Rib fixation for flail chest physiology and the facilitation of safe prone spinal surgery: illustrative case

Abstract

BACKGROUND Spine fractures are frequently associated with additional injuries in the trauma setting, with chest wall trauma being particularly common. Limited literature exists on the management of flail chest physiology with concurrent unstable spinal injury. The authors present a case in which flail chest physiology precluded safe prone surgery and after rib fixation the patient tolerated spinal fixation without further issue. OBSERVATIONS Flail chest physiology can cause cardiovascular decompensation in the prone position. Stabilization of the chest wall addresses this instability allowing for safe prone spinal surgery. LESSONS Chest wall fixation should be considered in select cases of flail chest physiology prior to stabilization of the spinal column in the prone position. Further research is necessary to identify patients that are at highest risk to not tolerate prone surgery.

Treatment approach for coexisting chest wall fractures and unstable thoracolumbar spine fractures in polytrauma patients requiring prone spine surgery

“…Similarly, Wessell et al published a case of flail chest physiology associated with unstable cervical and thoracic fractures that tolerated proning only after rib fixation. 21 This patient was scheduled to undergo occipital-cervical-thoracic fusion for C1 burst fracture, C2 lamina fracture, left C5–7 lateral mass fractures, and T1 three-column injury. He developed hemodynamic instability shortly after prone positioning that was refractory to pressor therapy.…”