Electronic ISSN 2287-0237

VOLUME

STRAIGHT BACK SYNDROME; A MISLEADING CONDITION IN CARDIOLOGY, DEMONSTRATED WITH MAGNETIC RESONANCE IMAGING

SEPTEMBER 2014 - VOL.8 | CASE REPORT

Straight back syndrome (SBS) is a deformed thoracic spine disease sometimes considered  as a  pseudo-heart disease because its pathology can prominently affect  the normal function of the heart system. SBS patients often present with signs and symptoms that are similar to some cardiac diseases that hide those of the thoracic spine.1,2 Consequently, SBS has become the one of the most common misleading conditions in cardiology. Investigations for SBS are frequently performed in patients with an abnormal systolic murmur with no evidence of any cardiac-related cause. This article will detail  the importance of the straight back syndrome in diagnostic cardiology and demonstrate a case with Magnetic Resonance Imaging.

Keywords:

straight back syndrome (SBS), MRI, misleading condition 

MEDIA
Figure A:
Normal anatomy of thoracic spine and sternum. The picture shows the reference point of the thoracic spine and sternum; the suprasternal notch is situated opposite the 3rd and 4th thoracic vertebrae, the angle of Louis (manibriosternal joint) is opposite to T4 and T5 spines, the body of the sternum (the area between the angle of Louis and the Xyphoid) is placed opposite T5-T8.
Figure B:
The Computerized Tomography image on the sagittal view of the thoraco-lumbar spine of the SBS-affected patient shows the position displacement of the spine because of the loss of the normal kyphosis of the thoracic spine in SBS. The thoracic sternum is angled downwardly in the SBS hence the suprasternal notch is not situated opposite the 3rd and 4th thoracic vertebrae, the angle of Louis (manibriosternal joint) is not opposite to T4 and T5 spines, the body of the sternum (the area between the angle of Louis and the Xyphoid) is not placed opposite T5-T8.
Figure C:
Shows the diagnostic criteria of SBS 2; the ratio of the distance from the mid anterior border of the T8 to the sternum (C2) to the length of the thoracic cage in the right-left direction at the level of the dome of the right diaphragm (C1) less than 1/3 according to Davies’s and Leon’s proposal respectively.
Figure D:
Shows the diagnostic criteria of the SBS; the measured distance from the mid anterior surface of the T8 spine to the vertical line that connects between the top of the anterior border of the T4 spine to the anterior surface of the inferior part of the T12 spine (less than 1.2 cm).
Figure E1-E2:
Shows the short-cut method to diagnose SBS using MRI by measuring the distance (D2) between the anterior surface of the thoracic spine to the vertical line that connects between the posterior surface of the superior of the thoracic spine (that is opposite to the suprasternal notch and the posterior surface of the thoracic spine that is opposite to the Xyphoid) in every image slice on the sagittal view of the thoracic spine (E1). If the distance is less than 1.2 cm, SBS is diagnosed. The measurement of the A-P dimension of the thoracic cage on the sagittal view (by measuring the distance (D2) between the anterior surface of all the thoracic spine located within the length of the angle of Louis to the xyphoid to the posterior surface of sternum on the MRI image) on the sagittal view of the thoracic spine (E2) is necessary to make sure that the maximum distance value is measured. If the maximum value of the A-P dimension is less than 11 cm in female and 12 cm in male then SBS is diagnosed. The patient has D1 = 7.5 mm and D2 = 6.43 cm hence SBS diagnosis is confirmed.
Figure F:
Demonstrates the characters of the twelve lead ECG of the patient that shows left axis deviation and incomplete right bundle branch block.
Figure G:
Demonstrates the abnormal narrowing of the thoracic cage in the A-P dimension of the patient on the T1W bb image on the short axis plane.
Figure H:
Demonstrates the septal leaflet of the tricuspid valve prolapse of the patient (see arrow).
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