Soundararajan Dilip Chand Raja, Shanmuganathan Rajasekaran, K. S. Sri Vijayanand, Ajoy Prasad Shetty, Rishi Mugesh Kanna


December 2020, Volume 29, Issue 2, pp 188 - 192 Case Report Read Full Article 10.1007/s00586-020-06619-w

First Online: 06 October 2020

Purpose

A 17-year-old adolescent with neurofibromatosis and severe cervicothoracic deformity was identified to have thoracic inlet compression leading to bradycardia and hypotension, only during prone positioning, and we discuss its successful management.

Methods

Preoperative halo-gravity traction reduced the deformity from 126° to 91°. During prone positioning, sudden onset bradycardia was followed by asystole, which disappeared immediately on turning over to supine position. Surgery was called off after two additional failed attempts of prone positioning.

Results

A retrospective analysis of CT and MRI showed severe narrowing of the thoracic inlet. In this patient, the right thoracic inlet was severely narrow, and prone positioning caused a further dynamic compromise stimulating right vagal nerve. The right vagus supplies the sinoatrial node, which is the natural pacemaker of the heart, and its stimulation causes sympathetic inhibition. Bezold–Jarisch reflex is a cardio-inhibitory reflex occurring due to vagal stimulation resulting in sudden bradycardia, asystole, and hypotension. To facilitate prone positioning, the medial end of the clavicles, along with limited manubrium excision, was performed relieving the vagal compression. C2–T4 instrumented decompression followed by anterior reconstruction and cervical plating was performed. The postoperative period was uneventful, and the final deformity was 45°.

Conclusion

Bezold–Jarisch Reflex as a result of narrow thoracic inlet caused by cervical kyphosis and compensatory hyperlordosis of the upper thoracic spine has never been reported. This case highlights the need to introspect into thoracic inlet morphology in severe cervicothoracic deformities. Thoracic inlet decompression is an efficient way of addressing this unique complication.


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