Bilateral Sternocostal Joint Resection for Chronic Refractory Pain After Nuss Procedure

Abstract

Chronic postoperative pain that can be difficult to treat may occur after the Nuss procedure. This report introduces a case of unrelenting chronic postoperative pain at the bilateral sternocostal joints after the Nuss procedure that responded to bilateral resection of sternocostal joints.

This report documents a case of chronic bilateral sternocostal joint pain after the Nuss procedure that was treated successfully by bilateral sternocostal joint resection after failing to respond to conventional treatment modalities.

A 41-year-old man presented for surgical evaluation of chronic chest pain that had persisted since he underwent a Nuss procedure at the age of 16 years. He underwent rod removal at the age of 18 years and débridement of excessive scar tissue at 26 years. He reported severe pain localized bilaterally along the sternocostal margins from the level of the sternal angle to the level of the xiphisternal junction that was exacerbated by movement of the upper extremities. Conservative treatments had been attempted, including intercostal nerve blocks, ultrasound-guided injections of anesthetic agents locally, and nonsteroidal anti-inflammatory drug therapy, with no significant relief.

On physical examination, well-healed chest incisions and tenderness to palpation along the bilateral sternocostal margins were noted. His Zubrod score was 1, and pain score was 8 of 10 at baseline. Computed tomography of the chest revealed a possible nonunited fracture or an osteocartilaginous pseudarthrosis at the right anterior sixth rib but no residual pectus deformity and no apparent abnormalities localized to the sternocostal joints. Nuclear medicine single-photon emission computed tomography bone scan revealed mild asymmetry at the sternoclavicular articulations, prominent ossifications at the anterior costochondral joints, and bilaterally increased radiotracer activity at anterior sixth costochondral joints (Figure). Magnetic resonance imaging of the thorax did not reveal any additional findings. Transthoracic echocardiography was unremarkable. Pulmonary function testing showed a forced vital capacity of 4.56 L (85% of predicted), forced expiratory volume in the first second of 3.5 L (82% of predicted), diffusing capacity of lung for carbon monoxide of 60% predicted, and maximum voluntary ventilation of 59% predicted.

Figure.

Increased radiotracer activity of bilateral costochondral joints on single-photon emission computed tomography scan.

We discussed all options and decided first to optimize all medical and nonoperative therapies for him. We obtained a consultation with a rheumatologist for an autoimmune disorder screening, given his issues at the sternocostal joints, and with an interventional radiologist to see whether he would be a candidate for a radiologically guided percutaneous cryoablation. Bilateral sternocostal joint resection was discussed as a potential last-resort surgical option if these measures were unsuccessful.

He returned to our clinic 2 months later, after having consulted interventional radiology and rheumatology specialists. He had undergone intercostal nerve blocks again without relief and therefore was not considered a good candidate for cryoablation. We offered a resectional procedure to disarticulate the sternum from the costal cartilages on either side.

Paravertebral catheters were placed preoperatively. A vertical midline chest incision was made. The underlying soft tissue was divided with electrocautery down to the chest wall. Bilateral pectoralis major advancement flaps were developed, and the costal cartilages were exposed on both sides. The costal cartilage spanning from the sternum to the ribs from the third through seventh sternocostal joints was resected bilaterally. We ensured complete resection of the rib heads where they articulated with the sternum. Significant premature ossification was noted in the costal cartilages of these ribs. A 19F Blake drain was placed and secured. Estimated blood loss was 100 mL. Operative time was 75 minutes.

His postoperative course was unremarkable with no immediate postoperative complications. Intravenous patient-controlled analgesia was discontinued on postoperative day 2, and paravertebral catheters were removed on postoperative day 3. He was discharged home on postoperative day 5 after drain removal. At the 1-month postoperative follow-up, his chronic pain had completely resolved. He had switched from using oxycodone to using ibuprofen only occasionally.

Comment

Costal cartilage resection is well established as an effective treatment of conditions such as slipped rib syndrome, with high satisfaction rates in those who fail to respond to conservative management.^1,2 However, its use has not been reported for the management of chronic pain after pectus repair with the Nuss technique. The pain localized to the sternocostal joints after the Nuss procedure may resemble or be considered a subtype of costochondritis. As in this patient, signs of inflammation and swelling are absent in costochondritis, and the pain is aggravated by deep breathing and movement of the upper extremities.³ Unlike in this patient, however, costochondritis is typically unilateral. This patient experienced symptoms bilaterally. Costochondritis is generally a self-limited process that typically responds to pain control and anti-inflammatory medications, with corticosteroid or sulfasalazine injections reserved for refractory patients. This patient had severe, debilitating, chronic pain that did not respond to any other form of treatment until bilateral sternocostal joint resection was performed. Interestingly, his joints had demonstrated ossification, an unusual finding, given his relatively young age; we speculate that this phenomenon was related to his history of Nuss procedure and linked with his pain issues. In our opinion, for the rare but difficult scenario of a post-Nuss patient with severe chronic pain localized to the sternocostal joints who fails to respond to cryoablation and other conservative modalities, bilateral sternocostal joint resection may be a potentially useful option. Our patient’s preoperative bone scan had demonstrated abnormalities of the costochondral joints, and history and physical examination findings were notable for fairly localized pain to the sternocostal junctions on each side. Although more study is needed on this issue, we urge caution with regard to applying this type of operation in the absence of these or similar findings that would be indicative of a self-limited process involving the joints.