Flatback Syndrome: Standing Upright Again
If you find yourself leaning forward, bending your knees to stand straight, or getting exhausted after just a few minutes on your feet, you may have flatback syndrome. It’s treatable.
What Is Flatback Syndrome?
A healthy lower back has a natural inward curve called lordosis. That curve helps keep your head balanced over your pelvis so you can stand upright with little effort.
Flatback syndrome happens when the lower back loses that curve and becomes flat. Without it, your body tips forward. To stay upright, you have to work constantly, tightening your back muscles, bending your knees and tilting your pelvis, which leads to pain and fatigue.
Physical therapy can help with mild cases. When flatback causes significant pain or keeps you from standing and walking comfortably, surgery to restore the curve can often correct the problem.
What Causes Flatback Syndrome
- Previous spinal fusion: especially older scoliosis surgeries using straight rods that flattened the lower back, or fusions done without enough lordosis
- Disc degeneration: collapsing discs gradually flatten the lower back
- Compression fractures that wedge the vertebrae forward
- Adjacent segment disease above or below a prior fusion
- Ankylosing spondylitis and other inflammatory conditions
Symptoms
Common symptoms
- Leaning forward when you stand or walk
- Low back pain and muscle fatigue that worsen as the day goes on
- Needing to bend your knees or hips to stand upright
- Difficulty looking straight ahead
Symptoms patients often ignore
- Neck and upper back pain from straining to look forward
- Thigh and buttock fatigue from constantly bracing
- Leaning on a shopping cart, counter or cane to get through errands
- Feeling like you’re “falling forward” when you stop moving
How We Diagnose Flatback Syndrome
- Exam: your standing posture, flexibility of the spine and hips, and a neurological check
- Full-length standing X-rays: measure the lumbar curve and overall spinal balance, including how far the head sits in front of the pelvis
- CT scan: shows prior fusions, hardware and bone quality
- MRI: checks for nerve compression above or below a prior fusion
- Bone density testing before any reconstructive surgery
Treatment Options
Non-surgical treatment
- Physical therapy: strengthening the back extensors, core and hip muscles
- Stretching tight hip flexors and hamstrings
- Pain management with medications and injections
- Assistive devices such as a cane or walker for longer distances
When surgery makes sense
When pain and forward lean significantly limit your life, surgery to restore the lower back’s curve can often correct the problem and help you stand upright again:
- Osteotomies: carefully reshaping one or more vertebrae to restore the inward curve
- Sagittal balance correction: realigning the spine so your head sits over your pelvis
- Revision fusion: extending or revising a previous fusion
Why Choose Dr. Betsy Grunch for Flatback Syndrome
- Duke-trained: neurosurgical residency and spine research fellowship at Duke University School of Medicine, where she received the Spine Young Investigator Award
- Experience you can count on: in practice since 2013, performing 400 to 600 surgeries a year and more than 5,000 procedures over her career
- Revision and reconstruction experience: careful planning from full-length X-rays to restore balance, especially after previous surgery
- The right treatment for you: board-certified (FAANS, FACS, FCNS), she starts with the least invasive option that will work, and recommends surgery when it can correct the problem
- Clear answers: known online as Ladyspinedoc, she makes sure you understand your imaging and every option in front of you
What to Expect If You Need Surgery
Before surgery
You’ll meet with Dr. Grunch or one of her physician assistants to review your full-length X-rays, CT and MRI. Reconstructive surgery requires careful planning, including bone health testing and medical clearance.
Procedure day
Corrective surgery is a major operation, usually several hours long, followed by a hospital stay of several days.
Recovery timeline
- First days: up and walking with help
- Weeks 1-6: gradual walking; no bending, lifting or twisting
- Months 2-3: physical therapy to rebuild strength and posture
- Months 6-12: the fusion becomes solid and endurance continues to improve
Frequently Asked Questions
Why do I lean forward?
Without the normal inward curve of the lower back, your body’s center of gravity shifts forward, and your muscles have to work constantly to hold you up.
Can physical therapy fix flatback?
Therapy can strengthen the muscles that hold you upright and reduce symptoms, but it can’t restore a curve that has been fused flat or lost to disc collapse.
I had scoliosis surgery years ago. Could this be flatback?
Yes. Older scoliosis surgeries using straight rods are a common cause. A full-length standing X-ray can tell.
Is surgery for flatback risky?
It is a major surgery, and Dr. Grunch will discuss the benefits and risks honestly. For the right patient, it can make a big difference in pain and the ability to stand and walk.
How is flatback different from sagittal imbalance?
Flatback is one of the most common causes of sagittal imbalance, the broader problem of the spine tipping forward.
Take the First Step Toward Relief
Whether you need a diagnosis, a treatment plan or a second opinion, Dr. Grunch and the Southern Neurosurgery team are here to help.
Call 470-293-9800 to schedule an appointment or contact us online.
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We see patients across metro Atlanta and North Georgia at our offices in Gainesville, Sandy Springs and South Atlanta (Riverdale). Find the office nearest you.
This page is for educational purposes only and is not a substitute for medical advice. If you have sudden weakness, numbness in the groin, or bladder or bowel changes, call 911 or go to the nearest emergency room.