Prevention and Management of Iatrogenic Flatback Deformity

Potter, Benjamin K.; Lenke, Lawrence G.; Kuklo, Timothy R.

doi:10.2106/00004623-200408000-00027

Cited by 148 publications

(92 citation statements)

References 77 publications

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“…26,42 It has been noticed that posterior correction using segmental pedicle screw instrumentation can result in a further decrease in TK, because of various factors, including prone positioning, compressing maneuver, direct vertebral de-rotation, etc. 23,27,30,39 Although so far there is insufficient evidence showing that this further decrease of TK after surgery affects the quality of life in patients treated for AIS, it may still increase the risk of adjacent-segment disease and be a potential cause of iatrogenic loss of lumbar lordosis. Adjacent-segment disease, including cervical kyphosis and junctional kyphosis proximal to the fused thoracic spine, was found to be related to TK decrease after AIS correction, especially when pedicle screw instrumentation was used.…”

mentioning

confidence: 99%

“…Iatrogenic loss of lumbar lordosis and related flat-back syndrome are usually discussed when the lumbar spine is involved in fusion surgery, but decrease of lumbar lordosis in the unfused lumbar spine due to TK decrease has been recently noticed, and it may be considered a different kind of iatrogenic flat back. 27,30 Adverse consequences like disc degeneration, positive sagittal balance, back pain, and related loss of quality of life could be reasonably predicted with age. 11,12,14 It is reasonable to pay more attention to TK restoration in order to minimize the adverse effects of its decrease when correcting the coronal deformity.…”

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confidence: 99%

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Main thoracic curve adolescent idiopathic scoliosis: association of higher rod stiffness and concave-side pedicle screw density with improvement in sagittal thoracic kyphosis restoration

Liu

Li²,

Li³

et al. 2015

SPI

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OBJECT The aim of this study was to evaluate the effects of rod stiffness and implant density on coronal and sagittal plane correction in patients with main thoracic curve adolescent idiopathic scoliosis (AIS). METHODS The authors conducted a retrospective study of 77 consecutive cases involving 56 female and 21 male patients with Lenke Type 1 main thoracic curve AIS who underwent single-stage posterior correction and instrumented spinal fusion with pedicle screw fixation between July 2009 and July 2012. The patients' mean age at surgery was 15.79 ± 3.21 years. All patients had at least 1 year of follow-up. Radiological parameters in the coronal and sagittal planes, including Cobb angle of the major curve, side-bending Cobb angle of the major curve, thoracic kyphosis (TK), correction rates, and screw density, were measured and analyzed. Screw densities (calculated as number of screws per fusion segment × 2) of < 0.60 and ≥ 0.60 were defined as low and high density, respectively. Titanium rods of 5.5 mm and 6.35 mm diameter were defined as low and high stiffness, respectively. Patients were divided into 4 groups based on the type of rod and density of screw placement that had been used: Group A, low-stiffness rod with low density of screw placement; Group B, low-stiffness rod with high density of screw placement; Group C, high-stiffness rod with low density of screw placement; Group D, high-stiffness rod with high density of screw placement. RESULTS The mean coronal correction rate of the major curve, for all 77 patients, was (81.45% ± 7.51%), and no significant difference was found among the 4 groups (p > 0.05). Regarding sagittal plane correction, Group A showed a significant decrease in TK after surgery (p < 0.05), while Group D showed a significant increase (p < 0.05); Group B and C showed no significant postoperative changes in TK (p > 0.05). The TK restoration rate was highest in Group D and lowest in Group A (A, −39.32% ± 7.65%; B, −0.37% ± 8.25%; C, −4.04% ± 6.77%; D, 37.59% ± 8.53%). Screw density on the concave side was significantly higher than that on the convex side in all the groups (p < 0.05). CONCLUSIONS For flexible main thoracic curve AIS, both rods with high stiffness and those with low stiffness combined with high or low screw density could provide effective correction in the coronal plane; rods with high stiffness along with high screw density on the concave side could provide better outcome with respect to sagittal TK restoration.

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confidence: 99%

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confidence: 99%

Main thoracic curve adolescent idiopathic scoliosis: association of higher rod stiffness and concave-side pedicle screw density with improvement in sagittal thoracic kyphosis restoration

Liu

Li²,

Li³

et al. 2015

SPI

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“…Moreover, it has also been proven that applying this method is directly related to improving the health and quality of the life of the patients with AIS (11,12). The patients who have significantly lost their lordosis often need to spend high energy and a compensatory and painful mechanism such as pelvic retroversion to maintain their gravity line and balance (13,14). The concept of spinopelvic compensatory mechanism was explained by some French researchers over 20 years ago, but it was published in the English-language papers for the first time in the past decade (15).…”

Section: Discussionmentioning

confidence: 99%

Evaluation of the Factors Affecting the Loss of Lumbar Lordosis in Surgical Treatment of Patients with Adolescent Idiopathic Scoliosis Using Segmental Instrumentation

et al. 2017

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Background: The identification of independent factors affecting the loss of lumbar lordosis can facilitate programmed surgery in adolescent idiopathic scoliosis (AIS) patients especially with considering the importance of sagittal characteristics. Objectives: This study aimed to investigate the factors affecting the amount of the loss of lumbar lordosis in surgical treatment of the patients with AIS using segmental instrumentation. Methods: In this study which was conducted in three years, 91 AIS patients who underwent segmental instrumentation were studied and 63 patients remained in the study according to the inclusion criteria. All patients' information was recorded on admission in separate forms and radiography results were coded and archived before the surgery for more evaluation. All patients were subject to standing whole spine radiograph again 12 months after the surgery. Ultimately, the information was put into predetermined forms and was used for a statistical analysis after the completion of forms.

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“…Although early surgical instrumentation was effective in addressing the frontal plane aspect of the scoliotic alignment, follow-up revealed often deleterious effects on the sagittal plane [18]. Doherty, in 1973, described what was later coined by Moe and Denis as "flatback syndrome," characterized by a fixed forward inclination of the trunk due to the loss of normal lumbar lordosis [18].…”

Section: Historical Perspective On Understanding Of Sagittal Alignmentmentioning

confidence: 99%

Sagittal Alignment in Spinal Deformity: Implications for the Non-Operative Care Practitioner

Bakarania¹,

Berdishevsky²,

Grimes³

et al. 2017

Innovations in Spinal Deformities and Postural Disorders

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Sagittal alignment has become a hot topic in the world of orthopedics, particularly as it pertains to adults with spine deformities and coexisting pain, activity limitations, and health-related quality of life. It is reported that the prevalence of spinal deformity in the older adult will continue to increase. Clinicians across disciplines recognize the myriad of variation that exists in sagittal alignment, and that there is not one ideal norm to ascribe to. Relatively new to the spine deformity community has been the discovery of the relationship between the pelvis and the femur (pelvic incidence) in dictating lumbar lordosis and overall spinal alignment. While it is acknowledged that variation exists, there is now evidence that there is a limited range within which we can compensate for loss of sagittal alignment and still function well. When compensations run out, the quality of life becomes affected. These alignment variations, compensations, and in some cases, loss of alignment all together have clinical implications for the physiotherapist working with the older adult population. The purpose of this chapter is to describe the current state of evidence-informed knowledge around spinopelvic parameters as they relate to the adult with spine deformity and offer clinical implications for the conservative care practitioner.

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Prevention and Management of Iatrogenic Flatback Deformity

Cited by 148 publications

References 77 publications

Main thoracic curve adolescent idiopathic scoliosis: association of higher rod stiffness and concave-side pedicle screw density with improvement in sagittal thoracic kyphosis restoration

Main thoracic curve adolescent idiopathic scoliosis: association of higher rod stiffness and concave-side pedicle screw density with improvement in sagittal thoracic kyphosis restoration

Evaluation of the Factors Affecting the Loss of Lumbar Lordosis in Surgical Treatment of Patients with Adolescent Idiopathic Scoliosis Using Segmental Instrumentation

Sagittal Alignment in Spinal Deformity: Implications for the Non-Operative Care Practitioner

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