Flatback Syndrome

[oscdude]

How common is the flatback syndrom now after long segmented spine fusion?

[This message was edited by OsCDuDe on 01-13-04 at 04:19 PM.]

[Wise Young]

oscdude,

The flatback syndrome or more frequently the "failed back syndrome" is not a desirable consequence of fusion. The incidence is relatively high but also declining as surgeons are becoming aware of how to prevent this consequence. It results from too much fusion of the spinal column. Here are some references.

Wise.

• Buttermann GR, Glazer PA, Hu SS and Bradford DS (1997). Revision of failed lumbar fusions. A comparison of anterior autograft and allograft. Spine. 22: 2748-55. Department of Orthopaedic Surgery, University of California-San Francisco, California. STUDY DESIGN: The radiographic and clinical results of two different anterior structural grafts were compared in 38 patients who had combined anterior-posterior revision surgery for failed lumbar fusion. OBJECTIVES: Failed lumbar fusion surgery, such as pseudarthrosis or flatback deformity, may result in disabling pain. The optimum revision technique has yet to be defined. The authors of the current study sought to determine which of two different types of anterior graft yields the best results. SUMMARY OF BACKGROUND DATA: Posterior procedures for revision of a failed lumbar fusion have not yielded reliably successful results. A combined anterior-posterior approach may be effective in restoring sagittal balance and enhancing fusion rates. Recent studies have shown femoral ring allografts to be effective in lumbar fusion revision, but no studies have compared these with other types of structural grafts. METHODS: Thirty-eight patients with pseudarthrosis were treated with combined anterior-posterior lumbar spine fusion using either femoral ring allografts (26 patients) or tricortical iliac autografts (12 patients). Radiographic follow-up examination and retrospective patient self-assessment questionnaires were used to evaluate outcomes. Results were assessed by independent reviewers after a mean follow-up period of 35 months. RESULTS: Radiographic follow-up examination revealed acceptably low pseudarthrosis rates for structural autografts (0%) and allografts (6%). The questionnaires revealed significant improvement in pain for both groups. Allograft patients showed greater improvement in function, less pain medication usage, and higher overall success rates (83%) than autograft patients (64%). CONCLUSIONS: Femoral ring allografts are as effective, clinically and radiographically, as tricortical iliac autografts when used as an anterior structural element in revision lumbar spine fusion in patients who have undergone multiple surgical procedures for pseudarthrosis or flatback deformity. The slightly greater improvement for the allograft group needs to be confirmed in a larger study.
• Dewald CJ, Millikan KW, Hammerberg KW, Doolas A and Dewald RL (1999). An open, minimally invasive approach to the lumbar spine. Am Surg. 65: 61-8. Department of General Surgery, Rush Medical College, Rush Presbyterian St. Luke's Medical Center, Chicago, Illinois, USA. A minimum 2-year follow-up retrospective review was undertaken to assess our experience with an anterior paramedian muscle-sparing approach to the lumbar spine for anterior spinal fusion (ASF). The records of 28 patients (November 1991 through January 1996) undergoing ASF via a left lower quadrant transverse skin incision (6-10 cm) with a paramedian anterior rectus fascial Z-plasty retroperitoneal approach were reviewed. Diagnosis, number, and level of lumbar interspaces fused, types of fusion, estimated blood loss, length of procedure, length of hospital stay, and complications were analyzed. All cases were completed as either a same-day anterior/posterior (24 of 28) or as a staged procedure at least 1 week after posterior fusion (4 of 28). The General Surgery service performed the muscle-sparing approach, whereas the Orthopedic Spine service performed the ASF. There were 14 men and 14 women, with a mean age of 35.5 years (range, 11-52 years). Diagnoses included spondylolisthesis in 20 cases (including four grade III or IV slips), segmental instability (degenerative or postsurgical) in 7, and 1 flatback deformity. A single level was fused in 20 cases (L4/5 in 4 and L5/S1 in 16), two levels were fused in 5 cases (L4/5 and L5/S1) and three levels were fused in 2 cases (L3/4, L4/5, and L5/S1). The mean length of stay was 7.4 days (range, 5-12 days). The mean estimated blood loss was 300 mL for the anterior procedure alone and 700 ml for both anterior/posterior procedures on the same day. The mean length of operating room time for the anterior approach and fusion was 117 minutes (range, 60-330 minutes). Posterior instrumentation was used in all cases. Anterior interbody struts used included 19 autogenous tricortical grafts, 4 fresh-frozen allografts (2 femoral rings and 2 iliac crests), 3 carbon fiber cages packed with autogenous bone, and a Harms titanium cage with autograft. There was one L5 corpectomy for which a large tricortical allograft strut was utilized. There were no vascular, visceral, or urinary tract injuries. In three cases a mild ileus developed, which resolved spontaneously. We conclude that the anterior paramedian muscle-sparing retroperitoneal approach is safe, uses a small skin incision, avoids cutting abdominal wall musculature, and allows for multiple-level anterior spinal fusions by a variety of interbody fusion techniques. This approach does not require transperitoneal violation or added endoscopic instrumentation, nor does it limit fusion level and technique of fusion, as is the case with the recently popularized laparoscopic approach to the lumbar spine.
• Farcy JP and Schwab FJ (1997). Management of flatback and related kyphotic decompensation syndromes. Spine. 22: 2452-7. Spine Service, Maimonides Medical Center, Brooklyn, New York, USA. STUDY DESIGN: The authors, in this retrospective study, examined a group of patients with flatback syndrome and a related kyphotic decompensation syndrome. Results of nonrealignment treatment as well as revision surgery with sagittal realignment were reviewed. OBJECTIVES: To determine effectiveness of physical therapy and limited surgical (instrumentation removal) as well as major realignment surgical treatment in the sagittally malaligned spine. SUMMARY OF BACKGROUND DATA: Flatback is a sagittal plane deformity associated with distraction instrumentation for scoliosis correction. Kyphotic decompensation syndrome involves malaligned fusions from the sacrum for disease other than scoliosis. Several studies describe surgical realignment for flatback involving instrumentation systems no longer commonly applied. Guidelines for a systematic approach to flatback and kyphotic decompensation syndromes are lacking. METHODS: Forty-eight patients with flatback and kyphotic decompensation syndromes were reviewed. Treatment groups were defined by treatment approach and level of previous fusion. Effectiveness of treatment was reviewed in terms of radiographic sagittal alignment and self-reported pain. RESULTS: Twenty patients were treated without realignment revision surgery. Twenty-eight patients were treated with anterior and posterior osteotomies and realignment with instrumentation. For patients originally fused to the sacrum, realignment averaged 12 cm. Pain was reduced from 7 to 3 (10-point scale). In patients fused to L4 or L5, realignment averaged 7 cm. Pain was reduced from 6 to 2. Magnetic resonance imaging revealed viable caudal discs in four patients who were consequently spared extension of fusion to the sacrum. CONCLUSIONS: Treatment without realignment surgery demonstrated long-term success in 27% of cases. The latter all had two intact discs below the previous fusion and sagittal malalignment less than 4 cm. Realignment surgery effectively reduced pain in patients failing a conservative approach.
• Lagrone MO, Bradford DS, Moe JH, Lonstein JE, Winter RB and Ogilvie JW (1988). Treatment of symptomatic flatback after spinal fusion. J Bone Joint Surg Am. 70: 569-80. Orthopaedic Service, Letterman Army Medical Center, Presidio San Francisco, California 94129. Fifty-five patients who had loss of lumbar lordosis after spinal fusion and subsequently had corrective osteotomies were studied. When they were first seen, fifty-two patients (95 per cent) were unable to stand erect and forty-nine (89 per cent) had back pain. The previous use of distraction instrumentation with a hook placed at the level of the lower lumbar spine or the sacrum was the factor that was most frequently identified as leading to the development of the flatback syndrome. Sixty-six extension osteotomies were performed in these fifty-five patients. Nineteen patients (35 per cent) had an associated anterior spinal fusion. Thirty-three patients (60 per cent) had one or more complications, including pseudarthrosis, a dural tear, failure of hardware, neurapraxia, and urinary tract infection. The results of the operation were evaluated at follow-up by review of clinical records, radiographs, and questionnaires. At an average follow-up of six years (range, two to fourteen years), most patients felt that they had benefited from the corrective osteotomies. However, twenty-six patients (47 per cent) continued to lean forward and twenty patients (36 per cent) continued to have moderate or severe back pain. The failure to restore sagittal plane balance led to a higher rate of pseudarthrosis, which was associated with recurrent deformity. Anterior spinal fusion combined with posterior osteotomy resulted in greater maintenance of correction. The prevention of flatback syndrome is important, since its treatment is difficult. When a spinal fusion must be extended to the level of the lower lumbar spine or the sacrum, the use of distraction instrumentation should be avoided in order to prevent this deformity.
• Sarwahi V, Boachie-Adjei O, Backus SI and Taira G (2002). Characterization of gait function in patients with postsurgical sagittal (flatback) deformity: a prospective study of 21 patients. Spine. 27: 2328-37. Hospital for Special Surgery, New York, New York 10021, USA. STUDY DESIGN: This study prospectively analyzed gait in 21 patients with flatback and reviewed radiographs and charts. OBJECTIVE: To analyze the effect of sagittal imbalance on gait and hip and knee joints. SUMMARY OF BACKGROUND DATA: Loss of lumbar lordosis causes anterior displacement of the center of gravity, which creates instability and increases the work of gait. Several compensatory changes occur in response. The long-term effect of these changes on extra-axial joints has not been reported, nor have many studies analyzed the gait deviations in patients with flatback. Over time, as patients' ability to compensate is limited, increased gait deviations result. METHODS: A total of 21 of 44 patients who had gait analysis as part of the preoperative workup were selected based on outlined criteria. Kinetics and kinematics data were analyzed along with radiographic and chart review. Normal healthy individuals served as controls. RESULTS: Gait deviations were present in gait kinetics and kinematics, including decreased stride length and velocity, to almost 60% of controls. Stance duration was prolonged with increased hip and knee flexion during stance. Hip and knee extensor moments were decreased with vertical ground reaction force showing slower rate of loading, reduced peak values, and flattening of normal loading response. CONCLUSION: Patients with flatback develop several compensatory mechanisms. The goal of the compensation is to maintain an efficient gait and decrease joint damage, but these safeguards fail over time. Flatback not only causes backache, abnormal posture, and abnormal body mechanics but also compromises the stability of gait and taxes the knee and hip joints adversely.
• Voos K, Boachie-Adjei O and Rawlins BA (2001). Multiple vertebral osteotomies in the treatment of rigid adult spine deformities. Spine. 26: 526-33. Scoliosis Service, The Hospital for Special Surgery, New York, New York 10021, USA. STUDY DESIGN: Retrospective review of the clinical and radiographic results in adult revision spine deformity surgery using the techniques of osteotomies to effect spine balance and curve correction. OBJECTIVES: To assess the efficacy of multiple vertebral osteotomies in correction of rigid spine deformities in adult patients undergoing revision surgery. METHOD: The records and radiographs of 27 adult patients with idiopathic scoliosis who underwent revision surgery requiring anterior release (discectomy and/or osteotomy) and posterior osteotomy to correct rigid spinal deformities were retrospectively reviewed. RESULTS: All 27 patients were available for follow-up evaluation. Fifteen patients had anterior discectomies followed by posterior osteotomies, whereas 12 had anterior and posterior osteotomies in staged or sequential (same day) fashion. Diagnosis was idiopathic scoliosis for the index operation. At revision, the primary deformity was flatback deformity in 10 patients and pseudarthrosis with progressive deformity in 17 patients. Eleven patients had predominant sagittal decompensation, 11 patients had multiplanar decompensation, and five patients were balanced. The average number of osteotomies performed anteriorly was 4.3 levels (range, 1-8) and the average number of osteotomies posteriorly was 4.6 levels (range, 1-10). There were a total of nine complications in eight patients including three pseudarthroses (11%), five hardware failures (19%), and one transient neurologic deficit (4%). There were no deep wound infections, deep vein thromboses, pulmonary emboli, or deaths. The average scoliosis correction was 40% (range, 5-81%), whereas the average sagittal balance was corrected 6.5 cm (range, -5-29.5 cm), on average, and coronal balance was corrected 2.5 cm (range, 1-6 cm), on average. CONCLUSION: This study demonstrates multiple vertebral osteotomies (anterior and/or posterior) in the management of rigid adult spine deformities and deformity correction with an acceptable complication rate. Use of vertebral osteotomies for patients undergoing revision spine surgery is a safe and reasonable approach to obtain an arthrodesis.

[madnsn2]

TO DR WISE YOUNG MODERATOR
URGENT I'm FEMALE 44 NO KIDS NON SMOKER NON DRINKER, AND AT 13 underwent asap idiopathic scoliosis when it was found during school screenings in Cal and was a gymnast, My spine body size film sowed my spine as a full S shape and the Dr said i would be hunchback and or have breathing issues if not treated, I also was found a benign tibia large tumor removed during surgery and had endured a body cast for 10 ms post op . I was told no horse backs no skiing no falling on ice no running and to lift weight so off and on through yrs i was active at gyms

Other than my 1o yr f/up back in NYC at Bellevue scoliosis my Dr was Dr Gordon Engler head of juvenile scoliosis and he followed me up after my surgery was done by Scott Mubarak in UCSD, we moved back to NYC three mos post surgery for family help

I was symptom free from my fusion from T2 to L4 S1 till 2008 when while at work in my timeshare sales Job i got up after sitting over an hour and literally was unable to stand erect. It was searing pain i went home saw an Or tho surgeon in NV 2 days later had Mri's w contrast a scoliosis series and Ct scan and i was told i had severe facet arthrosis, DDD , severe extremity radiculopathy and severe flat back syndrome obvious to the naked eye too.

He showed me i could not erect myself with out bending my knees even then i couldn't stand erect fro more than 10 seconds if that. I had noticed i walked head down and craned forward to see where i was going but thought it was form long hrs as a rep sitting all day and not any pathology related

I did stepped PM including over 20 facet blocks epis and finally 2 painful radio frequency ablations that did not work .

I was taken out of work on LTD and have been on lots of pain meds and experienced neuropathic symptoms in left leg that would be pins needles and numbness in hands. A bit of radiating pain but the numb dead feeling was worse

About 6 months ago here in OC CA i noticed and told my PM that whee i sit on a toilet for longer than 3 minutes my entire leg and groin goes DEAD i try to stand and fall i literally cannot feel that left leg and the odd groin area feeling of being under anesthesia and no feeling would take minutes to go away after banging my leg or kicking and walking it off

THese symptoms were very odd and not acceptable then i noticed although i am very insomniac. cant sleep more than 3 hrs, i found i lost the feelings OR THE need to urinate or move bowels .

Id get a slight Full bladder feeling and sit on the toilet running water , to try to get myself to pee. I have sat till my leg is completely dead and kept my finger under cold water waiting.

I had the sensation i needed to urinate but finally after 3-8 minutes IT would trickle out urine and never felt i was emptying the bladder.

I admit, i don't eat, i stopped eating real food 2 yrs ago, I HAVE NO APPETITE, i am complicated further since in 09 i was admitted for 6 pulmonary embolisms and was kept in CRIT CARE for 8 days released into hospice with oxygen for 5 months and would get heparin ivs for 5 months

AFTER being studied my in hospital HEMO oncologist for the PEs he did genetic testing and found i had a rare mutation in my blood called MTHFR and it literally changes my INR levels on a daily basis

IN 2 yrs i have never had a normal INR range of 2.0 -3.0 BUT 3 times in 2 yrs I'm always on the thick side , he upped my coumadin to 12.5 mg of coumadin then i started bleeding in Oct 2010 out of my ears, nose wrists and ankles through pores he told me to go to Hoagg since the laB would take 3 days for results and the phlEBOTOMIST said i was at 9.0 for my INR !!!

i GOT ANGRY ILL ADMIT, the hemo dr said at least you wont get any chance of PEs now. He lowered my coumadin and that was the last time i had my blood tests and stopped seeing him..

SO a few times my calves have gotten painful and hard i know that is symptoms of another clot maybe but then went away fast

NOW Present DAY
I mentioned to my Pain Dr the increased left leg dead feeling and I'm doing a new CT and rib fracture rule out film done too since i had broke the 9 and 10th rib in 03 and Broke 2 toes very easily by hitting a coffee table in JAN that are still healing , its attributed to my overall lack of a healthful eating and lack of vitamins and calcium.

I use a walker cannot uphold my torso for 2 yrs and i also upon exam last year MY DR noted i lost all lower extremity reflexes in knees and ankles and desensitized upper arm feelings.

I googled my symptoms and CAUDIA EQUNIA CAME UP AS A POTENTIAL DISEASE I MAY HAVE AND READING THE SYMPYOMS ARE EXACLTY WHAT IM DEALING WITH

I READ , ONE MUST GET TO A EMERGENCY ROOM WITHIN 48 HRS OF SYMPTOMS PRESENTING FOR A BETTER FIX OUTCOME TO THIS IMMEDIATE NEEDED SURGERY.

I even have temp blindness when i open my eyes after napping OR am waking and would put my glasses on and have to rub my eye to blink repeatedly to get my bad vision to come back

so i need to know what spinal Chord Injury Dr as well as FLATBACK revision surgeon in OC or LA can help.

Dr Pashman is no longer at cedars Siani, My original Harrington rods are intact since 81 and there is asymmetric collapse of multi levels as well as the flat back the extremity radiculopathy ,m myofascial pain syndrome, chronic intractable mechanical pain , degenerative disc dessication from L3 to L4-S1 and , and L5.

On my fathers side including him and 4 siblings ALL died by age 52 from complications from MTHFR like aneurysms, cardiac arrest from a clot or PUl embolisms.

I am heterozygous for MTHFR cause my mother has it now and is in hospice expected to die soon from Pulmonary Hypertension , 2 heart attacks and congestive hear failure for over 2 yrs, her kidneys are at 30% and her pulse is 40 beats BP 70 over 40.

I need a top Dr like Larry Lenke or Dr Bridwell but in CA, i cannot fly due to PEs and the pain of the air bumps rack my body with pain from the turbulence I scream.

I want a surgeon who does revisions at least 50-100 from old Harrington rods a year NOT a reg Ortho Surgeon who wants to try it out as a guniea pig.

IF I have Spinal Chord Injury time is ticking so ive read. From the RESEARCH Ive done past wk, I FEEL I HAVE CAUDA EQUINA ON TOP OF FLATBACK , continued Scoliosis to the left, mulitple levels of complete collapse of disc dessication, RADICUOLPAHY, Severe FACET ARTHROSIS , Myofascial Pain, AND Chronic Mechanical INTRACTBLE pAIN.

I did my NEW Ct Scan for Thoraic and Lumbar last thur and waiting for the report , it took 3 Radiologists to move me onto a table cause i cannot lay flat on my back and must be in a 50 degree angle when i sleep or sit so my legs had to propped up to head level which couldnt fit through tunnel and for 20 min i was crying trying to breath shallow as my leg weigh forced my back to straighten due to not enough pillow height

The inability to get urine started, NO UTI symptoms NO blood in urine or burning just unable to pee or feel need to have bowel movements and those and many other symtpoms popped up CAUDA EQUINA SPINE CHORD INJRUY as potential.

The dead anasthetic left leg and groin area is the most horible feelign if i sit upright on the hard tiolet or any hard surface after a few minutes,

Last NIGHT I STUCK a Safety Pin in my left leg when it deadened on the toilet and didnt feel a thing even though it draws blood.

So i KNOW something is Wrong.

Also i havent slept in a bed in 2 yrs since I became disabled, i must sleep in a 50 % angle in a recliner , like an inverted L shape , in the same position i stand in pitched foward . WHAT DO I DO? Or just let nature takes it course IM tired of fighting i DID NOT sign UP for this after 29 yrs Symptom free from Harrington sugery

[CurvySAT05]

Yes, you NEED to go up to Cedar Sinai and see Dr. Robert Pashman. He is the one who diagnosed me with flatback syndrome after my 3rd back surgery for scoliosis failed. I also saw a doctor in OC, Dr. Jeffrey Deckey out of the Orthopedic Specialty Institute. He does surgery at St. Joes in Orange. Of the two doctors they were BOTH very knowledgeable, had tons of experience with revision surgery for scoliosis, etc. but Dr. Deckey had a MUCH better bedside manner and was willing to take the time to explain all the details to me. At the time my insurance was a POS (no, not a piece of sh**) where I had HMO and PPO benefits, so I was able to get multiple opinions through the PPO, but had to have my surgery under the HMO, so once I decided on the doctor I wanted to do the surgery I set my medical group, found a good primary care doctor and started the authorization for surgery. I had my revision with Dr. Deckey on 12-5-07 and can say that I sit up nice and straight. I am no longer hunched over and don't have to lean on shopping carts when I am standing (I have an incomplete spinal cord injury so I can stand and walk short distances with the use of crutches).
My pain management doctor is in Aliso Viejo, and he is an ANGEL. I see Dr. Scott Martin and he adequately treats my pain, following up with anything needed such as a CT scan, etc. He did a trial implant of a Spinal Cord Stimulator to trick my body into thinking I don't have pain, and the trial worked so well that I had a permanent implant not long after.
It does sound like you might have herniated discs that are pressing into your spinal canal. It is imperative that you see a good orthopedic surgeon ASAP. When you call to schedule the appointment let them know you are having issues with bowel and bladder control and see if they can schedule you soon, talk to the doctor and get permission to double book, etc. The other possibility is going to the ER where the doctor works and tell them your symptoms, and if the ER doc thinks it is required they can call in a specialist right then.

[retto76]

I had a spinal fusion in 1989 at age 13 for idiopathic scoliosis. It was done with Luque instrumentation - the "next generation" curved rods that were supposed to prevent issues like flatback from arising. Well, they are now finding that the newer instrumentation doesn't always prevent flatback. I had revision surgery in 2007 which extended my original (T4-L4) fusion down to the sacrum, along with a couple of osteotomies and a lot of pedicle screws and whatnot. My surgery was done at Northwestern in Chicago by Dr Tyler Koski. He was awesome. I have secondary progressive multiple sclerosis also, and am in a powerchair now fulltime because of it.

I'd highly recommend that you see a surgeon who has extensive experience with flatback in patients with long fusions. The average ortho does not have this experience, and you do not want to be their guinea pig to practice techniques on. As mentioned previous, Drs Lenke & Bridwell in St Louis are among the best. Drs. Berven & Hu at UCSF are excellent as well. I belong to some flatback support groups on Yahoo Groups, and Dr Pashman has been a surgeon that's been consulted with, but I don't recall anyone deciding to undergo surgery with him. That doesn't mean that he's not a good choice, but I've just heard more about the surgeons at UCSF instead.

Many people have had revisions done with surgeons who have less experience. Unfortunately, many of them have found that it would have paid to do more research and travel a bit to have their surgeries with someone that had more experience.

Good luck with it all! The recovery was quite long, but I feel that it was worth it for me. It cut down a lot of pain issues (which of course is not a guarantee), and helped get me upright again.

[madnsn2]

to CURVY
Dr Pashman i dont know if he is still at CS

I also have cigna Open Access and some CA surgeons dont take it. PS when i say i cant fly i mean it the pain from sitting erect and any turbulence makes me scream out i had to go see MOM with first heart attack June 2010 and the 33 hrs to get there and back to NY was too much she is dying soon and i wont even be able to go to funeral , not ot metnion my blood clot disorder which is a concern when fyling ive had 6 at one time and almost died in 09.

I just had a CT w/out contrast and pain Dr is doing my review for continued LTD from work I've been out 16 mos coming up to the 24 mo (disabled from all work light or sedentary which i am i done want any hassels though i cant take any mor stress, the blood thinners and pain have made me lose 25% of my hair .

i leave my apt about 5 times a mo, once to Pain doc , 1x wk for mail that's it, everything like water and my protein bars i live on and scripts are delivered
My situation is also complicated by my Pulm Embolisms and the clotting disorder and there is hi levels of increased chances of developing clots after surgeries like these

I am really ready to stop the blood thinners and just let go and let nature takes its course

I'm 44 and TIRED and angry and truly don't care about whether i live or not at this point. I've lost the best young yrs of my life , never had kids and have NO ONE to help me w anything after surgery so that's why i put it off and the risks too

Now it appears Ive waited till Cauda Equina seems to have begun i even have the feeling of something crawling over my left shoulder which is every night same arm and nothing is there
ALL symptoms of cauda equina not to mention i have had no reflexes in low extremities for over a year now so , i hope u know what i mean when i say I'm just done with it all
thanks for input and suggestions I'm glad it worked out for you
madnsn2