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Scoliosis Progression After the Nuss Procedure for Pectus Excavatum: A Case Report

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Abstract

Introduction

Pectus excavatum and scoliosis are associated conditions with a high rate of coincidence. However, there are no reports to guide surgeons on the management of adolescents with moderate scoliosis and pectus excavatum, because there are conflicting conclusions in the literature regarding how the Nuss procedure with substernal bar affects scoliosis.

Cases

In 2017, we encountered two patients with moderate scoliosis treated with a spinal orthosis. After undergoing the Nuss procedure for pectus excavatum, their scoliosis acutely progressed into surgical magnitude requiring posterior instrumented spinal fusion. The first patient progressed 26° despite the pre-Nuss radiographs showing him to be Risser 4/5, while the second patient also progressed 26° from the Nuss procedure. Both patients acknowledged noncompliance with brace wear because of discomfort after the Nuss procedure. However, their progression rate still doubles the rate of reported rapid accelerators, indicating that a significant component of curve progression is directly attributed to forces on the spine from the corrective maneuver with substernal bar.

Conclusion

The purpose of this case report is to describe the features of these two patients to help with clinical decision-making in patients with moderate scoliosis (curves >25°) who are contemplating the Nuss procedure for correction of pectus excavatum. We caution patients and providers that spinal deformity could worsen with surgical intervention of the pectus excavatum via the Nuss procedure and necessitate scoliosis surgery.

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References

  1. Haller Jr JA, Kramer SS, Lietman SA. Use of CT scans in selection of patients for pectus excavatum surgery: a preliminary report. J Pediatr Surg 1987;22:904–6.

    Article  Google Scholar 

  2. Waters P, Welch K, Micheli LJ, et al. Scoliosis in children with pectus excavatum and pectus carinatum. J Pediatr Orthop 1989;9:551–6.

    Article  CAS  Google Scholar 

  3. Hong JY, Suh SW, Park HJ, et al. Correlations of adolescent idiopathic scoliosis and pectus excavatum. J Pediatr Orthop 2011;31:870–4.

    Article  Google Scholar 

  4. Kelly RE, Goretsky MJ, Obermeyer R, et al. Twenty-one years of experience with minimally invasive repair of pectus excavatum by the Nuss procedure in 1215 patients. Ann Surg 2010;252:1072–81.

    Article  Google Scholar 

  5. Park HJ, Kim JJ, Park JK, et al. Effects of Nuss procedure on thoracic scoliosis in patients with pectus excavatum. J Thorac Dis 2017;9:3810–6.

    Article  Google Scholar 

  6. Wang Y, Chen G, Xie L, et al. Mechanical factors play an important role in pectus excavatum with thoracic scoliosis. J Cardiothorac Surg 2012;7:118.

    Article  Google Scholar 

  7. Nuss D, Kelly Jr RE, Croitoru DP, et al. A 10-year review of a minimally invasive technique for the correction of pectus excavatum. J Pediatr Surg 1998;33:545–52.

    Article  CAS  Google Scholar 

  8. Niedbala A, Adams M, Boswell WC, et al. Acquired thoracic scoliosis following minimally invasive repair of pectus excavatum. Am Surg 2003;69:530–3.

    PubMed  Google Scholar 

  9. Ghionzoli M, Martin A, Bongini M, et al. Scoliosis and pectus excavatum in adolescents: does the Nuss procedure affect the scoliotic curvature? J Laparoendosc Adv Surg Tech A 2016;26:734–9.

    Article  Google Scholar 

  10. Chung JH, Park HJ, Kim KT. Scoliosis after pectus excavatum correction: does it improve or worsen? Eur J Cardiothorac Surg 2017;52:76–82.

    Article  Google Scholar 

  11. Sanders JO, Browne RH, McConnell SJ, et al. Maturity assessment and curve progression in girls with idiopathic scoliosis. J Bone Joint Surg Am 2007;89:64–73.

    Article  Google Scholar 

  12. Creswick HA, Stacey MW, Kelly Jr RE, et al. Family study of the inheritance of pectus excavatum. J Pediatr Surg 2006;41:1699–703.

    Article  Google Scholar 

  13. Ravitch MM. The operative treatment of pectus excavatum. Ann Surg 1949;129:429–44.

    Article  CAS  Google Scholar 

  14. Hebra A. Minimally invasive pectus surgery. Chest Surg Clin N Am 2000;10:329–39. vii.

    CAS  PubMed  Google Scholar 

  15. Moss RL, Albanese CT, Reynolds M. Major complications after minimally invasive repair of pectus excavatum: case reports. J Pediatr Surg 2001;36:155–8.

    Article  CAS  Google Scholar 

  16. Hebra A, Kelly RE, Ferro MM, et al. Life-threatening complications and mortality of minimally invasive pectus surgery. J Pediatr Surg 2018;53:728–32.

    Article  Google Scholar 

  17. Haller Jr JA. Complications of surgery for pectus excavatum. Chest Surg Clin N Am 2000;10:415–26. ix.

    PubMed  Google Scholar 

  18. Nuss D, Croitoru DP, Kelly Jr RE, et al. Review and discussion of the complications of minimally invasive pectus excavatum repair. Eur J Pediatr Surg 2002;12:230–4.

    Article  CAS  Google Scholar 

  19. Hoel TN, Rein KA, Svennevig JL. A life-threatening complication of the Nuss procedure for pectus excavatum. Ann Thorac Surg 2006;81:370–2.

    Article  Google Scholar 

  20. Jeong JY, Suh JH, Yoon JS, et al. Delayed-onset hypovolemic shock after the Nuss procedure for pectus excavatum. J Cardiothorac Surg 2014;9:15.

    Article  Google Scholar 

  21. Yang MH, Cheng YL, Tsai CS, et al. Delayed cardiac tamponade after the Nuss procedure for pectus excavatum: a case report and simple management. Heart Surg Forum 2008;11:E129–31.

    Article  Google Scholar 

  22. Chang PY, Hsu ZY, Chen DP, et al. Preliminary analysis of the forces on the thoracic cage of patients with pectus excavatum after the Nuss procedure. Clin Biomech (Bristol, Avon) 2008;23:881–5.

    Article  Google Scholar 

  23. Neves SC, Pinho AC, Fonseca JC, et al. Finite element analysis of pectus carinatum surgical correction via a minimally invasive approach. Comput Methods Biomech Biomed Engin 2015;18:711–20.

    Article  Google Scholar 

  24. Nagasao T, Noguchi M, Miyamoto J, et al. Dynamic effects of the Nuss procedure on the spine in asymmetric pectus excavatum. J Thorac Cardiovasc Surg 2010;140:1294–1299.e1.

    Article  Google Scholar 

  25. Minkara A, Bainton N, Tanaka M, et al. High risk of mismatch between Sanders and Risser staging in adolescent idiopathic scoliosis: are we guiding treatment using the wrong classification. J Pediatr Orthop 2018. https://doi.org/10.1097/BPO.0000000000001135 [Epub ahead of print].

  26. Ouellet JA, LaPlaza J, Erickson MA, et al. Sagittal plane deformity in the thoracic spine: a clue to the presence of syringomyelia as a cause of scoliosis. Spine (Phila Pa 1976) 2003;28:2147–51.

    Article  Google Scholar 

  27. Winter RB, Lonstein JE, Heithoff KB, et al. Magnetic resonance imaging evaluation of the adolescent patient with idiopathic scoliosis before spinal instrumentation and fusion: a prospective, double-blinded study of 140 patients. Spine (Phila Pa 1976) 1997;22:855–8.

    Article  CAS  Google Scholar 

  28. Do T, Fras C, Burke S, et al. Clinical value of routine preoperative magnetic resonance imaging in adolescent idiopathic scoliosis: a prospective study of three hundred and twenty-seven patients. J Bone Joint Surg Am 2001;83:577–9.

    Article  CAS  Google Scholar 

  29. Diab M, Landman Z, Lubicky J, et al. Use and outcome of MRI in the surgical treatment of adolescent idiopathic scoliosis. Spine (Phila Pa 1976) 2011;36:667–71.

    Article  Google Scholar 

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Authors and Affiliations

  1. Texas Scottish Rite Hospital for Children, 2222 Welborn St., Dallas, TX, 75219, USA

    Lorena V. Floccari MD, Daniel J. Sucato MD, MS & Brandon A. Ramo MD

Authors
  1. Lorena V. Floccari MD
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  2. Daniel J. Sucato MD, MS
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  3. Brandon A. Ramo MD
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Corresponding author

Correspondence to Lorena V. Floccari MD.

Additional information

Author disclosures: LVF (none), DJS (none), BAR (none).

IRB approval: Not required.

Funding: None.

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Floccari, L.V., Sucato, D.J. & Ramo, B.A. Scoliosis Progression After the Nuss Procedure for Pectus Excavatum: A Case Report. Spine Deform 7, 1003–1009 (2019). https://doi.org/10.1016/j.jspd.2019.01.009

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