A Normal Spinal Column & Flatback Syndrome

Looking at someone straight on the spine should be straight.

Looking at someone from the lateral or side view the spine shows its varying curvature.

In the neck (cervical spine) and the lower back (lumbar spine) are inward curves known as lordosis.

The thoracic spine, there is an outward curve or kyphosis.

 

The goal is to have an economical stance and gait that does not require excessive energy.

The curves need to be well-balanced.

The gravity line should fall through:

• The head and cervical spine
• Behind the sacrum
• Through the center of the hips

Like this minimum energy is exerted for standing and walking.

When these curves are not balanced, like what happens with excessive kyphosis in the thoracic spine or loss of normal lordosis in the lumbar spine, the patient may begin to experience symptoms.

Loss of lumbar lordosis or actual kyphosis in the lumbar spine that presents symptoms is named flatback syndrome.

Symptoms

The main symptoms of flatback are:

• Difficulty standing up straight
• Low back pain
• Thigh pain
• Groin pain

Symptoms will worsen as the day progresses with fatigue and increasing difficulty to stand up straight with correct posture.

Individuals will flex or bend their hips and knees to get into an upright position.

This is what causes the exhaustion as the day goes on.

Some patients also have symptoms of:

• Sciatica
• Spinal stenosis
• Leg pain
• Weakness made worse from walking

Some individuals have neck and upper back pain as they strain to get themselves upright.

Trying to live like this can lead to a disabling condition that requires pain medications, and limits the individual’s ability to perform daily activities.

 

Causes

Flatback syndrome was first described in patients who had been treated with Harrington spinal instrumentation.

This was the earliest type of spine implantation to correct scoliosis.

This instrumentation had a tendency to flatten the normal curve or lordosis in the lumbar spine.

This system was used from the 1960s to the 1980s.

With today’s implant systems and techniques, this problem doesn’t really occur anymore.

But not to knock the system, those treated with Harrington rods did very well for decades.

The spine compensates for the flattening of the lordosis with the normal discs underneath the fused area.

However, when the discs below the fusion would wear out (degenerate), the patients would lose the ability to stand upright and pain would develop.

Other causes include:

Ankylosing Spondylitis

• A chronic inflammatory arthritic disease that causes stiffness and loss of lordosis.

Degenerative Disc Disease

• The normal aging process of the wear and tear/degeneration of the discs, that are the shock absorbers of the spine.
• In the lumbar area, these discs contribute to normal curvature.
• As the discs degenerate, the spine stiffens and the curvature disappears.
• The patient has progressive difficulty in achieving an upright posture.

Post-Laminectomy Syndrome

• After a laminectomy procedure used to decompress the spine nerves, loss of lordosis and instability can develop.
• This type of procedure is associated with failed back surgery syndrome.

Compression Fractures

• Single or multiple vertebrae collapsing can result in loss of lordosis and flatback.
• The vertebrae are the building blocks of the spine.

Diagnosis

The diagnosis begins with a patient’s history.

A doctor will look for the common symptoms like the presentation of difficulty standing upright along with back pain.

If there is a history of prior surgery or a disease making them susceptible to the syndrome.

Full standing x-rays will be ordered.

The lateral side view is specifically the side that will be helpful (see x-ray).

 

The patient stands, knees straight, the posture can be seen to be stooped forward.

This is depicted by the gravity line/plumb line falling in front of the sacrum.

Finally, MRI’s, CT scans, can be utilized to provide information about the health of the:

• Discs
• Vertebrae
• Degree of openness of the spinal canal to see if there is compression of the spinal nerves or not

 

 

Non-surgical Treatment

Patients should try non-surgical treatment first like:

• Chiropractic
• Physical therapy
• Non-steroidal anti-inflammatory medication

Conditioning and endurance exercise programs can provide relief. But, if the structural problem is too great for conservative therapy then surgery is an option.

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NCBI Resources

Sometimes low back pain comes out of nowhere, but that sudden twinge in the lower back does have a cause. With some cases, there’s a trigger, like picking up a heavy object/furniture from an awkward position.  But sometimes it can be a mystery and a challenge to diagnose.

It is important to know the cause of lower back pain to figure out the proper treatment plan. Otherwise, one could receive treatment for the wrong diagnosis and possibly exacerbate the existing injury.