- The thoracic spine leans forward excessively and the low back cannot accommodate;
- The lumbar spine does not have adequate lordosis (backward bend) to balance the kyphosis (forward bend) of the thoracic spine;
- A combination of above.
The amount of symptoms associated with flatback syndrome depends directly on how far a patient leans forward. The body is designed so the head is positioned directly over the hips when viewed from the front or the side. It is common to see people who lean forward a bit. The problem is that gravity pulls straight down. When the head and trunk are positioned over or near the center of the hips, the body can use the muscles to adapt. However, as the “weight bearing line” (an imaginary line dropped from one’s head to the ground) moves forward, the muscles tire more quickly. Try walking bending forward 30-45 degrees, and you will quickly see what I mean. Over time, the body has a harder and harder time standing up straight, and that causes pain, and makes it hard to move well.
As always, treatments depend on symptoms. Most patients who lean forward a bit can do well with physical therapy alone. In more serious cases, only a surgery will help. If the head is not repositioned over the hips, the body will continue to lean forward.
In the case of patients with multiple prior spine surgeries, many surgeons recommend “more of the same” - another small surgery to try and correct the problems after the last surgery. Other times they say there is nothing that they can do (which may be true). Few spine specialists have the experience to tackle the toughest reconstructive problems in the spine.
In the most serious situations, only a bone cutting and repositioning surgery will correct the problem. These are called “osteotomies”.
Click on the photos on the left for stories about patients who required corrective osteotomies to allow them to stand up straight again.
It is very obvious when a person has flatback syndrome. Often they try to offset their forward bend by flexing (bending) their hips and knees a bit. They can stand up straight if they really force themselves, but cannot sustain this position for very long. The main challenge for spine specialists is to understand why a patient leans forward so much. Sometimes a series of fractures in the thoracic spine is the problem, other times patients have had a surgery (or series of surgeries) that lead to the problem.
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