Flatback Syndrome : Causes, Symptoms, Diagnosis and Treatment


To Know about Flatback syndrome, one should know about the natural curvature of the spine in the human body. There are four natural curves present in the human spine. These curves help the person stand straight and well balanced and also helps in moving or walking with minimum effort.

There are two lordotic curves and two kyphotic curves, which alternate to make an “S” like shape when viewed from the lateral side. The lordotic curve means the spine curves inward, and the kyphotic curve represents the spine curves outward. 

  • In the cervical spine (neck) and lumbar spine (lower back) – There is an inward curve known as lordosis.
  • In the thoracic spine and sacral spine – There is an outward curve, also known as kyphosis.


All these curves usually work in coordination to keep the spine aligned over the hips and pelvis. Whenever there’s an imbalance in any of these natural curves. The patient’s whole spinal alignment adjusts so the patient can continue to stand vertical or upright. Now let’s discuss the imbalance in which curves can lead to flatback syndrome. 

What is Flatback Syndrome?

The flatback syndrome is a deformity when the lower back (lumbar spine) losses its natural curvature and becomes flat over time. In flatback syndrome, there will be loss of normal lumbar lordosis (reduced lordosis). This causes chronic pain, imbalance in the spine, and the patient will feel difficulty in standing and performing daily life activities. 

Patients may not initially detect these subtle changes, but over time, they may note problems with standing vertical or worsening leg or back pain. Symptoms of flatback syndrome often worsen day by day. 

The severity of symptoms is inversely proportional to the curvature, which means the lessened the curvature, the more severe the symptoms. Now let’s discuss the symptoms of the flatback syndrome

Flatback Syndrome Symptoms

Patients suffering from flat back syndrome often may not know that they are suffering from this condition as their spine has been changing slowly with time. The main symptoms of the flatback syndrome include

Postural Issues 

The patient’s head starts to lean forward, away from the body’s midline, and they have difficulty standing upright. The patient’s spine will automatically try to compensate for this imbalance by tilting the pelvis, flexing the hips and the knees so he can continue to stand erect. 


This new adapted posture may temporarily help the patient stand erect, but it can lead to severe and chronic pain over time.

Chronic pain

The flat spine implies stress on the vertebrae and disc, which gives recurring back pain. Pain may also occur in the groin and thigh areas. 

Muscle Fatigue

The patient’s symptoms often worsen as the day progresses as many patients flex at the hips and knees to maintain a correct standing posture. These compensatory changes lead to excess muscle fatigue as muscles in those regions exhaust their resources. 

Interference in daily work 

A flat lumbar spine tilts the pelvis posteriorly, making it hard for the patients to sit for an extended time.

Causes of Flatback Syndrome

In the earlier days, there has been a correlation between flatback syndrome and scoliosis. Earlier It has been seen that flatback syndrome sometimes occurs after a few years or decades in patients who suffer scoliosis. Doctors used Harrington rods for the correction of scoliosis. This was one of the first spinal implants used for the correction of scoliosis. 

The Harrington rod, which is used to straighten the abnormal curve of scoliosis, also tends to straighten the inward curve (lordosis) in the lumbar spine. This occurred mainly when the doctors implemented the Harrington rod to treat scoliosis in the L4/L5 region. 

Other causes of the Flatback syndrome include

Vertebral Compression Fracture

As in the name, vertebrae word is coming, so in this fracture of one or multiple vertebrae occur due to osteoporosis. This condition often causes the weakening of the bone, and with the increased pressure, a fracture can occur. Fracture often changes the spine’s alignment and can lead to loss of (inward curve) lordosis, i.e. flatback syndrome.

Degenerative Disc Disease

The spine or backbone contains vertebral bodies and intervertebral discs. These intervertebral discs are the soft tissue cushion that lies between the two adjacent vertebrae in the vertebral column. The Intervertebral discs act as a shock absorber of the spine and allow for mobility. In the lumbar spine, these IV discs contribute to normal lumbar lordosis.


As the person ages, it is natural that these Intervertebral discs degenerate (wear and tear). As the disc degenerates, the upper spine begins to lean forward, and lumbar lordosis will decrease. This can lead to flatback syndrome, and as a result, the patient may suffer pain and difficulty in maintaining an upright posture.


Ankylosing Spondylitis

It is a chronic inflammatory disorder that affects the spinal column. Over time it could lead to stiffness, arthritis, and auto-fusion of the spinal vertebral bodies. This fusion causes the backbone or spine to be less flexible and often results in a hunched-forward posture. 


In this type of posture, you will often find increased thoracic kyphosis or decreased lumbar lordosis, which can lead to the flatback syndrome.

Post-Laminectomy Syndrome

It is a condition in which a patient suffers persistent pain in the back following surgery. A laminectomy is a procedure generally performed in the case of spinal stenosis. The spinal stenosis is a condition in which protruding disc creates continuous stress on the spinal nerve. 

So to get relief from this, laminectomy is performed, a part of vertebrae is removed to relieve stress on the nerves in the spinal cord. Post laminectomy syndrome is a disorder in which the individual continues to feel persistent pain following surgery to the back (correctional laminectomy). 

The flatback syndrome may develop in patients who were previously treated with a laminectomy. 

Diagnosis of the flatback syndrome

Making the correct diagnosis is the most critical aspect of any treatment. An accurate diagnosis will help your physician plan the right treatment option for this flatback deformity.

Patient history 

It is the main point that needs to be focused on. The history of any trauma, failed surgery, difficulty in standing upright associated with back pain will be essential factors in getting the precise diagnosis.

Physical examination 

The examiner will observe the gait and posture of the patient. As a flatback syndrome patient’s head will be directed forward, away from the midline of the body, and the patient will suffer difficulty in standing upright and in response to this, the patient’s hip and knees will be flexed so that he can stand upright.  

Spine X-ray 

The X-ray can be a valuable tool in diagnosing flatback syndrome. All the spinal column sections cervical, thoracic, lumbar spine, and pelvis can be checked with the full-length standing X-rays of the spine. The lateral view is very helpful. A spine X-ray helps the doctors in determining the degree of the flatback syndrome. 

CT scan and MRI

The doctor may also order MRI and CT scans. These advanced imaging techniques do not diagnose flatback syndrome but help identify other issues like health and integrity of the vertebrae, discs, and spinal stenosis (whether or not the compression of spinal nerves exists). 


The flatback syndrome involves two categories of treatment one is non-surgical, and the other is surgical.


  • Non-surgical or conservative treatment includes physical therapy and exercises, including proper stretching and strengthening exercises performed in a daily routine for improving posture. The main purpose of performing the exercises is to reverse the muscle imbalance pattern that keeps the lumbar spine straight.  
  • Spine-specialized physical therapy and spinal manipulation, which is known as chiropractic treatment, may also be beneficial. 
  • Pain medications are also given to manage the pain and symptoms. Individuals who are already suffering from joint arthritis or a pinched nerve, flatback syndrome often worsen the pain in these peoples. so spinal injections may be given to provide relief. 

Many patients can stabilize their symptoms by following these non-surgical treatment guidelines, and symptoms do not worsen so that they will require surgery. 


If the non-surgical treatment failed to provide symptomatic relief, and if the structural problem develops due to lack of curvature or if the malalignment is severe, then surgery is required.

The goal of surgery is to correct the spine, provide pain relief, and prevent the malalignment from worsening. This is done by adding curvature to the lumbar spine. 

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