A 67 year old female presented to Dr. Pashman with severe Flat back Syndrome after 5 previous spine surgeries for Adult Idiopathic Scoliosis. Dr. Pashman treated her with a Posterior Spinal Fusion from T8 to S1.

1. Case Review:
67 year old Female
presented with Flatback
after five previous Scoliosis
Surgeries
Robert S Pashman, MD
Scoliosis and Spinal Deformity Surgery
www.eSpine.com

2. Patient History
67-year-old female
Approximately 5 previous operations for Adult Idiopathic Scoliosis
Pseudoarthrosis, multiple times at L5-S1
Ultimately the patient had been fused up to T8, which had resulted in
iatrogenic flatback deformity with severe forward decompensation. The
patient could not walk upright, but necessarily needed to flex hips and
knees to maintain upright gait.
The patient also has severe cervical stenosis found on MRI, although she
does not have upper motor neuron symptoms. Clearly her sagittal
imbalance is causing more neural compression as the patient attempts to
hyper-lordose her neck to compensate for the severe decompensation.
Forward decompensation is causing significant buttock and posterior
thigh pain
The patient's past medical history is significant for treatment for breast
cancer including chemotherapy and radiation.

3. Pre-op X-rays
The patient’s head is
approximately 14 cm
anterior to the sacrum.

4. Indications for Surgery
Iatrogenic flat-back, status post multiple operations for adult idiopathic
scoliosis.
Severe low back and leg pain due to forward decompensation.
Significant radiculopathy due to nerve stretch symptoms including
neurapraxia.
Multiple co-morbidities including factor V deficiency, hypertension,
cervical stenosis.
Failure to function because of forward decompensation, low back pain.
Status post breast cancer treatment including chemotherapy and
radiation.

5. Surgical Strategy
Segmental spinal instrumentation, T8 to sacrum
Posterior spinal fusion, T8 to S1 using locally-harvested autogenous bone
and osteotomy bone.
Complete laminectomy, L1, L2 and L3.
Lateral recess decompression, L2-3, L3-4 and L1-2 for isolation of nerves.
Complete vertebrectomy, kyphectomy, pedicle subtraction osteotomy to
induce realignment of flat-back syndrome, lumbar 2.
Spinal osteotomy, T8-T9, T9-T10, T11-T12 for removal of retained
hardware and harvesting autogenous bone.
Intraoperative CT management using O-arm and neuronavigation for
placement of pedicle screws through fusion mass.
Intraoperative motor-evoked potential management and SSEP
management.
Plastic closure, status post multiple operations, lumbar spine.
Removal of retained hardware, T8 to S1 previously placed, producing
iatrogenic flat-back.

6. Post-Op Films
The patient is well balanced in both
frontal and saggital planes.

7. Pre-Op/Post-op Comparison

8. Pre-Op/Post-op Comparison
The patient is very happy
with her outcome. Her
symptoms resolved, and
she returned to work at 3
months post-op, and