Prevention and management of iatrogenic flatback deformity

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.