What is involved in flatback syndrome surgery?
The surgery is designed to correct spinal alignment. The gravity line must be restored to a normal or near normal location to relieve stress on the postural muscles of the back, hips and knees. This typically requires an osteotomy or multiple osteotomies. An osteotomy is a cut into bone, usually in a wedge shape to effect a correction in alignment.

There are a number of different types of osteotomies. The pedicle subtraction in which portions of the front (anterior) and back (posterior) vertebrae are removed is commonly performed (Figure 3). The Smith-Peterson is another type in which the posterior portion of the spine is cut. This is often combined with anterior surgery in which discs are removed from the front of the spine and structural cages or bone implants are placed to restore lordosis. Spinal instrumentation (rods and screws) are required to hold the corrected alignment while fusion occurs during the recovery phase. Patients who have prior spinal instrumentation usually require at least partial removal of existing implants before the osteotomies are performed.

Figure 3
This 42 year old woman underwent Harrington rod instrumentation 20 years earlier for scoliosis. She developed flatback syndrome for which she was treated with a pedicle subtraction osteotomy. The patient returned to full activity by 5 months following surgery.

Results of this surgery are usually highly satisfactory to the patient. However, patients who have had numerous prior operations, or in whom appropriate alignment is not restored, may not do as well.

Is the surgery risky?
As with all spinal surgeries, flatback surgery carries some risk. Categories of risk include neurological, bleeding, infection, failure to achieve appropriate spinal balance and relief of symptoms, loosening of spinal implants, pseudarthrosis (failure of fusion), and medical complications. Although these risks exist, the rates of these problems are low. For the appropriately selected patient, the benefits of surgery far outweigh the risks.

Does it take a long time to recover from this surgery?
Recovery from this spine surgery may include wearing a spinal brace and several months of restricted activity to ensure a successful surgical outcome. In addition, a program of physical therapy may be prescribed for strengthening and endurance to enhance recovery and return to full activity.

When should I consult a spinal specialist for flatback syndrome?
If you find that your posture is progressively stooped-forward and you have difficulty standing upright, you may have flatback syndrome. Other causes of forward pitched spinal alignment include neuromuscular problems such as Parkinson's disease and progressive kyphosis due to osteoporosis and other problems.

Early consultation with a spinal specialist is advised so that non-operative therapy can be instituted when appropriate. Early operative intervention may also be warranted and may result in a lesser procedure than if diagnosis and treatment are delayed.

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