Correlation of Surgical and Roentgenographic Findings Following Thoracoplasty for Chronic Pulmonary Tuberculosis

Abstract

THORACOPLASTY has become a routine surgical procedure for the treatment of chronic pulmonary tuberculosis, in cases in which other less radical measures have failed to yield the desired results. The medical profession at large and particularly roentgenologists, thoracic surgeons, and phthisiologists are being called upon daily to interpret roentgenograms of patients in whom this has been performed. To properly interpret studies of this nature, the surgical procedure must be understood and the sequelæ resulting therefrom recognized. In recent years, few papers have appeared dealing with the roentgenographic findings following thoracoplasty, and these describe individual phases rather than the subject as a whole. The vast material at Sea View Hospital permits a detailed study of this subject from both the surgical and roentgenological standpoints. In this communication we will attempt to correlate the surgical procedure and the roentgenographic changes seen following thoracoplasty in the examination of post-thoracoplasty roentgenograms. First Stage The surgical procedure in this stage consists of the subperiosteal resection of the upper three or four ribs, beginning as close to the vertebral margins as possible. The osseous portions of the first and second ribs are generally removed en toto, and only small anterior portions of the third and fourth ribs are left behind. Occasionally, portions of the transverse processes are removed with the costal structures. Roentgenographic examination following the first stage reveals anterior portions of the third and sometimes fourth ribs with the complete absence of the first and second ribs (Figs. 2, 6, 8, 12). The anterior remnants of the third and fourth ribs appear drawn backward, and the entire upper thorax in the area of rib resection appears narrowed. At times, the transverse processes appear irregular and sectioned, characteristic of surgical removal. The underlying lung is retracted downward and inward and appears airless (atelectatic) with its apex usually at the level of the third or fourth interspace (Fig. 6). Cavitation when visualized appears compressed and conforms to the general collapse of the lung (Figs. 5, 6, 11, 13). The mediastinum may be displaced slightly to the contralateral side, but not appreciably, and similarly the diaphragm may be somewhat depressed. The trachea as a rule is shifted considerably to the opposite side, but does not undergo any change in the caliber of its lumen. There is a scoliosis of the upper dorsal vertebræ with a convexity toward the side operated upon (Figs. 7, 8). Occasionally there is an anterior rotation of the lower cervical and upper dorsal vertebræ (Fig. 7). This rotation is away from the side operated upon. The scapula and clavicle at this time appear prominent with no appreciable change in position (Fig. 1).