Iatrogenic loss of lordosis is now frequently recognized as a complication following placement of thoracolumbar
instrumentation, especially with distraction instrumentation. Flat-back syndrome is characterized by forward inclination
of the trunk, inability to stand upright, and back pain. Evaluation of the deformity should include a full-length lateral
radiograph obtained with the patient’s knees and hips fully extended. The most common cause of the deformity
includes the use of distraction instrumentation in the lumbar spine and pseudarthrosis.
Surgical treatment described in the literature includes opening (Smith-Petersen) osteotomy, polysegmental osteotomy,
and closing wedge osteotomy. The authors will review the literature, cause, clinical presentation, prevention, and
surgical management of flat-back syndrome.