Iatrogenic thoracic inlet narrowing during growing rod distraction causing critical tracheal stenosis: a case report and management implications

Abstract Background Respiratory complications in pediatric spinal deformities are most commonly attributed to thoracic insufficiency syndrome resulting from reduced thoracic volume and impaired chest wall compliance. Severe airway compromise caused by extrinsic tracheal compression is rare and remains under-recognized. Here, we report a rare case of extrinsic tracheal compression caused by progressive upper thoracic hyperlordosis after successive growing-rod interventions. Case presentation A 6-year-old girl with progressive thoracolumbar kyphoscoliosis and compensatory upper thoracic lordosis (straight back) underwent halo-gravity traction and dual growing rod insertion surgery uneventfully, achieving considerable curve correction. In the subsequent first distraction surgery one year later, she developed airway spasm and hypoxemia during anesthetic intubation and encountered substantial difficulty in extubation postoperatively. Subsequent imaging and bronchoscopy showed severe tracheal narrowing at the thoracic inlet due to extrinsic compression. Initial attempts of rod adjustment provided little improvement. After thorough literature review and carefully weighing the pros and cons of various methods, a third posterior spinal procedure with multi-level posterior column osteotomies (PCOs) and kyphotic-contoured rods successfully restored upper thoracic kyphosis, widening the thoracic inlet and trachea. She was successfully extubated on postoperative day two and remained respiratory asymptomatic with stable deformity correction at 1-year follow-up. Conclusions This case highlights that the accompanying upper thoracic hyperlordosis (straight back) in pediatric spinal deformity may cause thoracic inlet narrowing and occult asymptomatic airway compression which may become critically aggravated after distraction-based growing rod surgery. Posterior restoration of upper thoracic kyphosis may be an effective and less invasive strategy for relieving tracheal compression in selected cases.