MANAGEMENT OF FLATBACK AND RELATED KYPHOTIC DECOMPENSATION SYNDROMES

Study Design. The authors, in this retrospective study, examined a gro up of patients with flatback syndrome and a related kyphotic decompens ation syndrome. Results of nonrealignment treatment as well as revisio n surgery with sagittal realignment were reviewed. Objectives. To dete rmine effectiveness of physical therapy and limited surgical (instrume ntation removal) as well as major realignment surgical treatment in th e sagittally malaligned spine. Summary of Background Data. Flatback is a sagittal plane deformity associated with distraction instrumentatio n for scoliosis correction. Kyphotic decompensation syndrome involves malaligned fusions from the sacrum for disease other than scoliosis. S everal studies describe surgical realignment for flatback involving in strumentation systems no longer commonly applied. Guidelines for a sys tematic approach to flatback and kyphotic decompensation syndromes are lacking.Methods. Forty-eight patients with flatback and kyphotic deco mpensation syndromes were reviewed. Treatment groups were defined by t reatment approach and level of previous fusion. Effectiveness of treat ment was reviewed in terms of radiographic sagittal alignment and self -reported pain. Results. Twenty patients were treated without realignm ent revision surgery. Twenty-eight patients were treated with anterior and posterior osteotomies and realignment with instrumentation. For p atients originally fused to the sacrum, realignment averaged 12 cm. Pa in was reduced from 7 to 3 (10-point scale). In patients fused to L4 o r L5, realignment averaged 7 cm. Pain was reduced from 6 to 2. Magneti c resonance imaging revealed viable caudal discs in four patients who were consequently spared extension of fusion to the sacrum. Conclusion s. Treatment without realignment surgery demonstrated long-term succes s in 27% of cases. The latter all had two intact discs below the previ ous fusion and sagittal malalignment less than 4 cm. Realignment surge ry effectively reduced pain in patients failing a conservative approac h.