• Eur Spine J · Dec 2024

    Defining modern iatrogenic flatback syndrome: examination of segmental lordosis in short lumbar fusion patients undergoing thoracolumbar deformity correction.

    • Bassel G Diebo, Manjot Singh, Mariah Balmaceno-Criss, Mohammad Daher, Lawrence G Lenke, Christopher P Ames, Douglas C Burton, Stephen M Lewis, Eric O Klineberg, Renaud Lafage, Robert K Eastlack, Munish C Gupta, Gregory M Mundis, Jeffrey L Gum, Kojo D Hamilton, Richard Hostin, Peter G Passias, Themistocles S Protopsaltis, Khaled M Kebaish, Han Jo Kim, Christopher I Shaffrey, Breton G Line, Praveen V Mummaneni, Pierce D Nunley, Justin S Smith, Jay Turner, Frank J Schwab, Juan S Uribe, Shay Bess, Virginie Lafage, Alan H Daniels, and International Spine Study Group (ISSG).
    • Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, 1 Kettle Point Ave, East Providence, RI, 02914, USA.
    • Eur Spine J. 2024 Dec 1; 33 (12): 462746354627-4635.

    PurposeUnderstanding the mechanism and extent of preoperative deformity in revision procedures may provide data to prevent future failures in lumbar spinal fusion patients.MethodsASD patients without prior spine surgery (PRIMARY) and with prior short (SHORT) and long (LONG) fusions were included. SHORT patients were stratified into modes of failure: implant, junctional, malalignment, and neurologic. Baseline demographics, spinopelvic alignment, offset from alignment targets, and patient-reported outcome measures (PROMs) were compared across PRIMARY and SHORT cohorts. Segmental lordosis analyses, assessing under-, match, or over-correction to segmental and global lordosis targets, were performed by SRS-Schwab coronal curve type and construct length.ResultsAmong 785 patients, 430 (55%) were PRIMARY and 355 (45%) were revisions. Revision procedures included 181 (23%) LONG and 174 (22%) SHORT corrections. SHORT modes of failure included 27% implant, 40% junctional, 73% malalignment, and/or 28% neurologic. SHORT patients were older, frailer, and had worse baseline deformity (PT, PI-LL, SVA) and PROMs (NRS, ODI, VR-12, SRS-22) compared to primary patients (p < 0.001). Segmental lordosis analysis identified 93%, 88%, and 62% undercorrected patients at LL, L1-L4, and L4-S1, respectively. SHORT patients more often underwent 3-column osteotomies (30% vs. 12%, p < 0.001) and had higher ISSG Surgical Invasiveness Score (87.8 vs. 78.3, p = 0.006).ConclusionsNearly half of adult spinal deformity surgeries were revision fusions. Revision short fusions were associated with sagittal malalignment, often due to undercorrection of segmental lordosis goals, and frequently required more invasive procedures. Further initiatives to optimize alignment in lumbar fusions are needed to avoid costly and invasive deformity corrections.Level Of EvidenceIV: Diagnostic: individual cross-sectional studies with consistently applied reference standard and blinding.© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.

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