Flatback Syndrome

If spine pain worsens, interferes with daily activities, or is accompanied by swelling and redness, it’s crucial to consult a healthcare professional. At Complete Orthopedics, our expert team specializes in addressing spine issues through customized treatment plans and surgical options. We prioritize understanding your symptoms, identifying the underlying causes, and recommending the most suitable treatments or surgeries.

Our clinics are conveniently located throughout New York City and Long Island, and we collaborate with six leading hospitals to ensure you receive the highest quality care for spine issues. Schedule an appointment with one of our orthopedic surgeons online or by phone. Learn about the causes and treatments for spine pain and determine when surgery might be necessary.

Overview

The straightening of the normal lumbar lordosis is known as a flatback syndrome. The condition may affect patients who had prior spine surgeries or suffer from degenerative spine conditions. Flatback syndrome results in back pain, difficulty walking and standing straight. The management of flatback syndrome involves the use of conservative measures and in some patients, surgical correction may be needed.

The human spine consists of 24 vertebrae stacked upon each other to form the vertebral column. The vertebral column provides a safe conduit for the spinal cord and the numerous spinal nerves branching from the spinal cord. Each vertebra joins the adjoining vertebrae through facet joints and the intervertebral discs.

Natural curves in the human spine.

The natural vertebral column is curved in an ‘S’ shape. The neck spine is curved inwards, the thoracic spine is curved backward and the lumbar spine is curved inwards. The natural curves in the spine function to keep the center of gravity of the spine in line with the pelvis and the legs. The natural alignment thus functions to maintain the balance of the body in activities such as standing, walking, etc.

In flatback syndrome, the natural inward curve of the spine is lost and the lumbar spine is straight. The resulting alignment shifts the balance of the spine forward and causes the symptoms associated with the flatback syndrome.

Symptoms of Flatback Syndrome

The symptoms of flatback syndrome can vary in severity but generally include:

Difficulty Standing Upright: One of the hallmark symptoms of flatback syndrome is the inability to stand up straight without discomfort. Individuals often feel like they are leaning forward.

Lower Back Pain: Chronic pain in the lower back is common due to the abnormal posture and strain on the muscles and ligaments.

Fatigue: Because the spine is not properly aligned, the muscles have to work harder to maintain balance, leading to fatigue, especially after standing or walking for extended periods.

Pain in the Legs: Some people with flatback syndrome experience pain that radiates down into the legs. This is often due to nerve compression or irritation.

Restricted Mobility: The loss of the natural curve can limit the spine’s flexibility, making it difficult to perform everyday activities.

Patients with flatback syndrome find it difficult to stand straight as the center of gravity shifts forward. The patients report a feeling of falling forward on walking or standing. Initially to compensate for the altered balance of the spine the patients may often bend their hips and their knees to stand straight. The back muscles contract to pull the spine back to stand straight.

Bending of the knees and hips along with constantly contracted back muscles, results in severe pain in the back and the legs. The patients may feel tired and fatigued and stoop while walking especially at the end of the day. They may use an assistive device in the form of a cane or a walker to support the body falling forward on walking.

Causes

Often patients who receive surgical treatment for scoliosis with a fusion of multiple segments end up with a flatback syndrome due to loss of natural curve. Patients having a prior surgical history of fusion of the lumbar spine or laminectomy of the lumbar spine may also develop the flat back syndrome.

Besides the history of prior surgery, the flatback syndrome may be present in certain patients due to a developmental deformity or they may be born with the condition (congenital). Patients suffering from ankylosing spondylitis in the advanced stage of disease may develop the flatback syndrome. The lumbar spine in ankylosing spondylitis becomes fused due to the ossification of ligaments and the formation of bridging syndesmophytes.

With advancing age, there may be a loss of disc height secondary to the decreased water content of the intervertebral disc and lead to degenerative changes in the vertebra. This results in loss of the natural lordotic curve of the lumbar spine that may cause the flatback syndrome. In patients with metabolic bone disease such as osteoporosis, there may be compression fractures of the vertebrae that may disturb the natural alignment of the spine and cause flatback syndrome.

Diagnosis

The diagnosis of flatback syndrome is made by the orthopedic spine surgeon after a thorough evaluation of the patient. The evaluation consists of extraction of the history of symptoms and any prior surgical procedures. The physician conducts a thorough examination of the spine to look for the alignment and the gait of the patient. The physician also checks for the integrity of the neurological system.

The physician may request a full-length X-ray to check for the alignment of the spine. CT scan may be done for further evaluation of the bony spine and an MRI may be done to look for the soft tissue structures of the spine.

Treatment

The flatback syndrome is initially managed using conservative treatment options. The conservative treatment options include physical therapy to strengthen and improve the flexibility of the back and the abdominal muscles. Gait training is done to help form a correct posture during walking.

Nonsteroidal anti-inflammatory medications and other pain medications such as Tylenol may be used to relieve the pain associated with the flatback syndrome. Heat and cold therapy may be used to reduce pain and inflammation of the lumbar spine. Epidural and nerve block injections may be used to provide pain relief and symptoms of radiculopathy.

Surgical Treatments:

• Spinal Fusion Revision: If flatback syndrome is the result of a previous spinal fusion surgery, a revision surgery might be necessary to restore the normal curvature of the spine.
• Osteotomy: This is a surgical procedure where a section of bone is removed to correct the alignment of the spine.
• Decompression Surgery: If there is nerve compression contributing to pain, decompression surgery can relieve the pressure on the nerves.

Surgery is reserved for patients who have failed to benefit from conservative measures. The surgical treatment of flatback syndrome involves correction of the lumbar curve to align the spine. A spinal osteotomy and pedicle subtraction surgery involve cutting a wedge-shaped part of the lumbar spine to make a natural curve. The surgery usually involves the fusion of the involved vertebrae using a cage and a bone graft. The fused segment is stabilized using a screw and a rod construct on either side of the midline.

The patients treated with surgical correction techniques experience significant relief of symptoms and are quickly able to get back to their daily routines. As with any surgery, there may be risks and complications associated with corrective surgery such as bleeding, infection, blood clot formation, failure of fusion, damage to nerves/dural sac, etc. The operating spine surgeon will discuss all the potential benefits and risks before doing the surgery.

Living with Flatback Syndrome

Living with flatback syndrome can be challenging, but there are ways to manage the condition and improve your quality of life. Here are some tips:

Stay Active: Regular exercise, especially activities that strengthen the core and improve flexibility, can help manage symptoms.

Maintain a Healthy Weight: Excess weight can put additional strain on the spine, so maintaining a healthy weight is important.

Use Proper Posture: Being mindful of your posture while sitting, standing, and lifting can help prevent further strain on the spine.

Follow Your Treatment Plan: Adhering to the treatment plan prescribed by your healthcare provider, including physical therapy and medication, is crucial for managing symptoms.

Seek Support: Joining a support group or seeking counseling can help you cope with the emotional aspects of living with a chronic condition.

Conclusion

Flatback syndrome is a condition that affects the natural curvature of the spine, leading to a forward-leaning posture and various symptoms like back pain and difficulty standing upright. It can result from degenerative disc disease, previous spinal surgeries, certain spinal conditions, or poor posture. Diagnosis typically involves a combination of medical history, physical examination, and imaging tests. Treatment options range from non-surgical methods like physical therapy and pain management to surgical interventions to correct the spine’s alignment. Living with flatback syndrome requires a combination of medical management, lifestyle adjustments, and support to improve quality of life.

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