P3C313: Thoracic Inlet Widening to Relieve Tracheal Compression After Scoliosis Surgery: A Multidisciplinary Approach

Introduction: Pediatric spinal deformities can be caused by congenital anomalies, musculoskeletal disorders, and connective tissue disorders. The misalignment of the spine can be described in different terms like scoliosis, kyphosis, and lordosis. The severity of the spine can lead to different treatment options like therapy or surgery. Surgical correction of the pediatric spinal deformity may lead to complications like infection, implant failure, or worsening deformity. Here we present a unique case in a patient with prior spine surgery with anterior and posterior compression of trachea using the sternal split approach.

Case Description: This is a 15 year old female with a history of global developmental delay, spastic cerebral palsy, seizures, scoliosis, and gastrojejunostomy tube feeding dependence. Patient underwent a posterior spinal fusion procedure at outside facility and then developed respiratory problems which was complicated by cardiac arrest eventually requiring a tracheostomy. The tracheostomy site developed recurrent granulation tissue formation leading to tracheal stenosis at level of T2-T3. Upon work up, CT scan of neck and chest revealed significantly narrowed thoracic inlet diameter due to prior spinal procedure and thoracic lordosis posteriorly and pulsation from innominate artery anteriorly. Patient underwent a planned operation to increase the anteroposterior diameter of the thoracic inlet to relieve compression of trachea in a multidisciplinary approach.

The pediatric spine team excised spinal instrumentation from T3-T4 and burred the fusion mass with bone grafting. Cardiothoracic and pediatric surgery used the sternal split approach which incorporates a median sternotomy and anterior neck incision to mobilize the carotid and trachea thus allowing T1-T3 exposure for anterior partial corpectomy. Plastic surgery proceeded with placing AlloDerm between the trachea and innominate artery to prevent fistula creation and complex chest wall reconstruction involving partial resection of manubrium and bilateral pectoral major advancement flaps. Pediatric ENT was readily available for intermittent bronchoscopy to visualize the resolution of the pulsation on the anterior trachea. Post-operatively, patient had no further respiratory events and was successfully weaned off the ventilator.

Discussion: Post-operative complications can widely vary in spinal surgeries. This case brings awareness that spinal surgical intervention could potentially compromise the airway. Typical surgical approaches to the thoracic inlet that are described are anterior or posterior thoracotomies. Others have described a trapdoor incision at the third intercostal space in children allowing elevation of trap door and good exposure of the vessels. The sternal split approach allows good exposure to the cervicothoracic junction while avoid resection of the clavicle or first rib. The different approaches gives options to pediatric surgeons to tackle unique issues for each patient.

Conclusion: There have been no reported cases of tracheal compression from both anterior and posterior approach. This multidisciplinary approach using the sternal split technique was successful in relieving tracheomalacia in our complicated spinal deformity patient.