What radiographic hallmarks indicate a flatback syndrome

Flatback syndrome is a sagittal malalignment syndrome. Radiographically the hallmarks of flatback syndrome include a markedly positive sagittal vertical axis and decreased lumbar lordosis after a spinal fusion procedure. Classically, it has been reported after use of a straight Harrington distraction rod to correct a lumbar or thoracolumbar curvature. When the thoracic and lumbar spine is fused in a nonphysiologic alignment with loss of lumbar lordosis, the patient cannot assume normal erect posture and assumes instead a stooped forward posture. The patient attempts to compensate for this abnormal posture by hyperextending the hip joints and flexing the knee joints. These compensatory mechanisms are ultimately ineffective in maintaining the SVA in a physiologic position and result in symptoms of back pain, knee pain, and inability to maintain an upright posture. Fixed sagittal malalignment of the spine has many etiologies.

Key Points

1. Systematic review of spine radiographs provides important information regarding spinal alignment, degenerative changes, fractures, and spinal instability.

2. Cervical flexion-extension views should be obtained only in neurologically intact, cooperative, and alert patients and are not advised in the immediate postinjury period.

3. Important radiographic measurements for assessment of spinal deformities include coronal and sagittal plane balance, thoracic kyphosis, lumbar lordosis, and pelvic parameters.

Websites

Standing balance and sagittal plane deformity: analysis of spinopelvic and gravity line parameters: http://www.medscape.com/ viewarticle/578313

Three-dimensional terminology of spinal deformity: http://www.srs.org/professionals/glossary/3-d.php

BiBLiOGRAPHY

1. Balderson RA, Auerbach JD. Imaging techniques. Semin Spine Surg 2007;19:57-124.

2. Bernhardt M, Bridwell KH. Segmental analysis of the sagittal plane alignment of the normal thoracic and lumbar spine and lumbosacral junction. Spine 1989;14:717-21.

3. Devlin VJ, Narvaez JC. Imaging strategies for spinal deformities. Spine State Art Rev 1998;12:1.

4. Lonstein JE. Patient evaluation. In: Lonstein JE, Bradford DS, Winter RB, et al., editors. Moe's Textbook of Scoliosis and Other Spinal Deformities. 3rd ed. Philadelphia: Saunders; 1995. p. 45-86.

5. O'Brien MF, Kuklo TR, Blanke KM, et al., editors. Spinal Deformity Study Group Radiographic Measurement Manual. Memphis, TN: Medtronic Sofamor Danek USA, Inc.; 2005.

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