Sequential correction of sagittal vertical alignment and lumbar lordosis in adult flatback deformity

Flatback deformity, or lumbar hypolordosis, can cause sagittal imbalance, causing back pain, fatigue, and functional limitation. Surgical correction through osteotomies and interbody fusion techniques can restore sagittal balance and relieve pain. This study investigated sagittal vertical alignment (SVA) and lumbar lordosis correction achieved through sequential procedures on human spine specimens.

Human T10-sacrum specimens were stratified into 2 groups: degenerative flatback specimens had smaller L1-S1 lordosis compared to the iatrogenic group (26.1°±15.0° vs. 47.8°±19.3°, p<.05). Specimens were mounted in the apparatus in simulated standing posture with a nominal sacral slope of 45 degrees and subjected to a 400N compressive follower preload. Sequential correction of degenerative lumbar flatback deformity involved: anterior lumbar interbody fusion (ALIF) at L5-S1, ALIF at L4-5, lateral lumbar interbody fusion (LLIF) at L2-3 and L3-4, and posterior column osteotomy (PCO) at L2-3 and L3-4. In iatrogenic specimens, flatback deformity was created by performing a posterior in-situ immobilization using pedicle screw instrumentation at L4-L5-S1 followed by distraction across the pedicle screws. We then performed LLIF at L2-3 and L3-4, followed by PCO at L2-3 and L3-4.

Statistically significant incremental corrections were noted in SVAs and lordosis after L5-S1 ALIF, L4-5 ALIF, and PCO in degenerative flatback specimens. For the iatrogenic group, statistically significant worsening was noted in measures of standing alignment after L4-L5-S1 hypolordotic fusion. Subsequent LLIF at L2-3 and L3-4 did not significantly improve sagittal alignment. However, after PCO at L2-3 and L3-4, final alignment parameters were not significantly different than preoperative baseline values prior to hypolordotic fusion.

ALIF cages in the lower lumbar segments significantly improved sagittal alignment in degenerative flatback specimens. In the upper lumbar segments, LLIF cages alone were ineffective at enhancing lumbar lordosis. LLIF cages in conjunction with PCO improved alignment parameters in degenerative and iatrogenic flatback deformities.