Management of flatback and related kyphotic decompensation syndromes.

STUDY DESIGN

The authors, in this retrospective study, examined a group of patients with flatback syndrome and a related kyphotic decompensation syndrome. Results of nonrealignment treatment as well as revision surgery with sagittal realignment were reviewed.

OBJECTIVES

To determine effectiveness of physical therapy and limited surgical (instrumentation removal) as well as major realignment surgical treatment in the sagittally malaligned spine.

SUMMARY OF BACKGROUND DATA

Flatback is a sagittal plane deformity associated with distraction instrumentation for scoliosis correction. Kyphotic decompensation syndrome involves malaligned fusions from the sacrum for disease other than scoliosis. Several studies describe surgical realignment for flatback involving instrumentation systems no longer commonly applied. Guidelines for a systematic approach to flatback and kyphotic decompensation syndromes are lacking.

METHODS

Forty-eight patients with flatback and kyphotic decompensation syndromes were reviewed. Treatment groups were defined by treatment approach and level of previous fusion. Effectiveness of treatment was reviewed in terms of radiographic sagittal alignment and self-reported pain.

RESULTS

Twenty patients were treated without realignment revision surgery. Twenty-eight patients were treated with anterior and posterior osteotomies and realignment with instrumentation. For patients originally fused to the sacrum, realignment averaged 12 cm. Pain was reduced from 7 to 3 (10-point scale). In patients fused to L4 or L5, realignment averaged 7 cm. Pain was reduced from 6 to 2. Magnetic resonance imaging revealed viable caudal discs in four patients who were consequently spared extension of fusion to the sacrum.

CONCLUSIONS

Treatment without realignment surgery demonstrated long-term success in 27% of cases. The latter all had two intact discs below the previous fusion and sagittal malalignment less than 4 cm. Realignment surgery effectively reduced pain in patients failing a conservative approach.