Describe the surgical treatment for flatback syndrome

Fixed sagittal plane imbalance, or flatback syndrome, refers to symptomatic loss of sagittal plane balance primarily through straightening of the normal lumbar lordosis. Symptoms include pain and inability to stand upright with the head centered over the sacrum without bending the knees. Patients typically report a sense of leaning forward, thoracic pain, neck pain, and leg fatigue. Surgical treatment options include osteotomies (Smith-Petersen type or pedicle subtraction type), combined anterior and posterior procedures, or vertebral column resection procedures.

Key Points

1. Selection of appropriate candidates for revision spinal surgery depends on comprehensive assessment to determine the factors that led to a less than optimal outcome following initial surgery.

2. For poor surgical outcomes due to errors in surgical strategy or surgical technique associated with the index procedure, appropriate revision surgery may offer a reasonable chance of improved outcome.

3. For surgical failures due to errors in diagnosis or inappropriate patient selection for initial surgery, revision surgery offers little chance for improved outcome.

4. In the absence of relevant and specific anatomic and pathologic findings, pain itself is not an indication for revision surgery.

Websites

Complications of revision spinal surgery: http://www.medscape.com/viewarticle/462159 Revision anterior lumbar surgery: http://www.medscape.com/viewarticle/577213 Proximal fusion levels: http://www.medscape.com/viewarticle/566466 Sagittal imbalance: http://www.medscape.com/viewarticle/462179 Revision surgery for spinal deformity: http://www.orthospine.com/

BiBLiOGRAPHY

1. Albert TJ, Pinto M, Denis F. Management of symptomatic lumbar pseudarthrosis with anteroposterior fusion: a functional and radiographic outcome study. Spine 2000;25:129.

2. Bridwell KH. Decision-making regarding Smith-Petersen vs. pedicle subtraction osteotomy vs. vertebral column resection for spinal deformity. Spine 2006;31:S171-S178.

3. Devlin VJ, Anderson PA. Revision cervical spine surgery. In: Margulies JY, Aebi M, Farcy JP, editors. Revision Spine Surgery. St. Louis: Mosby; 1999. p. 52-88.

4. Dubousset J, Herring A, Shufflebarger H. Crankshaft phenomenon in spinal surgery. J Pediatr Orthop 1989;9:541-50.

5. Kostuik JP. The surgical treatment of failures of laminectomy. Spine State Art Rev 1997;11:509-38.

6. Kostuik JP. Failures after spinal fusion. Spine State Art Rev 1997;11:589-650.

7. Luhmann SJ, Lenke LG, Bridwell KH, et al. Revision surgery after primary spine fusion for idiopathic scoliosis. Spine 2009;34:2191-7.

8. Margulies JY, Aebi M, Farcy JP, editors. Revision Spine Surgery. St. Louis: Mosby; 1999.

9. Patel A, Brodke DS, Pimenta L, et al. Revision strategies in lumbar total disc arthroplasty. Spine 2008;33:1276-83.

10. Schwender JD, Casnellie MT, Perra JH, et al. Perioperative complications in revision anterior lumbar spine surgery: incidence and risk factors. Spine 2009;34:87-90.

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