Reduction of normal lumbar lordosis can produce fixed sagittal imbalance resulting in flatback

1. FLAT BACK
SYNDROME
GEORGE SAPKASGEORGE SAPKAS
1st Orthopaedic Department1st Orthopaedic Department
Medical School-Athens UniversityMedical School-Athens University

2. Introduction
ReductionReduction
of normal lumbarof normal lumbar
lordosis canlordosis can
produce fixedproduce fixed
sagittal imbalancesagittal imbalance
resulting inresulting in
flatback deformity.flatback deformity.

3. Clinically, the deformityClinically, the deformity
appears as :appears as :
1.1. fixed lumbar flexionfixed lumbar flexion

4. 2.2. inability to standinability to stand
3.3. erect withouterect without
compensatorycompensatory
hip extensionhip extension
andand
knee flexion.knee flexion.
This results in muscleThis results in muscle
fatigue and activity-fatigue and activity-
related pain.related pain.

5. As the patient ages:As the patient ages:
1.1. reduced musclereduced muscle
strength,strength,
2.2. adjacent discadjacent disc
degeneration,degeneration,
andand
3.3. hip and pelvic diseasehip and pelvic disease
may combine tomay combine to
decrease the patient’sdecrease the patient’s
ability to compensateability to compensate
andand
may result in increasedmay result in increased
disability.disability.
Kostuik JP, et al, Spine 1988;

6. There are multipleThere are multiple
causes of thecauses of the
flat back syndrome.flat back syndrome.

7. Many reports describeMany reports describe
the results of placingthe results of placing
HarringtonHarrington
distractiondistraction
instrumentationinstrumentation toto
the sacrum.the sacrum.
This is of contemporaryThis is of contemporary
concern, becauseconcern, because
many patients treatedmany patients treated
for scoliosis 20 or 30for scoliosis 20 or 30
years ago areyears ago are
becomingbecoming
symptomatic.symptomatic.
Bradford DS, et al Clin Orthop 1994;
Denis F, et al Inc., 1994;
Farcy J-PC, et al Spine 1997
LaGrone MO, et al J bone Joint Sur {Am} 1988;

8. Other described causesOther described causes
include :include :
anterior compressionanterior compression
instrumentationinstrumentation
(Dwyer or Zielke)(Dwyer or Zielke)
without the use ofwithout the use of
structural interbody graftsstructural interbody grafts
DeWald RL, et al 1993

10. oror
the settling of athe settling of a
long posteriorlong posterior
lumbar fusionlumbar fusion
performed withoutperformed without
structural grafting.structural grafting.
DeWald RL, et al 1993
E.P.
F 77
09.02.04
2½
yrs pop

11. Fixed sagittalFixed sagittal
imbalance may alsoimbalance may also
be the result of :be the result of :
traumatrauma
Bradford DS, et al Spine 1987

12. oror
systemic illnesssystemic illness
such assuch as
ankylosingankylosing
spondylitisspondylitis
Bradford DS, et al Spine 1987

13. The treatment ofThe treatment of
a fixed sagittal deformitya fixed sagittal deformity
requires rebalancing of therequires rebalancing of the
spine with one or severalspine with one or several
osteotomies.osteotomies.
There are inherent dangersThere are inherent dangers
with reconstructivewith reconstructive
procedures needed toprocedures needed to
restore sagittal balance.restore sagittal balance.

14. Goals of surgical treatment
 Restoration of sagittal and coronalRestoration of sagittal and coronal
balance in a patient with fixed spinalbalance in a patient with fixed spinal
deformitydeformity
 Achievement of solid arthrodesisAchievement of solid arthrodesis
 Rigid internal fixation to permit aRigid internal fixation to permit a
brace-free mobilizationbrace-free mobilization
 Relief of axial and radicular painRelief of axial and radicular pain
Devlin J.V., Surg. Techn. Odf the spine 2003Devlin J.V., Surg. Techn. Odf the spine 2003

15. Diagnosis
 Back painBack pain
 Spinal fatigueSpinal fatigue
 Progressive spinalProgressive spinal
deformitydeformity
 Inability to stand erectInability to stand erect
with the knees fullwith the knees full
extendedextended

16.  A comprehensiveA comprehensive
musculoskeletalmusculoskeletal
examination includesexamination includes
consideration of theconsideration of the
following questions:following questions:

17. 1.1. Is the most severe spinalIs the most severe spinal
deformity located in thedeformity located in the
sagittal plane or coronalsagittal plane or coronal
plane ?plane ?
Is a complex deformityIs a complex deformity
involving multiple planesinvolving multiple planes
present ?present ?

18. 2.2. Is the spinalIs the spinal
deformitydeformity
balanced orbalanced or
unbalanced ?unbalanced ?
This is assessedThis is assessed
by theby the
relationship ofrelationship of
the C7 plump linethe C7 plump line
to the sacrum into the sacrum in
the coronal andthe coronal and
sagittal planessagittal planes

19. 3.3. Is the spinalIs the spinal
deformity flexibledeformity flexible
or rigid ?or rigid ?
Are flexibleAre flexible
nonfused spinalnonfused spinal
segments presentsegments present
above or below aabove or below a
previously fusedpreviously fused
spinal region ?spinal region ?

20. 4.4. What is the relationship ofWhat is the relationship of
the shoulders and pelvisthe shoulders and pelvis
to the spinal deformity ?to the spinal deformity ?
Factors such as shoulderFactors such as shoulder
imbalance, pelvicimbalance, pelvic
obliquity, and hip flexionobliquity, and hip flexion
contractures requirecontractures require
consideration whenconsideration when
planning osteotomyplanning osteotomy
proceduresprocedures

21. Radiographic
assessment
 GlobalGlobal
1.1. In the coronal planeIn the coronal plane
2.2. In the sagittal planeIn the sagittal plane
 RegionalRegional
 SegmentalSegmental

22. Pre-op
evaluation

27. Operative techniques

28. S.S.E.P. – M.E.P.

29. Smith - Peterson
Type Osteotomy
Smith Peterson et al J.B.J.S 27, 1:11, 1945

30. Indications
for surgery
 Ankylosing spondylitisAnkylosing spondylitis
 Post surgical flat backPost surgical flat back
syndromesyndrome
 Iatrogenic spinal deformitiesIatrogenic spinal deformities
arising after scoliosis fusionarising after scoliosis fusion
 Post-traumatic kyphoticPost-traumatic kyphotic
deformitydeformity
 Transition syndromesTransition syndromes
(proximal or distal) following(proximal or distal) following
degenerative lumbar spinaldegenerative lumbar spinal
proceduresprocedures

31. Contra- Indications
 Spinal deformities that can be treated bySpinal deformities that can be treated by
combined procedures such as:combined procedures such as:
– multiple anterior discectomies and fusionmultiple anterior discectomies and fusion
followed byfollowed by
– posterior segmental instrumentation and fusionposterior segmental instrumentation and fusion
 Patients with severe degree of fixedPatients with severe degree of fixed
decompensated spinal deformities in whomdecompensated spinal deformities in whom
spinal balance would not be achievedspinal balance would not be achieved
despite multiple S-P osteotomiesdespite multiple S-P osteotomies

32. Advantages
 May be used to treat coexistentMay be used to treat coexistent
sagittal and coronal spinal deformitiessagittal and coronal spinal deformities
 May result in long harmonious sagittalMay result in long harmonious sagittal
curves if multiple osteotomies arecurves if multiple osteotomies are
performed over adjacent levelsperformed over adjacent levels

33. Disadvantages
 Requires theRequires the anterioranterior
structures of the spine tostructures of the spine to
be flexiblebe flexible enough to allowenough to allow
the osteotomy gap tothe osteotomy gap to
completely closecompletely close
posteriorly.posteriorly.
 S-P type osteotomiesS-P type osteotomies
performed at spinalperformed at spinal
segments with existingsegments with existing
foraminal stenosisforaminal stenosis maymay
worsen foraminal stenosisworsen foraminal stenosis
as the posterior wedge isas the posterior wedge is
closedclosed
Cont..ed

34.  When multiple S-P typeWhen multiple S-P type
osteotomies areosteotomies are
performedperformed correction maycorrection may
occur preferentially at aoccur preferentially at a
single levelsingle level resulting inresulting in
less than completeless than complete
correction,correction,
nonharmoniousnonharmonious
correction, or a neurologiccorrection, or a neurologic
complicationcomplication
 If a large degree ofIf a large degree of
correction is obtained at acorrection is obtained at a
single spinal level ansingle spinal level an
anterior column defectanterior column defect
may be created becausemay be created because
the axis of closure of thethe axis of closure of the
osteotomy is located atosteotomy is located at
the posterior disc marginthe posterior disc margin

35. Procedure
 PlanningPlanning
1.1. Location of osteotomiesLocation of osteotomies
2.2. Size and number of osteotomiesSize and number of osteotomies
3.3. Distal extent of fusion and instrumentationDistal extent of fusion and instrumentation
4.4. Proximal extent of posterior fusion andProximal extent of posterior fusion and
instrumentationinstrumentation
5.5. Posterior vs. anterior and posterior surgeryPosterior vs. anterior and posterior surgery

36. Technique of osteotomy
 Position of patient prior to surgeryPosition of patient prior to surgery

37.  The osteotomies are V-The osteotomies are V-
shaped with their baseshaped with their base
located inferiorly in thelocated inferiorly in the
midline at the originalmidline at the original
interlaminar spaceinterlaminar space

38.  The lateral extensions ofThe lateral extensions of
the osteotomy passthe osteotomy pass
proximally across theproximally across the
original facet joints andoriginal facet joints and
exit through the neuralexit through the neural
foramen just proximal toforamen just proximal to
the pediclesthe pedicles

39.  Elevation of kidney rest assists inElevation of kidney rest assists in
closing the osteotomyclosing the osteotomy

40.  Closure of theClosure of the
posterior osteotomyposterior osteotomy
is accompanied byis accompanied by
opening of theopening of the
anterior and middleanterior and middle
spinal columnsspinal columns

41. Osteotomy
for
Ankylosing
Spondylitis

42. Goals of surgical
treatments
 Osteotomy of the spine in akylosingOsteotomy of the spine in akylosing
spondylitis is done to correct fixed rigidspondylitis is done to correct fixed rigid
deformities of the:deformities of the:
– cervical,cervical,
– thoracic,thoracic,
– lumbar spinelumbar spine
that are impairing functional status andthat are impairing functional status and
quality of lifequality of life

43. Indications for surgery
 In the cervical spine the flexionIn the cervical spine the flexion
deformity is often a result of adeformity is often a result of a
misdiagnosed fracture that went on tomisdiagnosed fracture that went on to
heal in a forward flexed positionheal in a forward flexed position
 Osteotomy of the lumbar spine isOsteotomy of the lumbar spine is
commonly done for lumbarcommonly done for lumbar
hypolordosis or actual kyphosis givinghypolordosis or actual kyphosis giving
rise to a fixed flexion deformityrise to a fixed flexion deformity

44. Contra - Indications
 Include patients who are not suitableInclude patients who are not suitable
candidates for medical reasons andcandidates for medical reasons and
where the severity of the deformitywhere the severity of the deformity
does not warrant the procedure.does not warrant the procedure.
 Severe osteopeniaSevere osteopenia

45. Advantages
 The osteotomy may de done from aThe osteotomy may de done from a single –single –
stage posterior approachstage posterior approach in the lumbar andin the lumbar and
cervical spines and allows for acervical spines and allows for a high degreehigh degree
of correctionof correction to be obtained in a safeto be obtained in a safe
manner with the least morbidity to themanner with the least morbidity to the
patientpatient
 The results can be very gratifying in terms ofThe results can be very gratifying in terms of
overall improvement in functional status andoverall improvement in functional status and
quality of lifequality of life

46. Disadvantages
 The disadvantages of the procedureThe disadvantages of the procedure
predominantly are those related topredominantly are those related to potentialpotential
complicationscomplications or morbidity from theor morbidity from the
procedureprocedure
 Many of these patients have concomitantMany of these patients have concomitant
medical illnesses and cardiac problems andmedical illnesses and cardiac problems and
must be carefully evaluated preoperativelymust be carefully evaluated preoperatively
from a medical standpointfrom a medical standpoint
 Major neurologic problems are relativelyMajor neurologic problems are relatively
infrequent; however they can be a majorinfrequent; however they can be a major
problem when they occurproblem when they occur

47. Lumbar spine
osteotomy Selected
levels of
osteotomy
L2
L3
L4

48.  Position of patient prior to surgeryPosition of patient prior to surgery

49. Exposure
secrets
 Be certain of theBe certain of the
level that you arelevel that you are
preparing to dopreparing to do
osteotomy at asosteotomy at as
the landmarks arethe landmarks are
obscured.obscured.
 RadiographicRadiographic
confirmation isconfirmation is
often necessaryoften necessary

52.  Elevation of kidney rest assists inElevation of kidney rest assists in
closing the osteotomyclosing the osteotomy

54.  lumbar kyphotic deformitylumbar kyphotic deformity
due to ankylosing spondylitisdue to ankylosing spondylitis
 Postoperative radiographPostoperative radiograph
following lumbarfollowing lumbar
extension osteotomy andextension osteotomy and
realignment of the spinerealignment of the spine

55. Pedicle subtraction
and
lumbar extension
osteotomy

56. Indications for Surgery
Loss of lumbarLoss of lumbar
lordosis (flat back)lordosis (flat back)
with associatedwith associated
complaints andcomplaints and
physical findings asphysical findings as
mentioned above.mentioned above.

57. Contraindications
1.1. History of ongoingHistory of ongoing
infection frominfection from
previous surgeryprevious surgery
2.2. SevereSevere
osteoporosis, whichosteoporosis, which
could lead to implantcould lead to implant
looseningloosening
3.3. SevereSevere
comorbiditiescomorbidities

58. Advantages
1.1. Elimination of the need for multipleElimination of the need for multiple
posterior osteotomies.posterior osteotomies.
2.2. Anterior disc space is not opened as aAnterior disc space is not opened as a
result of the posterior closure of theresult of the posterior closure of the
posterior elements.posterior elements.
3.3. Elimination of an anterior procedure.Elimination of an anterior procedure.
4.4. Biplanar osteotomy may be performed ifBiplanar osteotomy may be performed if
coronal decompensation exists.coronal decompensation exists.

59. Disadvantages
1.1. Coronal decompensation may occurCoronal decompensation may occur
if the osteotomy cuts are not parallel.if the osteotomy cuts are not parallel.
2.2. Blood loss, dural rents, andBlood loss, dural rents, and
neurologic compromise.neurologic compromise.

60.  Position of patient prior to surgeryPosition of patient prior to surgery

62. 35 degrees
wedge to be
resected
Type A

64.  Elevation of kidney rest assists inElevation of kidney rest assists in
closing the osteotomyclosing the osteotomy

66. Type B
•Vertebrae are exposed at appropiate levels to allow
osteotomy as indicated by dotted lines and shaded portion

67. •Complete laminectomy
and pedicle subtraction
are performed
•Wedge osteotomy of the
entire L4 verterbral body
is completed

68. •Wedge removal from
right side L4 body. Note
that anterior longitudinal
ligament is intact
•Precontoured posterior
instrumentation is
applied

69. •Compression of the
osteotomy

71. Posterior Lumbar
decancellation
osteotomy (eggshell
decancellation)
Michelle A., Krudger F.J J.B.J.S. 1949
Thomasen E. Cliin. Orthop. 1996
Heinig C.F. et al The Spine 1997

72. Indications
 The eggeshell procedure orThe eggeshell procedure or
transpedicular vertebrectomytranspedicular vertebrectomy
may be used for variety ofmay be used for variety of
indications.indications.
 The transpedicular approachThe transpedicular approach
can be used open orcan be used open or
percutaneously underpercutaneously under
computed tomography (CT)computed tomography (CT)
control biopsies or damagecontrol biopsies or damage
 The same approach can beThe same approach can be
used for total or partialused for total or partial
cancellous bone removal andcancellous bone removal and
decompression of the anteriordecompression of the anterior
portion of the spinal canal inportion of the spinal canal in
cases of tumor or fracturecases of tumor or fracture
 A posterior vertebrectomyA posterior vertebrectomy
and /or osteotomy forand /or osteotomy for
correction of a fixed sagittalcorrection of a fixed sagittal
deformity is the most complexdeformity is the most complex
indication for this approachindication for this approach

73. Operative technique
 The term eggshellThe term eggshell
describes thedescribes the
appearance of theappearance of the
vertebral body aftervertebral body after
the cancellous partthe cancellous part
of the vertebralof the vertebral
body has beenbody has been
removed leavingremoved leaving
only a cortical shellonly a cortical shell
similar to an emptysimilar to an empty
eggshell.eggshell.

74. Operative technique
 This operation consists ofThis operation consists of
removal of cancellous boneremoval of cancellous bone
of the selected vertebraof the selected vertebra
body through both pedicle tobody through both pedicle to
weaken the vertebral bodyweaken the vertebral body
and create a posteriorand create a posterior
compression of the vertebralcompression of the vertebral
body with minimal forcebody with minimal force
while the posterior arches ofwhile the posterior arches of
the adjacent vertebrae arethe adjacent vertebrae are
approximated under directapproximated under direct
vision by manipulating thevision by manipulating the
operating table or spinaloperating table or spinal
column and securing withcolumn and securing with
internal fixation.internal fixation.

78. Anterior Osteotomy(ies)
and
Posterior Corrective
osteotomy(ies)
and
stabilization

79. Indications
 Spinal deformitiesSpinal deformities
that can be treatedthat can be treated
by multiple anteriorby multiple anterior
discectomies –discectomies –
osteotomies andosteotomies and
fusion followed byfusion followed by
posterior segmentalposterior segmental
instrumentation andinstrumentation and
fusionfusion

80. Indications
 Patients with severe degreesPatients with severe degrees
of fixed decompensatedof fixed decompensated
spinal deformities in whomspinal deformities in whom
spinal balance would not bespinal balance would not be
achieved despite variousachieved despite various
types of posteriortypes of posterior
osteotomies e.g.:osteotomies e.g.:
– Smith-Peterson typeSmith-Peterson type
osteotomy,osteotomy,
– Pedicle Subtraction osteotomy,Pedicle Subtraction osteotomy,
– Posterior LumbarPosterior Lumbar
Decancellation osteotomyDecancellation osteotomy

81.  Preoperative standing anteroposteriorPreoperative standing anteroposterior
(AP) (A) and lateral (B) radiographs of a(AP) (A) and lateral (B) radiographs of a
patient with a sagittal imbalance followingpatient with a sagittal imbalance following
scoliosis surgeryscoliosis surgery

82.  Postoperative standingPostoperative standing
(AP) (A) and lateral (B)(AP) (A) and lateral (B)
radiographs followingradiographs following
revision surgery.revision surgery.
 Multilevel anteriorMultilevel anterior
discectomy and fusiondiscectomy and fusion
with non structuralwith non structural
grafting was followed bygrafting was followed by
multiple levelmultiple level SmithSmith
Peterson typePeterson type
osteotomiesosteotomies withwith
restoration of sagittalrestoration of sagittal
and coronal planeand coronal plane
alignment andalignment and
achievement ofachievement of
successful arthrodesissuccessful arthrodesis

83. Anterior intervertebral graftAnterior intervertebral graft
andand
posterior extensionposterior extension
osteotomyosteotomy
andand
stabilizationstabilization

84. University Hospital “ATTIKON”