surgeon who is well experienced in the techniques of osteotomy salvage surgery, and obtaining at least two or three total opinions to determine if the proposed surgical plan is appropriate.

WRITTEN BY ELISABETH MINA