Floccari Lorena V, Sucato Daniel J, Ramo Brandon A
Texas Scottish Rite Hospital for Children, 2222 Welborn St., Dallas, TX, 75219, USA.
Texas Scottish Rite Hospital for Children, 2222 Welborn St., Dallas, TX, 75219, USA.
Spine Deform. 2019 Nov;7(6):1003-1009. doi: 10.1016/j.jspd.2019.01.009.
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.
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.
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.
漏斗胸和脊柱侧弯是相关联的病症，重合率很高。然而，对于患有中度脊柱侧弯和漏斗胸的青少年患者的治疗管理，尚无报告可供外科医生参考，因为关于采用胸骨后支撑条的努氏手术如何影响脊柱侧弯，文献中的结论相互矛盾。
2017年，我们遇到两名接受脊柱矫形器治疗的中度脊柱侧弯患者。在接受漏斗胸矫正的努氏手术后，他们的脊柱侧弯急剧进展到需要进行后路器械辅助脊柱融合手术的程度。第一名患者在努氏手术前的X线片显示其Risser分级为4/5，但术后仍进展了26°，而第二名患者在接受努氏手术后也进展了26°。两名患者均承认由于努氏手术后不适而未遵医嘱佩戴支具。然而，他们的进展速度仍是报告的快速进展者速率的两倍，这表明侧弯进展的一个重要因素直接归因于胸骨后支撑条矫正操作对脊柱施加的力。
本病例报告的目的是描述这两名患者的特征，以帮助临床医生对考虑采用努氏手术矫正漏斗胸的中度脊柱侧弯（侧弯角度>25°）患者做出决策。我们提醒患者及其医疗服务提供者，通过努氏手术对漏斗胸进行手术干预可能会使脊柱畸形恶化，进而需要进行脊柱侧弯手术。
