Ann Thorac Surg 1995;60:437-438
© 1995 The Society of Thoracic Surgeons
Case Reports
Sternal Release and Advancement With Thoracotomy and Osteotomy for Idiopathic Osteopenia
Timothy M. Anderson, MD,
William C. Horton, MD,
Thomas E. Whitesides, MD,
Joseph I. Miller, Jr, MD
Departments of Cardiothoracic Surgery and Orthopoedic Surgery, Emory University School of Medicine, The Emory Clinic, Atlanta, Georgia
Accepted for publication January 10, 1995.
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Abstract
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Transient neurologic changes developed in a rare case of progressive thoracic kyphosis secondary to idiopathic osteopenia with marked spinal and chest cage deformities. The patient underwent correction by both anterior thoracic and posterior spinal approaches, with concomitant sternal release and advancement. After 16 months he continues to have good anatomic and functional results.
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Introduction
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Osteopenia refers to a decrease in bone mass with resultant increase in radiolucency of bone and occurs in a variety of disorders, including osteoporosis, osteomalacia, hyperparathyroidism, neoplasm, and secondary to steroids. Regardless of the cause, it occurs when bone resorption exceeds bone formation [1]. This loss of bone mineral causes structural weakness and vertebral changes including wedging and compression, typically presenting as a kyphotic deformity [2]. We present a case of idiopathic osteopenia with kyphosis and a fixed sternal and rib cage collapse presenting with neurologic changes necessitating surgical correction.
A 43-year-old man presented with a history of a progressive thoracic kyphosis secondary to idiopathic osteopenia. Despite aggressive nonoperative management, over the past 14 years he had gone from a height of 1.9 to 1.4 m, with related transient weakness in the upper and lower extremities. The sternum was in a fixed, collapsed position with associated rib defects diminishing his thoracic volume and tethering the spine in a collapsed state, producing pulmonary compromise and impending cord compression at the apex of his deformity (Fig1
). The primary aim and goal of sternal and rib release was to untether the spine and allow rib cage expansion.
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Fig 1.. Lateral magnetic resonance image shows severe 110-degree upper thoracic kyphosis and compensatory 95-degree cervical lordosis preoperatively. Note the biconcave, wedged thoracic vertebrae.
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In the supine position, a vertical upper midline incision was taken down to the sternum, from the second intercostal space inferiorly to the sixth rib. The pectoralis major muscles were dissected bilaterally off the costochondral junctions. The cartilages of the second through fifth ribs were released on each side. The internal mammary arteries were divided bilaterally. The sternum was transected inferiorly at the level of the fifth intercostal space, enabling it to be advanced forward 2.5 cm. Because of a large anterior bow over the third intercostal space, a wedge anterior osteotomy was performed, allowing the sternum to come forward an additional centimeter. The inferior sternum was reattached to the transected portion (Fig2). The costal cartilages were reapproximated loosely to the body of the sternum. The pectoralis major muscles were reapproximated and the superficial layers closed.
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Fig 2.. Completed sternal advancement showing interrupted no. 2 wires reattaching the lower transected sternum. Costal cartilages were reapproximated loosely with 0 polydioxanone suture.
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A right posterolateral thoracotomy was performed through the nonresected bed of the fourth rib. From T-2 through T-6, the segmental vessels were divided and vertebrae were circumferentially exposed extraperiosteally. The anterior half of the vertebral bodies were excised to allow access to posterior disc spaces. All the intervening discs were resected back to the posterior longitudinal ligament. The morcellated graft from the vertebral body and fourth free rib were placed in the resected disc spaces and anteriorly to fuse the spine.
Postoperatively the patient was placed in halo gravity traction to help straighten the spine and optimize pulmonary toilet. On postoperative day 21 he underwent posterior fusion of T-1 through T-10 with autogenous graft from the iliac crest and a tracheostomy. Ventilatory assistance was required for 10 days. The halo cast was removed on the 37th postoperative day and the tracheostomy on the 51st postoperative day. Follow-up magnetic resonance imaging of the cervical and thoracic spine 1 day before discharge showed marked straightening of the thoracic spine. A lateral magnetic resonance image 2 months postoperatively showed improvement in the upper thoracic spine with a 50-degree curve and a cervical lordotic curve of 40 degrees. His most recent follow-up showed a height of 1.8 m.
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Comment
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The etiology of kyphosis ranges from benign postural changes to severe deformities produced by tuberculous disease. Although our patient had a history of exogenous steroid usage, extensive endocrine studies as well as other studies including undercalcified histology after trichrome labeling have forced us at this time to an ``idiopathic'' diagnosis for his osteopenia. Our patient had a kyphotic angle of 110 degrees, which is quite severe. Thoracic spine curvatures in the sagittal plane with a Cobb angle of 40 degrees or more are considered kyphotic [3].
Sternal release and osteotomies have been performed for congenital deformities such as pectus excavatum and pectus carinatum but rarely with kyphotic repairs. Our approach is similar to Welch and associates' technique of repair for pectus excavatum [4]. The combined anterior and posterior approaches to the spine for severe kyphotic deformities have been recommended by others [5]. The anterior approach allows for release of contractures, anterior cord decompression, and anterior stabilization with fusion [6]. The posterior approach allows for closing osteotomies and a circumferential fusion. This case is unusual due to the coexistence of severe spinal and chest deformities simultaneously addressed during correction and reconstruction. Through the combined efforts of the thoracic and orthopoedic surgeons, patients with these severe deformities can be cared for more effectively with improved results [7].
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Footnotes
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Address reprint requests to Dr Miller, Department of Cardiothoracic Surgery, The Emory Clinic, 25 Prescott St, Suite 3420, Atlanta, GA 30308.
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References
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- Resnick D, Niwayama G. Osteoporosis. In: Resnick D, Niwayama G, eds. Diagnosis of bone and joint disorders. Philadelphia: Saunders, 1981:1638–81.
- Hensinger RN. Kyphosis secondary to skeletal dysplasias and metabolic disease. Clin Orthop 1977;128:113–28.
- White AA, Panjabi MM, Thomas CL. The clinical biomechanics of kyphotic deformities. Clin Orthop1977;128:8–17.
- Welch KJ, Shamberger RC. Chest wall deformities. In: Shields TW, ed. General thoracic surgery. Philadelphia: Lea & Febiger, 1989:515–43.
- Bradford DS, Ganjavian S, Antonious D, et al. Anterior strut-grafting for the treatment of kyphosis: review of experience with forty-eight patients. J Bone Joint Surg 1982;64A:680–90.[Abstract/Free Full Text]
- Hodgson AR, Stock FE. Anterior spinal fusion: preliminary communication on the radical treatment of Pott's disease and Pott's paraplegia. Br J Surg 1956;44:266.
- Anderson TM, Mansour KA, Miller JI. Thoracic approaches to anterior spinal operations: anterior thoracic approaches. Ann Thorac Surg 1993;55:1447–52.[Abstract]
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Abstract
Introduction
