| Abstract|| |
Positional complications in spine surgery are not uncommon. Commonly encountered complications include ocular and aural, other than musculoskeletal injuries. However, development of Tietze's syndrome due to malpositioning has not been reported till date. A 40-year-old male patient presented with postlaminectomy syndrome, for which posterior pedicle screw fixation and fusion was performed. Postoperatively, patient complained of new-onset pain associated with redness and swelling at parasternal region. After thorough radiological investigations, he was diagnosed with Tietze's syndrome at 6th and 7th costo-cartilaginous junction. Tietze's syndrome is itself a rare entity, and its association with malpositioning during prone positioning is uncommon. It is important for the surgeons to be aware of the condition as Tietze's syndrome may be encountered as an off-centered complication due to malpositioning.
Keywords: Chest wall insult, positional complication, prone position, Tietze's syndrome
|How to cite this article:|
Kumar VA, Babu J N. Refractory tietze's syndrome occurring after lumbar spine surgery in prone position. Indian J Orthop 2019;53:574-7
| Introduction|| |
Majority of spine cases, especially lumbar surgeries are done through posterior approach where the patient has to be in prone position for longer durations. The positional complications are higher if the patient is under general anesthesia. Ocular and aural complications are very commonly reported in the literature, one of the reasons being improper positioning of the patient during anesthesia.
Tietze's syndrome is a condition of unknown etiology characterized by painful nonsuppurative swelling over costal cartilages. It was first described by Alexander Tietze in 1921.,, It is most commonly seen in young individuals and is equally prevalent among both sexes., This is one of the rarest diseases listed by National Institutes of Health, indicating its limited occurrence in the region. It commonly involves 2nd and 3rd costochondral junctions leading to chronic pain, but is usually self-limited. There were reports to state it can easily be misdiagnosed with malignancies, pneumonia, acute coronary syndrome, etc., This condition is differentiated from costochondritis with the presence of tender swelling at the coastal cartilaginous area.
Here, we report a refractory Tietze's syndrome developed few months postoperatively after lumbar fixation with pedicle screw system due to malpositioning during the surgery.
| Case Report|| |
A 40-year-old male patient (body mass index: 22.5) presented to our outpatient clinic with symptoms of postlaminectomy syndrome. After thorough clinical and radiological examination, he was diagnosed with L4–L5 instability with L4–S1 lumbar canal stenosis. After exhaustion of conservative management, he was advised posterior stabilization, fusion, and decompression. He successfully underwent the revision procedure where L4–S1 pedicle screw fixation with L5–S1 transforaminal lumbar interbody fusion was done.
After intubation and prone positioning, all bony landmarks (elbows and knees) were padded. For positional support, two soft cushion bolsters are used, one below chest wall and one below pelvis. Repositioning of the head was done regularly to avoid pressures on ocular bulbs. Surgery procedure took 3 hours and was uneventful. The patient was placed back to supine position and extubated. The patient showed no signs of any neurological abnormality.
On 2nd postoperative day, the patient complained of right-sided parasternal chest pain which was tender on examination. It was correlating to the area covered by proximal bolster placed during prone positioning. Pain was controlled with anti-inflammatory medications and the rest of the period was uneventful till suture removal. After 15 days, he started complaining of similar pain at the same point on right side of the chest. On examination, there was swelling, redness, tenderness, and local rise of temperature at the site [Figure 1]. His blood investigations showed increased erythrocyte sedimentation rate and C-reactive protein. Oral antibiotics and anti-inflammatory agents were given for a period of 5 days where pain started to come under control and he was discharged.
|Figure 1: Clinical picture showing redness and inflammation on anterior aspect of the chest wall|
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Later after 1 month, he returned back with the same complaint and with equal intensity. Then clinically, the diagnosis of Tietze's syndrome of lower ribs was made and has been advised for further investigations. Ultrasound of the area showed edematous coastal cartilage in the lower ribs with increased thickness of about 2.3 cm (normal 1.3 cm). Non-contrast computed tomography (NCCT) study of thorax was done to rule out other differential diagnoses [Figure 2]. Magnetic resonance imaging (MRI) showed thickening and enlargement of coastal cartilage at 6th and 7th costo-cartilaginous junction [Figure 3]. In delayed imaging phase of bone scintigraphy, there was avid uptake of radiotracer noted in the 6th and 7th costo-cartilaginous junctions on the right side. All investigations came with the positive correlation of the diagnosis made and was confirmed with Tietze's syndrome of the 6th and 7th ribs. Even after being on nonsteroidal anti-inflammatory drugs for 3 weeks, pain did not subside. Thereby, surgical excision of the 6th and 7th ribs' cartilage was performed followed by tumor necrosis factor inhibitors (adalimumab) for 6 months. He recovered completely with visual analog scale 0/10 over a period of 9 months.
|Figure 2: Noncontrast computed tomography of the thorax showing the presence of edema and induration around the right costal cartilage at the 6th rib|
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|Figure 3: Magnetic resonance imaging dorsal spine showing enlargement and thickening of coastal cartilage with hyperintensity noted at the 6th and 7th costochondral junctions|
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| Discussion|| |
Positional complications in spine surgeries are not uncommon. The most common one is posterior ischemic optic neuropathy that may either result due to improper padding of the eye causing a direct pressure effect when the patient is under general anesthesia or due to blood loss, hypotension, and anemia which all three may conspire to produce the condition., In a study by Chang et al., the incidence of ocular complications was a mere 0.028%. This, however, is a total nil if the surgery is being performed under spinal anesthesia. Other complications include upper and lower limb injuries due to inadequate padding of the pressure points, neck pain, and stiffness and brachial plexus injury. Oropharyngeal swelling and macroglossia are reported after cervical spine surgery in prone position.
The exact cause of Tietze's syndrome is still unknown (idiopathic); however, few researchers have speculated that multiple microtrauma to the anterior chest wall may lead to the development of Tietze's syndrome.,, Tietze's syndrome differentiates itself from costochondritis by the presence of reddish, tender swelling at the costochondral margin, making it the hallmark of the disease and also indicating its severity. It is mostly seen in the upper ribs, but very rarely reported in lower ribs. The incidence of Tietze's syndrome is not well studied, and, hence, only few clinicians have a handful of experience with it. Many studies contradicted each other regarding the sex distribution of the disease which has a wide range from equal to twice common in females to males., The rarity of the disease and the location of the pain often lead to differential diagnosis. Wide variety of conditions can cause symptoms similar to Tietze's syndrome, which includes irritation of nerve root from upper thoracic spine, fracture of rib, seronegative arthritis, ankylosing spondylitis, fibromyalgia, pneumonia, and coronary heart disease. Hence, it is always important to clinically exclude cardiac, gastrointestinal, and pulmonary origins of pain before confirming the diagnosis.
In the recent past, imaging has become an important diagnostic tool for the clinicians. However, in case of Tietze's syndrome, simple imaging of plain radiograph is often misleading as it is normal in almost all instances. Ultrasound of the area may be useful in visualizing the edema. Bone scintigraphy is an effective diagnostic tool for localizing the pathology in cases of costochondral pain. CT is also useful in these cases where the findings are chondral enlargement and destruction with/without calcification of costal cartilage. Although we find MRI not to be the diagnostic investigation of choice in this case, there are articles supporting MRI as a decisive investigation for Tietze's syndrome.
Tietze's syndrome which is a self-limiting chronic pain condition is itself a rare entity. Few case reports about variants of Tietze's syndrome have been mentioned in the literature.,,,, However, as per the author's knowledge, occurrence of Tietze's syndrome following surgery in prone position is a rarest complication which is not reported till date. Surgeons should be aware of this complication and try to prevent such incidents through proper cushioning at the dependent areas during prone positioning.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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Dr. Viswanadha Arun Kumar
Mallika Spine Centre, 12-12-30, Old Club Road, Kothapet, Guntur - 522 001, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3]