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 Spine Test 5: Recent Topics in Spine Surgery
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CME 3: July, August, September 2004
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The Journal of Bone and Joint Surgery (American) 86:1793-1808 (2004)
© 2004 The Journal of Bone and Joint Surgery, Inc.

Current Concepts Review

Prevention and Management of Iatrogenic Flatback Deformity

Benjamin K. Potter, MD1, Lawrence G. Lenke, MD2 and Timothy R. Kuklo, MD3

1 Department of Orthopaedic Surgery and Rehabilitation, Walter Reed Army Medical Center, 6900 Georgia Avenue, Building 2, Washington, DC 20307
2 Department of Orthopaedic Surgery, Washington University School of Medicine, One Barnes-Jewish Hospital Plaza, Suite 11300 West Pavilion, St. Louis, MO 63110
3 15619 Thistlebridge Drive, Rockville, MD 20853. E-mail address: timothy.kuklo{at}na.amedd.army.mi

The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. A commercial entity (Medtronic Sofamor Danek; Restricted Research Grant for T.R. Kuklo, Walter Reed Army Medical Center, Washington, DC, and L.G. Lenke, Washington University School of Medicine, St. Louis, MO) paid or directed, or agreed to pay or direct, benefits to a research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the United States Army or the Department of Defense.

The most common cause of iatrogenic flatback syndrome is Harrington distraction instrumentation extending into the lower lumbar spine.

Other common causes and exacerbating factors include failure to enhance regional lordosis during lumbar fusion for degenerative spondylosis, development of pseudarthrosis or postoperative loss of correction, development of kyphosis at the thoracolumbar junction, development of degeneration and decompensation cephalad or caudad to a prior fusion, and hip flexion contractures.

Prevention of flatback syndrome involves preoperative assessment of sagittal balance, avoidance of distraction instrumentation and extension of long fusions into the lower lumbar spine, enhancement of physiologic lordosis during lumbar fusions, and intraoperative positioning with the hips extended.

Treatment of flatback syndrome involves corrective pedicle subtraction or Smith-Petersen osteotomies with segmental instrumentation.

Polysegmental osteotomies and vertebral column resection may be utilized in cases of sloping global sagittal imbalance and related severe coronal imbalance, respectively.

Following surgical treatment, sagittal balance is generally improved with fair-to-good clinical outcomes, high patient satisfaction, and moderately high perioperative complication rates.


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