• Jean-Marc Vital, Louis Boissière, Anouar Bourghli, Jean-Etienne Castelain, Vincent Challier, and Ibrahim Obeid.
• Orthopedic Department, Spine Unit 1, Bordeaux University Hospital, Bordeaux, France.
• Eur Spine J. 2015 Jan 1;24 Suppl 1:S107-11.

IntroductionFlat-back syndrome is one of the main causes of surgical failure after lumbar fusion and can lead to a revision surgery to correct it. Three-column pedicle subtraction osteotomy is an efficient technique to restore lumbar lordosis (LL) for fixed sagittal malalignment. The fusion mass stemming from the past surgeries makes the procedure demanding as most anatomical landmarks are missing.Material And MethodsThis review article will focus on the correction of this lack of LL through the fusion mass. We will successively review the preoperative management, the surgical specificities, and various types of clinical cases that can be encountered in flat-back syndromes.ConclusionPSO in the fixed fusion mass is technically demanding. Preoperative CT-scan and preoperative navigation allow us to push the limits when anatomical landmarks disappear. Bleeding and neurologic are the two major complications feared by the surgeon. The best way to avoid these revision surgeries is to restore a proper lumbar lordosis at the time of initial surgery by considering lumbo-pelvic indexes.

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