Flat Back Syndrome - Justin Paquette, MD

Dr. Sechrest: Hello, I'm Dr. Randale Sechrest, your host for eOrthopod.TV. Today I have with me as my guest, Dr. Justin Paquette. Dr. Paquette is a neurosurgeon who practices complex spine surgery in Los Angeles, California. Dr. Paquette did his medical training at Albany Medical College. He then went on to complete residency in neurosurgery at the Harvard Tuss Combined Program in Boston, Massachusetts. From there he completed a fellowship in complex spine surgery in Los Angeles at Cedar-Sinai. Good afternoon, Dr. Paquette.

Dr. Justin Paquette: Good afternoon.

Dr. Sechrest: Today I'd like to discuss a fairly common situation that is sometimes called "Flat Back Syndrome". Dr. Paquette, can you define what this term Flat Back Syndrome means?

Dr. Justin Paquette: So Flat Back Syndrome refers basically to a loss of the normal curve in the lumbar spine. When you look at an x-ray from the side, in the lumbar spine you should see a nice C-shaped curve. What the Flat Back Syndrome refers to is that C-shaped curve is no longer there and sometimes it can be reversed. So the spine, rather than being curved back at the base, now starts to tilt forwards. The overall result of that is that the whole body itself is now tilted forwards and out of balance. We call this positive sagittal balance, and essentially just means that the patient always leans forwards. The problem with that is that the body doesn't like it, and the body wants to bring itself back into proper balance and so to do that, all of the muscles in your low back have to try to pull the spine back into position. Over time, this leads to a lot of pain, not only in the low back, but in the mid-back, in the neck, it can cause headaches, and also causes pain and fatigue in the hamstrings and the quadriceps. People will often times walk in a stooped position with their legs bent in an ultimate attempt to recreate that normal balance.

Dr. Sechrest: And the source of the pain is mostly the muscle spasm that this imbalance causes? Or are we getting mechanical pain from the spine itself.

Dr. Justin Paquette: It can be both, but in essence, it's mostly muscular pain, especially when we're talking the pain that travels up the back, between the shoulder blades, the neck, the head, and the legs.

Dr. Sechrest: Okay, so most of that is trying to compensate for this abnormal posture?

Dr. Justin Paquette: Correct.

Dr. Sechrest: And those, when we start out those structures are normal. So the neck muscles and the hamstrings may be normal, they're just constantly squeezing down, trying to support it. Does that lead to deformity in those other areas?

Dr. Justin Paquette: Yes, that's absolutely correct. In longstanding cases of Flat Back Syndrome where people have tried to accustom themselves into that Flat Back Syndrome, you can lead to a variety of things such as shortening and constriction of some of the muscles that attach to the pelvis; sometimes even contractures, which means that they are permanently scarred down in a shorter position to the hips because they've been working all the time. You also will see sometimes people develop kind of a jut in their neck as they basically try to look in a horizontal gaze to compensate for their overall body being positioned way forward.

Dr. Sechrest: Now how does a person become suspicious, a patient I'm talking about, that they may be developing Flat Back Syndrome.

Dr. Justin Paquette: Flat Back Syndrome can essentially be produced by two different situations. One of them is surgery. We know that if a fusion surgery is done in the lumbar spine without attempts to preserve or create that normal lumbar lordosis and curve, if the person fuses forward and flat, that without a doubt causes Flat Back Syndrome. It can also happen without surgery where there is excessive wear and tear in the discs and the joints in the spine, and things start to slip forwards, one on top of the other one; and that also can lead to a loss of the normal alignment in the back. The symptoms that people get are however very similar, which is basically severe and persistent back pain, especially when trying to lean forward or holding some thing or picking something up in front of you; standing and walking for any kind of period of time. Ultimately the pain that begins in the low back, now transcends up the entire back in-between the shoulders, neck, the head, and develops the leg problems as well.

Dr. Sechrest: When a patient with Flat Back Syndrome presents to your office, what's the routine that you go through to try to evaluate the situation? What tests are necessary? What are you trying to accomplish during that first office visit?

Dr. Justin Paquette: When I initially evaluate a patient in my office with concerns for Flat Back Syndrome, the first step is just the clinical examination, and looking particularly at the pelvic girdle itself, looking at the quadriceps, the hamstrings, seeing if they have become contracted. Palpating the back itself, which sometimes allows you to feel for slippages or an abnormal curve. The most important, obviously, are the films, the radiology films, and those can include more in-depth films such as a CAT scan or an MRI scan. However, one should be able to pretty easily diagnose a Flat Back Syndrome based just upon x-rays that we can do in our office. I would get two different types. One would be flexion-extension x-rays of the lower spine, and what that essentially does, is dynamically allow me to see how the spine moves en concert. When you look at an MRI or CT you're just lying there the whole time, you don't see how the spine moves, whereas with the flexion-extension films we can actually see, when someone is going back and forth, is there any evidence of spondylolistheses, is there moving abnormally, etc. Then the other films I would get would be an AP and lateral, or front, back, and side x-rays of the whole spine, those scoliosis films we've been talking about. That will help me measure the overall balance of the patient's body, and if the balance ends up being too far forward, that also is diagnostic for Flat Back Syndrome.
Dr. Sechrest: Now you've mentioned this balance problem. Treatment - is there any role for conservative treatment in Flat Back Syndrome? Is there anything short of surgery that will improve the situation for the patient.

Dr. Justin Paquette: As long as the patient hasn't developed any kind of concerning neurologic deficits, we will always try conservative therapies first. Those are going to basically be any kind of modality that can strengthen the back and help control the pain in the back. Some of those things are going to be pain medicines whether they be anti-inflammatories, whether they be muscle relaxers, pain medicines, ice can sometimes help with calming down the inflammation of a flamed back, but by far and away the most important thing that somebody can do in this situation is physical therapy. Strengthening the core muscles, strengthen the upper muscles, the leg muscles, not because that's going to change the position of the spine, but because it will make it easier for the body to use the muscles to compensate. They won't get as tired as quickly, they won't get de-conditioned as quickly, and, overall, the patient's condition will be better.

Dr. Sechrest: What do you use to make the decision, that conservative therapy has failed, and surgery is something that would be in the patient's best interest? What tips your hand to suggest surgery to a patient?

Dr. Justin Paquette: So in the situation where the patient is requesting surgery and we have to determine, "Are you ready for it really?" First of all, I find from the patient exactly how much it is bothering them, exactly what is it preventing them from doing, because we need to make sure that it's a significant effect upon their life. Number 2 is because of conservative therapy; I would want to see at least six months of physical therapy and really trying hard and working with physical therapy without an appropriate relief. Attempts to use all types of medications, especially anti-inflammatory medications, which still hadn't helped; then the patient basically saying that, "It is just overall affecting my lifestyle." When they've come to that conclusion, then I think it if reasonable to entertain the possibilities of surgical correction.

Dr. Sechrest: Now you mentioned two situations that you can develop Flat Back. One is as a complication of previous surgery; and the other is just from the degenerative process itself. Are you more likely to recommend revision surgery, surgery to correct that deformity that was caused by an earlier surgery, than you are surgical intervention for someone who develops Flat Back from a degenerative standpoint - they've never had surgery on their back?

Dr. Justin Paquette: I think in either situation the symptoms probably are going to be very similar. Even the person who has had surgery, and the other person who hasn't had surgery, if they both are suffering from the phenomenon of Flat Back Syndrome, they're both going to be having very significant pain and disability from that. So when I determine whether or not to do surgery, it's actually not important whether they've been operated on or not before. It certainly makes the surgery a little more complicated if they have been operated on, because you have to take out the prior instrumentation, then we have to deal with some of the ca. But the same criteria I would apply to both patients.
Dr. Sechrest: And the surgical correction for Flat Back Syndrome, can you describe what your goals are when you go in to operate on a patient who, primarily has Flat Back Syndrome, and you're trying to correct that? What are your goals at the time of operation?

Dr. Justin Paquette: The two main goal of operating for Flat Back Syndrome are as follows: 1) to get all the pressure off the nerves to make sure all the nerves at the base of the spine are fully decompressed; and, 2) the most important goal - is to restore the person's normal lumbar curve and also the person's normal overall spinal balance. If you don't do that with the surgery, then you've not helped the patient because they will not ultimately be satisfied with the outcome. You must restore the balance, and to do that, sometimes we employ a variety of different things, but it would involve more screws; and then trying to mobilize the spine to be able to bring it back into a normal curve. Now sometimes, depending upon what was done before for surgery, we can do this all by just making some cuts to the joints in the back and that will allow enough flexibility through what's called Smith-Pete or a pontiosteotomy, just a complicated word saying just cutting through some of the bone in the back to loosen it up. That may be enough to bring back the curve and then align the patient into good balance. Sometimes, however, the Flat Back Syndrome is too significant to do that with. What we actually have to do is a more in-depth procedure called the pedicle subtraction osteotomy. Now what this essentially means is that, from the back of the spine, and all my surgery is done from the back, you go in and basically take out a pie-pieced cut into one of those vertebrae that have been fused in the wrong position, and by taking out that pie-pieced cut you can then take the spine and lever on it backwards into a normal position. So, if it's stuck forwards like this, you make a little cut down through the bone and then close it down like a book, and then lock it together with rods and screws above and below. That can give a 30-40° change in the patient's overall spine position. It can be a very effective tool in restoring the person's proper sagittal balance.

Dr. Sechrest: So, really, what you're saying is if you had a piece of wood, for example, that's crooked, if you cut a wedge out of it, pull it back, and nail it together, then you're better off.

Dr. Justin Paquette: Absolutely.

Dr. Sechrest: Now, unfortunately, you have to do that while protecting all the nerves in the spine because you have to get around them to get in there and make that cut so that you can then stabilize it. I'm assuming you're still using the pedicle screws, the metal screws and the rods to strut and hold that spine in the position to where you want it to heal.

Dr. Justin Paquette: Absolutely.

Dr. Sechrest: Now, what should a patient expect if they're going to have surgery for Flat Back Syndrome? How long are they in the hospital? How long is it going to take them to heal?
Dr. Justin Paquette: The recovery process for one of these types of surgeries for Flat Back Syndrome is a bit variable depending upon how many levels of the spine have to be incorporated into the surgery of the fusion itself. But I would say, on average, the patient would probably have a surgery lasting 4-6 hours, would be up and walking the next day, would be in the hospital an average of 5 days. The pain that they would have post-surgically would be all from the muscle spasms that occur because of the surgery; and as the weeks go on, that would get significantly better. They would note that, even just the first day they stood up, they would be much straighter and much taller as well. I tell folks that a major turning point in the pain from the surgery is around 4-6 weeks out from surgery, when they're feeling much better, more mobile, etc., and that's when I allow them to get into an aggressive physical therapy program, core muscle strengthening, major motion, and flexibility. Certain individuals, if they're doing very well, could drive within a couple of weeks, maybe go back to work within a couple of weeks.

Dr. Sechrest: I don't think a lot of physicians who are not spine specialists are familiar with the concept of Flat Back Syndrome; and, I think that a lot of patients who see a general physician, or perhaps an orthopaedic surgeon who is not specialized in spinal surgery, or a physiatrist, for that matter, who is taking care of spine patients but doesn't really do surgery and understand some of these concepts. So I suspect a lot of patients have Flat Back Syndrome and they've been told they have degenerative disc disease, or they have back pain and nothing can be done. Do you have any advice for patients who may be suffering from back pain that has not responded to treatment by their regular spine physician, or their primary care physician, when they should maybe think about looking at a spine specialist to try to see if, maybe this deformity is potentially correctable? How would you advise a patient?

Dr. Justin Paquette: I think you're correct that that situation exists a lot out there. If it is just because some people just don't see these pathologies that often, they're not going to know what to do for it when they do see it. I think that if somebody has back pain, it is very reasonable to have an internal medicine doctor or physiatrist manage that for a good period of time. If, however, there is no change and no improvement, or if the symptoms get worse certainly, one has to be concerned that maybe something else is going on. I think that every patient is entitled to asking for a second opinion. You shouldn't feel that you're hurting the feelings of the original doctor, it happens all the time, and so ask for a second opinion. Say, "This is what I've been doing. I still have this pain. Is there anything else going on that you, maybe from your different field of expertise could comment on?" Another thing a patient should get is the written copy of the reports, of the x-rays or the CAT scans, or the MRI scans, and read through that, because there may be mentions of possibilities or other diagnoses, that you have not been told, or heard about yet.

Dr. Sechrest: This has been a fascinating discussion about what I would say a relatively little know situation that can come both from an attempt to try to fix someone's back - surgery that actually gives them another problem. Also a little known problem that comes from degeneration that we may, as physicians, just sort of assume that this is another person with back pain and they're older and they're probably going to have to put up with this and there is no solution. Interestingly, I would like to ask one other question, what's the youngest person you've seen with Flat Back Syndrome? Do you see this as primarily a disease of the elderly? Or do you see this in younger folks?

Dr. Justin Paquette: I would have to say that, in general, this is a disease of the elderly or the middle-aged especially in terms of the degenerative process and the fact that most older folks are getting lumbar fusions. However, I have seen a few pediatric scoliosis cases who, in the past, were treated with, say, Harrington rods, or older types of instrumentation which ended up leading to Flat Back Syndrome as well as the lowest level of the spine started to degenerate, and this was earlier. So, the youngest I've probably seen would be young 20s, maybe 20 years old.

Dr. Sechrest: Do you feel like that you see mostly patients with Flat Back Syndrome who have had surgery? Or do you see a mix, 50-50? Or do you see a lot of folks, elderly folks, who just have Flat Back Syndrome who have never had surgery?

Dr. Justin Paquette: I certainly see both, but I would probably have to say that, more often than not, these are individuals that have been operated on in the past. Most commonly, actually, it is actually surgeries that didn't involve fusions. People who have had some kind of tightness or stenosis in the back, maybe somebody did a laminectomy in the back, which basically means you take all the bone off the back; and sometimes even affect the joints that are there, too. We know now that if you take off the whole roof of the spine, over time, since there is nothing else to attach the back and to really hold it back there, over time the spine starts to tilt forward and tilt forward and tilt forward and that produces a Flat Back Syndrome.

Dr. Sechrest: One last final question, I think, and that is, are there any specific complications that are specific to the treatment of Flat Back Syndrome that you worry about that aren't the normal complications that you would see from spine surgery?

Dr. Justin Paquette: There are a few, yes. The whole angling of the spine can lead to some other issues as well. You know, in front of the spine, there are very important nerves and blood vessels that, as the spine tilts forwards, can get very stuck to that spine. The aorta, the vena cava, and the vessels that come off of those, wrap around the front of the spine, and sometimes they can get scarred down and stuck there. If you end of trying to reposition the spine, sometimes it can rip little holes in those as it comes back. It's very uncommon, but certainly it is something that we look at on the preoperative MRI or CT scans. In addition, what also happens sometimes is the nerves that come out of the spine, in the level of the Flat Back Syndrome, change. They actually shorten up, because when the back collapses and goes down, the nerves now have redundant lengths in them. They shorten as they go into the spine. When you then lengthen the spine again as you bring it to normal position, sometimes you can cause a little stretch in those nerves and cause a little bit of nerve pain or some tingling for a while postoperatively.

Dr. Sechrest: Most of that generally goes away with time?

Dr. Justin Paquette: It will almost always go away.

Dr. Sechrest: Okay, great. Do you have any other comments about Flat Back Syndrome that we've not discussed?

Dr. Justin Paquette: I think that's pretty good.

Dr. Sechrest: Well, thank you. Thanks again.

Dr. Justin Paquette: Thank you.

Dr. Sechrest: Thanks for watching today. If you have questions about the topic that we discussed today, or any orthopaedic topic, be sure to visit eOrthopod.com. If you're an orthopaedic surgeon or healthcare provider interested in participating as a guest on eOrthopod TV, you'll also find instructions on how to apply to become a guest on eOrthopod TV. Thanks for watching.